Mesh complications and failure rates after transvaginal mesh repair compared with abdominal or laparoscopic sacrocolpopexy and to native tissue repair in treating apical prolapse

Early safety and efficiency outcomes of a novel interdisciplinary laparoscopic resection rectopexy combined with sacrocolpopexy for women with obstructive defecation syndrome and pelvic organ prolapse: a single center study

BACKGROUND

Obstructive defecation syndrome (ODS) defines a disturbed defecation process frequently associated with pelvic organ prolapse (POP) in women that substantially compromises quality of life. Conservative management offers limited relief and a surgical intervention may be required. This is characterized by individual approaches. AIM OF THE STUDY: This retrospective single center study evaluated the surgical and clinical short-term outcome of a novel interdisciplinary laparoscopic resection rectopexy (L-RRP) with mesh- sacrocolpopexy (L-SCP) for women suffering from ODS and POP.

METHODS

The study participants underwent surgery in an interdisciplinary laparoscopic approach. Safety was the primary endpoint, assessed via postoperative morbidity classified by Clavien-Dindo scale. Secondary outcomes included evaluation of bowel function, fecal and urinary incontinence and pelvic organ prolapse status at 12 months follow-up. Additionally, a biological mesh (BM) was offered to women, who asked for an alternative to synthetic mesh material (SM).

RESULTS

Of the 44 consecutive patients requiring surgery for ODS and POP, 36 patients underwent the interdisciplinary surgical approach; 28 patients with SM and 8 patients with BM. In total 5 complications occurred, four of them were classified as minor. One minor complication was observed in the BM group. One anastomotic leakage occurred in the SM group. The two ODS scores, the bowel dysfunction score, and the incontinence score improved significantly (p = 0.006, p = 0.003, p < 0.001, and p = 0.0035, respectively). Pelvic floor anatomy was fully restored (POP-Q 0) for 29 (80%) patients after surgery. 17 patients (47%) suffered from urinary incontinence before surgery, which was restored in 13 patients (76.5%).

CONCLUSIONS

The interdisciplinary approach with L-RRP and L-SCP and the use of a BM in a small subgroup were technically feasible, safe, and effective in this single center setting. The study's retrospective design, the small sample size and the lack of comparators limit the generalizability of the findings requiring future randomized trials.

TRIAL REGISTRATION

Retrospectively registered at clinicaltrials.gov, trial number NCT05910021, date of registration 06/10/2023.

Specialty-Specific Trends in Surgery for Apical Pelvic Organ Prolapse Post Vaginal Mesh

IMPORTANCE

Since transvaginal mesh (VM) kits for apical pelvic organ prolapse (APOP) were labeled "high-risk" in 2016 and subsequently banned in 2019 by the U.S. Food and Drug Administration, the most common remaining surgical options include abdominal mesh-augmented sacrocolpopexy (AS) and transvaginal native tissue suspension (VN).

OBJECTIVE

The objective of this study was to determine temporal trends in APOP procedures for urologists and gynecologists.

STUDY DESIGN

Between 2011 and 2020, the American College of Surgeons National Surgical Quality Improvement Program database was queried for AS, VM, and VN.

RESULTS

There were 26,477 cases of APOP repair (32% AS, 6% VM, 62% VN) included, 9% by urologists. Urologists operated on older (65 vs 61 years) patients with more medical comorbidities. Urologists performed significantly higher proportion of AS (65% vs 29%) and VM (8% vs 6%) relative to VN (27% vs 65%) than gynecologists ( P < 0.0001). Transvaginal mesh utilization has decreased over time for both specialties ( P < 0.05); nonsignificant trends toward increasing AS ( P = 0.1646) in urologists and VN ( P = 0.0913) in gynecologists concurrently occurred. Significant independent predictors of the operating surgeon being a urologist were surgery being performed in the latter half of the cohort (2016-2020; odds ratio [OR], 1.22), non-White patient race (OR < 1 for all), a concomitant sling being placed (OR = 0.89), the surgery being VM (OR = 2.95) or AS (OR = 4.36), the patient being older (OR > 1 for each age range), and having a higher frailty index score (OR = 1.16).

CONCLUSIONS

Significant differences in APOP repair choices exist between specialties. Urologists operate on older, more medically complex patients while demonstrating a strong preference for mesh-augmented compared with transvaginal native tissue repairs.

Postoperative complications and unanticipated healthcare encounters following mini-laparotomy vs. laparoscopic/robotic-assisted sacrocolpopexy: a comparative retrospective study

BACKGROUND

Pelvic organ prolapse is a debilitating condition impacting lives of millions of women worldwide. Sacrocolpopexy (SCP) is considered an effective and durable surgical technique for treatment of apical prolapse. The aim of this study was to compare short-term outcomes including postoperative complications and unanticipated healthcare encounters between patients who underwent SCP with a mini-laparotomy approach compared to patients treated with laparoscopic and robotic-assisted laparoscopic SCