A multicenter, prospective trial to evaluate mesh-augmented sacrospinous hysteropexy for uterovaginal prolapse

Anterior approach sacrospinous hysteropexy: native tissue compared with mesh-augmented repair for primary uterovaginal prolapse management

INTRODUCTION AND HYPOTHESIS

Anterior sacrospinous hysteropexy (SSH) was popularized by transvaginal mesh kits. Following mesh-kit market withdrawal, we hypothesized similar efficacy through native-tissue reattachment of the pubocervical fascia with fixation of the anterior cervix to the sacrospinous ligament. Few analyses for anterior native-tissue versus mesh-augmented SSH exist.

METHODS

A retrospective analysis of women who underwent transvaginal anterior SSH between 01 January 2016 and 31 December 2022 was performed. Women who underwent a mesh-augmented (Uphold Lite Vaginal Support System™) versus native-tissue repair were compared. Composite success was defined as no bulge symptoms, no retreatment, and no recurrence beyond the hymen with apex nondescended > one third of the total vaginal length. Descriptive and bivariate statistics were obtained as indicated.

RESULTS

Of 223 women screened, inclusion criteria were met by 124 (40 mesh-augmented; 84 native-tissue). There was no difference in pre-operative characteristics between groups. Composite success was demonstrated in 95.2% of women with a median follow-up of 224 days (range: 30-988). Two women in the mesh-augmented group reported bulge symptoms and underwent re-treatment with a pessary. Four women in the native-tissue group reported bulge symptoms; 3 underwent re-treatment (2 pessary, 1 surgery). There were no differences in composite success rates between groups (p=0.954). There were additionally no differences in intra-operative (p=0.752) or post-operative (p=0.292) complication rates between the groups. There were no mesh-related complications, including exposure or chronic pelvic pain.

CONCLUSIONS

Ninety-five percent of women achieved surgical success and the use of mesh augmentation did not confer added benefit in terms of efficacy or complications when compared with native tissue. Further long-term data are needed to continue our assessment of native-tissue anterior SSH.

Evaluation of surgical treatment of genital prolapse using synthetic mesh in an outpatient procedure and patient satisfaction

OBJECTIVE

- To study a new strategy for one day prolapse surgery with mesh, to identify risk factors for one day procedure failure and patient satisfaction.

METHODS

- This retrospective observational study was conducted at Saint Etienne University Hospital, France. All patients who received a prolapse treatment by synthetic mesh between January 2016 and April 2019 in one day surgery procedure were included in the study. Exhaustive variables was collected and all patients were contacted for a satisfaction survey.

RESULTS

- During the periode patients were included. 6 of them required readmissions included 5 hospitalization for urinary retention and 1 for abnormal bleeding. Among the patients, 87% were satisfied. Only the anesthetic management was significantly associated with an ambulatory surgery success (p = 0,02) and satisfaction (p = 0,001).

CONCLUSION

- This study shows the technical feasibility and safety of prosthetic prolapse surgery during outpatient hospitalization. The success of a rapid pathway in one day surgery depends on a good selection of patients, proper planning of surgical procedures and optimization of anesthesia protocols. The prevention of outpatient failures is justified for medical and economic reasons respecting the quality and safety of patients.

Vaginal mesh hysteropexy: a review

PURPOSE OF REVIEW

Pelvic organ prolapse surgery is performed via native tissue or graft augmented repair. Graft augmentation with synthetic mesh was introduced to improve long-term surgical outcomes compared with vaginal native tissue repairs. Vaginal hysteropexy has recently become increasingly popular due to patient preference and an improved morbidity profile over hysterectomy, while maintaining comparable efficacy. As long-term outcomes remain unanswered, mesh augmentation to vaginal hysteropexy has sought to improve efficacy while minimizing complications.

RECENT FINDINGS

Recent studies have demonstrated superiority of vaginal mesh hysteropexy to vaginal hysterectomy with native tissue vault suspension. Short-term follow-up of vaginal mesh hysteropexy has also demonstrated lower blood loss and operative time with improved vaginal length compared with hysterectomy. Mesh exposure rates across studies were low and comparable to those of abdominally placed prolapse mesh.

SUMMARY

Vaginal mesh hysteropexy is a comparably well tolerated and effective surgical treatment option for women with uterovaginal prolapse. Although vaginal mesh kits are not commercially available, this procedure may be a viable treatment option in select patients.

Complications and objective outcomes of uterine preserving surgeries for the repair of pelvic organ prolapse versus procedures removing the Uterus, a systematic review

BACKGROUND

Several authors have recently compared the outcomes and complications of surgical procedures that preserve or remove the uterus in the treatment of pelvic organ prolapse (POP) and stress urinary incontinence (SUI). Following the publication of several high quality randomized control trials on this topic we performed a new systematic review and meta analysis of this data.

METHODS

We performed a systematic literature search in ClinicalTrials.gov, PubMed, Scopus, Ovid, EBSCO host, Science Direct, Web of Science, and Cochrane CENTRAL for randomized controlled and cohort trials of uterine sparing prolapse repair (hysteropexy) versus hysterectomy with suspension. A total of 1285 patients from 14 studies were included in our systematic review and meta-analysis.

RESULTS

Uterine sparing procedures (hysteropexy) were comparable to hysterectomy with suspension for recurrence rates (RR = 0.908, 95% CI [0.385, 2.143]), reoperation rates (RR = 1.517, 95% CI [0.802, 2.868]), length of hospital stay, (SMD =  - 0.159 days, 95% CI [-0.375, 0.057]), voiding dysfunction (RR = 1.089, 95% CI [0.695, 1.706]), and intraoperative blood loss (SMD =  - 0.339, 95% CI [-0.631, 0.047]). However, hysteropexy had shorter operative time than hysterectomy with suspension (SMD =  - 1.191 h, 95% CI [-1.836, -0.545]), and fewer visceral injuries (RR = 0.421, 95% CI [0.244, 0.725]).

CONCLUSION

We found no significant differences in the outcomes or major complications of uterine preserving surgical procedures versus those which include hysterectomy in the treatment of POP. Hysteropexy procedures may be associated with a shorter operative time and fewer visceral injuries. This is consistent with older analyses.

Hysterectomy with uterosacral suspension or Uphold™ hysteropexy in women with apical prolapse: a parallel cohort study

INTRODUCTION AND HYPOTHESIS

The aim was to compare objective and subjective cure rates between Uphold™ hysteropexy (HP) and vaginal hysterectomy (VH) with uterosacral suspension.

METHODS

A sample size of 49 in each arm would be required to detect a clinical difference of 20% between the groups. Owing to delayed recruitment, this originally planned randomised controlled trial was changed to a patient preference study after randomising initial 6 participants. Women with symptomatic stage ≥2 uterine descent wishing a surgical solution were included. Routine follow-up was scheduled at 6 weeks, 6 months, 12 months, and annually thereafter. Primary outcome was absence of stage ≥2 apical prolapse. Secondary outcomes included a composite cure of no leading edge beyond the hymen, absence of bulge symptoms and no retreatment; patient-reported outcomes were based on quality-of-life questionnaires (PFDI-20, PFIQ-7, PISQ-12, PGI-I, EQ5D and a health score).

RESULTS

We recruited 50 patients undergoing VH between 2011 and 2013 and 51 patients undergoing HP between 2011 and 2016. Participants were followed up for a median of 25 months (23-96). Five women from the VH (10%) and 7 from the HP (14%) group were lost to follow-up. Combined anatomical and symptomatic outcomes were available for 41 (82%) VH and 39 (76%) in the HP group. There was no difference in objective apical outcomes; the incidence of stage 2 prolapse was 0% in the VH group and 2% in HP group (p = 0.50). We found no difference in the composite cure rate (78% VH vs 85% HP, 0.45) between the groups. There was no significant difference in surgical complications (p = 0.33), assessed using Clavien-Dindo classification. There was a 2% surgery rate for mesh exposure in the HP group.

CONCLUSIONS

Uphold™ uterine suspension and VH appear to have similar objective and subjective cure at 25 months, with no significant difference in surgical complications.

Joint Report on Terminology for Surgical Procedures to Treat Pelvic Organ Prolapse

Surgeries for pelvic organ prolapse (POP) are common, but standardization of surgical terms is needed to improve the quality of investigation and clinical care around these procedures. The American Urogynecologic Society and the International Urogynecologic Association convened a joint writing group consisting of 5 designees from each society to standardize terminology around common surgical terms in POP repair including the following: sacrocolpopexy (including sacral colpoperineopexy), sacrocervicopexy, uterosacral ligament suspension, sacrospinous ligament fixation, iliococcygeus fixation, uterine preservation prolapse procedures or hysteropexy (including sacrohysteropexy, uterosacral hysteropexy, sacrospinous hysteropexy, anterior abdominal wall hysteropexy, Manchester procedure), anterior prolapse procedures (including anterior vaginal repair, anterior vaginal repair with graft, and paravaginal repair), posterior prolapse procedures (including posterior vaginal repair, posterior vaginal repair with graft, levator plication, and perineal repair), and obliterative prolapse repairs (including colpocleisis with hysterectomy, colpocleisis without hysterectomy, and colpocleisis of the vaginal vault). Each of these terms is clearly defined in this document including the required steps of the procedure, surgical variations, and recommendations for procedural terminology.

Feasibility of vaginal mesh for anterior vaginal wall prolapse in an ambulatory setting: A retrospective case series

INTRODUCTION

Vaginal mesh has been proven to be an effective aid in the treatment of cystocele. Could an ambulatory approach be feasible for the Uphold Lite®-mesh?

HYPOTHESIS

We investigate the feasibility of an ambulatory approach of Uphold Lite® insertion in a well-selected population. Risk factors for a non-successful ambulatory approach are identified.

METHODOLOGY

We conducted a retrospective case series of 236 women who underwent Uphold Lite® vaginal mesh insertion for the treatment of pelvic organ prolapse at our center. Indications for surgery were symptomatic anterior and/or apical prolapse, stages POPQ≥2. We compared women having an ambulatory approach, to those having a one day hospitalization planned but needed to stay. Comparisons between percentages were calculated using the chi-square or Fisher's exact test, depending on the number of women in each group. The mean comparisons were performed using the Student t-test, and the median test comparisons by the Kruskal-Wallis test. A difference was considered significant if p<0.05.

RESULTS

The most common reason for staying (85.7% of all ambulatory failures) after Uphold® surgery is the presence of an elevated post void residual. This complication was more found in the following: surgery in the afternoon, use of high-dose morphinics in general anesthesia, and in women with a higher parity.

CONCLUSIONS

Our study shows that Uphold® surgery in a one-day setting is feasible and safe. Women desiring this approach should be counselled on the 42.6% risk of one-day failure though, mostly due to non-validation of a post void residual. General anesthesia with high-dose morphinics, a higher parity, and surgery in the afternoon are risk factors for failure of an ambulatory protocol.

Effect of Vaginal Mesh Hysteropexy vs Vaginal Hysterectomy With Uterosacral Ligament Suspension on Treatment Failure in Women With Uterovaginal Prolapse: A Randomized Clinical Trial

IMPORTANCE

Vaginal hysterectomy with suture apical suspension is commonly performed for uterovaginal prolapse. Transvaginal mesh hysteropexy is an alternative option.

OBJECTIVE

To compare the efficacy and adverse events of vaginal hysterectomy with suture apical suspension and transvaginal mesh hysteropexy.

DESIGN, SETTING, PARTICIPANTS

At 9 clinical sites in the US Pelvic Floor Disorders Network, 183 postmenopausal women with symptomatic uterovaginal prolapse were enrolled in a randomized superiority clinical trial between April 2013 and February 2015. The study was designed for primary analysis when the last randomized participant reached 3 years of follow-up in February 2018.

INTERVENTIONS

Ninety-three women were randomized to undergo vaginal mesh hysteropexy and 90 were randomized to undergo vaginal hysterectomy with uterosacral ligament suspension.

MAIN OUTCOMES AND MEASURES

The primary treatment failure composite outcome (re-treatment of prolapse, prolapse beyond the hymen, or prolapse symptoms) was evaluated with survival models. Secondary outcomes included operative outcomes and adverse events, and were evaluated with longitudinal models or contingency tables as appropriate.

RESULTS

A total of 183 participants (mean age, 66 years) were randomized, 175 were included in the trial, and 169 (97%) completed the 3-year follow-up. The primary outcome was not significantly different among women who underwent hysteropexy vs hysterectomy through 48 months (adjusted hazard ratio, 0.62 [95% CI, 0.38-1.02]; P = .06; 36-month adjusted failure incidence, 26% vs 38%). Mean (SD) operative time was lower in the hysteropexy group vs the hysterectomy group (111.5 [39.7] min vs 156.7 [43.9] min; difference, -45.2 [95% CI, -57.7 to -32.7]; P = <.001). Adverse events in the hysteropexy vs hysterectomy groups included mesh exposure (8% vs 0%), ureteral kinking managed intraoperatively (0% vs 7%), granulation tissue after 12 weeks (1% vs 11%), and suture exposure after 12 weeks (3% vs 21%).

CONCLUSIONS AND RELEVANCE

Among women with symptomatic uterovaginal prolapse undergoing vaginal surgery, vaginal mesh hysteropexy compared with vaginal hysterectomy with uterosacral ligament suspension did not result in a significantly lower rate of the composite prolapse outcome after 3 years. However, imprecision in study results precludes a definitive conclusion, and further research is needed to assess whether vaginal mesh hysteropexy is more effective than vaginal hysterectomy with uterosacral ligament suspension.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01802281.

The resurrection of sacrospinous fixation: unilateral apical sling hysteropexy

INTRODUCTION AND HYPOTHESIS

The apical compartment is a keystone in POP treatment. Sacrospinous fixation, suggested half a century ago, today is still one of the most popular and efficient methods of colpo-hysteropexy. However, it has specific side effects: chronic pain syndrome, dyspareunia and а high rate of cystocele de novo. We aimed to evaluate the efficacy and safety of unilateral sacrospinous hysteropexy with a synthetic apical sling combined with anterior subfascial colporrhaphy.

METHODS

Following the suggested technique, 174 women with anterior-apical prolapse underwent surgery. The follow-up period took 12 months. Pre- and postoperative examination included: urogynecological examination (POP-Q), uroflowmetry, ultrasound of the bladder and filling in of validated questionnaires (PFDI-20, PISQ-12).

RESULTS

The mean surgery time was 26 ± 7.84 min. No cases of damage of the bladder or rectum or of intraoperative clinically significant bleeding were noted. At the 12-month follow-up, the recurrence rate in the apical compartment was 0.7% (1/147) and in the anterior compartment 7.4% (11/147). The efficacy of the surgery reached 96.5%. During 12 months of follow-up, no cases of mesh exposure or chronic pelvic pain syndrome were detected. The incidence of dyspareunia de novo was observed in just one patient.

CONCLUSIONS

A unilateral sacrospinous fixation with a synthetic mesh (apical sling) combined with anterior subfascial colporrhaphy enhances the anatomical efficacy of surgery. It also helps to avoid specific side effects of traditional sacrospinous fixation.

Morbidity of a Single Incision Transvaginal Mesh to Correct Apical Prolapse

STUDY OBJECTIVE

To determine complications and related reintervention rates associated with use of the Uphold Vaginal Support System (Boston Scientific, Boston, MA) for symptomatic vaginal apical prolapse.

DESIGN

A multicenter retrospective study.

SETTING

Two teaching hospitals.

PATIENTS

Fifty-nine women with symptomatic vaginal apical prolapse.

INTERVENTION

Vaginal apical prolapse surgery using the Uphold Mesh Kit system with or without other concomitant procedures.

MEASUREMENTS AND MAIN RESULTS

A chart review was performed, including the following parameters: perioperative and postoperative complications, repeat surgery, and recurrence rate. A total of 59 patients met the criteria for inclusion in the study. Bladder perforation occurred perioperatively in 1 patient. Postoperative voiding difficulties were observed in 16 patients (27.1%), including 9 women (15.2%) who left the hospital with an indwelling catheter in place. There were 5 cases (8.5%) of transient groin pain, all of which resolved spontaneously. One patient developed a vaginal hematoma. Nine women (15%) required reoperation, including 4 (6.7%) because of recurrent prolapse and 1 (2%) for pelvic pain considered related to the mesh. Three patients (5%) required release of a midurethral sling (MUS) that had been placed concomitantly with the Uphold system. Two patients (3%) required a MUS for de novo stress incontinence.

CONCLUSION

Use of the Uphold Vaginal Support System for symptomatic vaginal apical prolapse was associated with a significant risk of obstructed micturition. In our study population, 15% required repeat surgery, mainly for recurrent pelvic organ prolapse and de novo stress urinary incontinence. No surgical-related complication resulted in long-term morbidity.

Comparison of UpholdTM Vaginal Mesh Procedure with Hysterectomy or Uterine Preservation for the Treatment of Pelvic Organ Prolapse

Hysterectomy is the empirical treatment for female pelvic organ prolapse (POP) without robust evidence to prove its efficacy. Uphold transvaginal mesh (TVM) system is an innovated device with smaller area, superior anterior/apical support with single incision to treat POP. The prospective cohort study aims to evaluate Uphold TVM's performance with or without concomitant hysterectomy. Inclusion criteria specify patients suffering from stage 2 or more anterior/apical prolapse without previous hysterectomy. Exclusion criteria specify those with contraindications to uterine preservation, such as leiomyomas, adenomyosis, endometrial hyperplasia, abnormal uterine bleeding, postmenopausal bleeding, cervical dysplasia, receiving tamoxifen treatment, family history of gynecology cancer, or colon cancer and incapability to be routinely followed. Thirty patients are recruited in the hysterectomy group and 66 patients in the hysteropexy group. The results demonstrate that patients with Uphold mesh only experience longer vaginal length, shorter operation duration, less blood loss and less post-operation pain. The performance in anatomical correction, lower urinary tract symptoms improvement, de novo dyspareunia, urodynamic study parameters and mesh extrusion rates are comparable with or without uterus preservation. The information is useful in pre-operation counseling, when the patient can make an educated choice whether or not to receive concomitant hysterectomy.

No. 351-Transvaginal Mesh Procedures for Pelvic Organ Prolapse

OBJECTIVE

This guideline reviews the evidence related to the risks and benefits of using transvaginal mesh in pelvic organ prolapse repairs in order to update recommendations initially made in 2011.

INTENDED USERS

Gynaecologists, residents, urologists, urogynaecologists, and other health care providers who assess, counsel, and care for women with pelvic organ prolapse.

TARGET POPULATION

Adult women with symptomatic pelvic organ prolapse considering surgery and those who have previously undergone transvaginal mesh procedures for the treatment of pelvic organ prolapse.

OPTIONS

The discussion relates to transvaginal mesh procedures compared with other surgical options for pelvic organ prolapse (mainly about vaginal native tissue repairs and minimally about other alternatives such as biological and absorbable vaginal mesh and abdominally placed surgical mesh).

OUTCOMES

The outcomes of interest are objective and subjective success rates and intraoperative and postoperative complications, such as adjacent organ injury (urinary, gastrointestinal), infection, hematoma/bleeding, vaginal mesh exposure, persistent pain, dyspareunia, de novo stress urinary incontinence, and reoperation.

EVIDENCE

PubMed, Medline, the Cochrane Database, and EMBASE were searched using the key words pelvic organ prolapse/surgery*, prolapse/surgery*, surgical mesh, surgical mesh*/adverse effects, transvaginal mesh, and pelvic organ prolapse.

RESULTS

were restricted to English or French language and human research. Articles obtained through this search strategy were included until the end of June 2016. Pertinent new studies were added up to September 2016. Grey literature was not searched. Clinical practice guidelines and guidelines of specialty societies were reviewed. Systematic reviews were included when available. Randomized controlled trials and observational studies were included when evidence for the outcome of interest or in the target population was not available from systematic reviews. New studies not yet included in systematic reviews were also included. Only publications with study groups larger than 20 individuals were selected because this criterion was used in the largest meta-analysis referenced in this guideline. A total of 1470 studies were obtained; after selecting only applicable studies and excluding duplicates, 68 manuscripts were reviewed and included.

VALUES

The content and recommendations were drafted and agreed upon by the principal authors and members of the Urogynaecology Committee. The Board of the Society of Obstetricians and Gynaecologists of Canada approved the final draft for publication. The quality of evidence was rated using the criteria described in the Grading of Recommendations Assessment, Development and Evaluation methodology framework. The Summary of Findings is available upon request.

BENEFITS, HARMS, AND/OR COSTS

It is expected that this guideline will benefit women with pelvic organ prolapse by ensuring that health care providers are aware of outcomes related to transvaginal mesh procedures and steps in the management of related complications. This should guide patient-informed consent before such procedures are undertaken. The benefits clearly outweigh the potential harms or costs of implementation of this guideline, although no direct harms or costs are identified.

GUIDELINE UPDATE

Evidence will be reviewed 5 years after publication to decide whether all or part of the guideline should be updated. However, if important new evidence is published prior to the 5-year cycle, the review process may be accelerated for a more rapid update of some recommendations.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Hysteropreservation versus hysterectomy in the surgical treatment of uterine prolapse: systematic review and meta-analysis

INTRODUCTION AND HYPOTHESIS

The efficacy and safety of removing or preserving the uterus during reconstructive pelvic surgery is a matter of debate.

METHODS

We performed a systematic review and meta-analysis of studies that compared hysteropreservation and hysterectomy in the management of uterine prolapse. PubMed, Medline, SciELO and LILACS databases were searched from inception until January 2017. We selected only randomized controlled trials and observational cohort prospective comparative studies. Primary outcomes were recurrence and reoperation rates. Secondary outcomes were: operative time, blood loss, visceral injury, voiding dysfunction, duration of catheterization, length of hospital stay, mesh exposure, dyspareunia, malignant neoplasia and quality of life.

RESULTS

Eleven studies (six randomized and five non-randomized) were included involving 910 patients (462 in the hysteropreservation group and 448 in the hysterectomy group). Pooled data including all surgical techniques showed no difference between the groups regarding recurrence of uterine prolapse (RR 1.65, 95% CI 0.88-3.10; p = 0.12), but the risk of recurrence following hysterectomy was lower when the vaginal route was used with native tissue repair (RR 10.61; 95% CI 1.26-88.94; p = 0.03). Hysterectomy was associated with a lower reoperation rate for any prolapse compartment than hysteropreservation (RR 2.05; 95% CI 1.13-3.74; p = 0.02). Hysteropreservation was associated with a shorter operative time (mean difference -12.43 min; 95% CI -14.11 to -10.74 ; p < 0.00001) and less blood loss (mean difference -60.42 ml; 95% CI -71.31 to -49.53 ml; p < 0.00001). Other variables were similar between the groups.

CONCLUSIONS

Overall, the rate of recurrence of uterine prolapse was not lower but the rate of reoperation for prolapse was lower following hysterectomy, while operative time was shorter and blood loss was less with hysteropreservation. The limitations of this analysis were the inclusion of nonrandomized studies and the variety of surgical techniques. The results should be interpreted with caution due to potential biases.

Minimally invasive surgery in pelvic floor repair

PURPOSE OF REVIEW

To review the use and efficacy of minimally invasive surgery in pelvic organ prolapse (POP) repair. This review summarizes surgical options for management of POP with special emphasis on minimally invasive surgical approach and discusses the recent experience and feasibility of integrating robot-assisted technology.

RECENT FINDINGS

Minimally invasive approaches have equal efficacy and less morbidity than laparotomy for POP repair, particularly apical prolapse. Robotics may facilitate the rate of minimally invasive surgery for POP repair with greater cost and as yet no proven superiority for conventional laparoscopy.

SUMMARY

Minimally invasive surgery is the preferred approach to POP repair. Conventional laparoscopic or robotic sacral colpopexy is recommended for apical defect and procidentia.

Antimicrobial and anti-biofilm properties of polypropylene meshes coated with metal-containing DLC thin films

A promising strategy to reduce nosocomial infections related to prosthetic meshes is the prevention of microbial colonization. To this aim, prosthetic meshes coated with antimicrobial thin films are proposed. Commercial polypropylene meshes were coated with metal-containing diamond-like carbon (Me-DLC) thin films by the magnetron sputtering technique. Several dissimilar metals (silver, cobalt, indium, tungsten, tin, aluminum, chromium, zinc, manganese, tantalum, and titanium) were tested and compositional analyses of each Me-DLC were performed by Rutherford backscattering spectrometry. Antimicrobial activities of the films against five microbial species (Candida albicans, Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus, and Enterococcus faecalis) were also investigated by a modified Kirby-Bauer test. Results showed that films containing silver and cobalt have inhibited the growth of all microbial species. Tungsten-DLC, tin-DLC, aluminum-DLC, zinc-DLC, manganese-DLC, and tantalum-DLC inhibited the growth of some strains, while chromium- and titanium-DLC weakly inhibited the growth of only one tested strain. In-DLC film showed no antimicrobial activity. The effects of tungsten-DLC and cobalt-DLC on Pseudomonas aeruginosa biofilm formation were also assessed. Tungsten-DLC was able to significantly reduce biofilm formation. Overall, the experimental results in the present study have shown new approaches to coating polymeric biomaterials aiming antimicrobial effect.

Surgical Updates in the Treatment of Pelvic Organ Prolapse

Pelvic organ prolapse affects approximately 8% of women, and the demand for pelvic organ prolapse surgery is expected to increase by nearly 50% over the next 40 years. The surgical techniques used to correct pelvic organ prolapse have evolved over the last 10 years, with multiple well-designed studies addressing the risks, outcomes, reoperation rates, and optimal surgical approaches. Here we review the most recent evidence on the route of access, concomitant procedures, and synthetic materials for augmenting the repair. Ultimately, this review highlights that there is no optimal method for correcting pelvic organ prolapse and that the risks, benefits, and approaches should be discussed in a patient-centered, goal-oriented approach to decision-making.

Hysteropexy: Evidence and Insights

Uterovaginal prolapse may be treated with or without concomitant hysterectomy. Many patients express interest in uterine-sparing prolapse procedures, for which there are increasing evidence available regarding techniques and outcomes. Uterine-sparing procedures to treat uterovaginal prolapse require a unique set of surgical considerations including uterine abnormalities, possibility of occult malignancy, and future pregnancy. Data, including randomized controlled trials, support the use of sacrospinous hysteropexy. Other prospective trials detailing outcomes following uterosacral hysteropexy, mesh augmented sacrospinous hysteropexy, and sacrohysteropexy are also encouraging.

The hybrid technique of pelvic organ prolapse treatment: apical sling and subfascial colporrhaphy

INTRODUCTION AND HYPOTHESIS

The majority of patients with cystocele undergoing reconstructive surgery have combined defects of pubocervical fascia and uterosacral/cardinal ligament complex. In this regard, the simultaneous correction of both defects is rational. Furthermore, decreasing the use of synthetic materials in pelvic floor surgery is an important goal. The aim was to evaluate the objective and subjective cure rate of a hybrid technique: bilateral sacrospinous fixation using modern monofilament synthetic tape (apical sling) combined with the original technique of subfascial colporrhaphy.

MATERIALS AND METHODS

This prospective study involved 148 women suffering from cystocele combined with apical prolapse. We used the following criteria to evaluate the results of surgical treatment: results of the vaginal examination (POP-Q system), urodynamic tests, bladder ultrasound, special questionnaires (Pelvic Floor Distress Inventory [PFDI-20], Pelvic Floor Impact Questionnaire [PFIQ-7], Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire [PISQ-12], International Consultation on Incontinence Modular Questionnaire Short Form [ICIQ-SF]). All listed parameters were determined before the surgery and at control examinations at 1, 6, and 12 months after the treatment.

RESULTS

At the 1-year follow-up, the objective cure rate for prolapse was 97.8%. The rate of anatomical recurrence was 2.2% (3 out of 138). The following long-term complications were noted: de novo urgency and stress urinary incontinence de novo in 2 (1.4%) and 4 (2.9%) patients, respectively. Comparison of the scores by the questionnaires also revealed a significant improvement in the quality of life in the postoperative period. Patient satisfaction rate was 97.1%.

CONCLUSION

The hybrid technique is an effective and safe uterus-sparing method for patients with advanced forms of cystocele combined with apical prolapse. This technique improves voiding function, quality of life, and provides a high satisfaction rate.

Vaginal and laparoscopic mesh hysteropexy for uterovaginal prolapse: a parallel cohort study

BACKGROUND

There is growing interest in uterine conservation at the time of surgery for uterovaginal prolapse, but limited data compare different types of hysteropexy.

OBJECTIVE

We sought to compare 1-year efficacy and safety of laparoscopic sacral hysteropexy and vaginal mesh hysteropexy.

STUDY DESIGN

This multicenter, prospective parallel cohort study compared laparoscopic sacral hysteropexy to vaginal mesh hysteropexy at 8 institutions. We included women ages 35-80 years who desired uterine conservation, were done with childbearing, and were undergoing 1 of the above procedures for stage 2-4 symptomatic anterior/apical uterovaginal prolapse (anterior descent at or beyond the hymen [Aa or Ba ≥ 0] and apical descent at or below the midvagina [C ≥ -TVL/2]). We excluded women with cervical elongation, prior mesh prolapse repair, cervical dysplasia, chronic pelvic pain, uterine abnormalities, and abnormal bleeding. Cure was defined as no prolapse beyond the hymen and cervix above midvagina (anatomic), no vaginal bulge sensation (symptomatic), and no reoperations. Pelvic Organ Prolapse Quantification examination and validated questionnaires were collected at baseline and 12 months including the Pelvic Floor Distress Inventory Short Form, Female Sexual Function Index, and Patient Global Impression of Improvement. In all, 72 subjects/group were required to detect 94% vs 75% cure (80% power, 15% dropout). Intention-to-treat analysis was used with logistic regression adjusting for baseline differences.

RESULTS

We performed 74 laparoscopic sacral hysteropexy and 76 vaginal mesh hysteropexy procedures from July 2011 through May 2014. Laparoscopic patients were younger (P < .001), had lower parity (P = .006), were more likely premenopausal (P = .008), and had more severe prolapse (P = .02). Laparoscopic procedure (174 vs 64 minutes, P < .0001) and total operating time (239 vs 112 minutes, P < .0001) were longer. There were no differences in blood loss, complications, and hospital stay. One-year outcomes for the available 83% laparoscopic and 80% vaginal hysteropexy patients revealed no differences in anatomic (77% vs 80%; adjusted odds ratio, 0.48; P = .20), symptomatic (90% vs 95%; adjusted odds ratio, 0.40; P = .22), or composite (72% vs 74%; adjusted odds ratio, 0.58; P = .27) cure. Mesh exposures occurred in 2.7% laparoscopic vs 6.6% vaginal hysteropexy (P = .44). A total of 95% of each group were very much better or much better. Pelvic floor symptom and sexual function scores improved for both groups with no difference between groups.

CONCLUSION

Laparoscopic sacral hysteropexy and vaginal mesh hysteropexy had similar 1-year cure rates and high satisfaction.

The Design of a Randomized Trial of Vaginal Surgery for Uterovaginal Prolapse: Vaginal Hysterectomy With Native Tissue Vault Suspension Versus Mesh Hysteropexy Suspension (The Study of Uterine Prolapse Procedures Randomized Trial)

OBJECTIVES

We present the rationale for and design of a randomized controlled superiority trial comparing 2 vaginal surgical approaches for the treatment of uterovaginal prolapse. The Study of Uterine Prolapse Procedures Randomized Trial (SUPeR) trial compares the efficacy and safety of native tissue repair with vaginal hysterectomy and suture apical suspension versus uterine conservation with mesh hysteropexy through 36 to 60 months postoperatively for primary repair of uterovaginal prolapse.

METHODS

The selection of the primary outcome measure, timing of randomization, patient and evaluator masking to surgical intervention, collection and adjudication of adverse events, cost effectiveness evaluations, partnering with industry, and surgeon certification of competency to perform the 2 procedures is described. A composite primary outcome of success defined as no prolapse symptoms, no objective prolapse beyond the hymen, and no retreatment of prolapse, with a minimum of 36 months postsurgery follow-up using survival analyses is planned. Secondary outcomes measured at baseline and every 6 months postsurgery include validated condition-specific and general quality of life assessments, global impression of improvement, body image, and sexual function measures. Unique challenges during the trial design include maintenance of patient masking to the intervention with routine gynecologic health maintenance and maintenance of evaluator masking.

RESULTS

Recruitment and randomization of 180 participants is complete, and participants are currently in the follow-up phase.

CONCLUSIONS

This trial will provide information to help surgeons counsel patients and contribute evidence-based information regarding risks and benefits of 2 approaches for the treatment of uterovaginal prolapse.

Does prolapse equal hysterectomy? The role of uterine conservation in women with uterovaginal prolapse

Hysterectomy has historically been a mainstay in the surgical treatment of uterovaginal prolapse, even in cases in which the removal of the uterus is not indicated. However, uterine-sparing procedures have a long history and are now becoming more popular. Whereas research on these operations is underway, hysteropexy for the treatment of prolapse is not as well studied as hysterectomy-based repairs. Compared with hysterectomy and prolapse repair, hysteropexy is associated with a shorter operative time, less blood loss, and a faster return to work. Other advantages include maintenance of fertility, natural timing of menopause, and patient preference. Disadvantages include the lack of long-term prolapse repair outcomes and the need to continue surveillance for gynecological cancers. Although the rate of unanticipated abnormal pathology in this population is low, women who have uterine abnormalities or postmenopausal bleeding are not good candidates for uterine-sparing procedures. The most studied approaches to hysteropexy are the vaginal sacrospinous ligament hysteropexy and the abdominal sacrohysteropexy, which have similar objective and subjective prolapse outcomes compared with hysterectomy and apical suspension. Pregnancy and delivery have been documented after vaginal and abdominal hysteropexy approaches, although very little is known about outcomes following parturition. Uterine-sparing procedures require more research but remain an acceptable option for most patients with uterovaginal prolapse after a balanced and unbiased discussion reviewing the advantages and disadvantages of this approach.

Utero-vaginal suspension using bilateral vaginal anterior sacrospinous fixation with mesh: intermediate results of a cohort study

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse is a major burden for the public health system, affecting up to 30 % of all women. One mesh kit has been introduced for pelvic organ prolapse surgery that can be inserted via a single anterior incision with the mesh arms driven through the sacrospinous ligament in a tension-free manner. The aim of this study was to describe the medium-term results of this vaginal mesh kit procedure for the combined treatment of the anterior vaginal wall and vault prolapse.

METHODS

This is a longitudinal case series of patients undergoing an anterior mesh operation between 2009 and 2013. All patients presenting with symptomatic stage II prolapse or higher were included when a minimum follow-up of 12 months was achieved. A structured interview and clinical examination were performed pre- and postoperatively.

RESULTS

One hundred and eighteen consecutive patients were operated with the Uphold® system during the study period. Three patients did not complete the 12-month follow-up and were excluded from the analysis, leaving 115 patients. Anatomical success at a mean follow-up of 23 months was 93 %, with a patient satisfaction rate of 95 %. Four patients (8 %) experienced de novo dyspareunia related to the mesh. The reoperation rate for mesh-related complications was 3.4 %; no patients were re-operated for POP recurrence.

CONCLUSIONS

The subjective and objective cure rates were high and the mesh-related re-operation rate was 3 % in the medium term, suggesting that this surgical technique may be an option for women requiring anterior and apical prolapse repair.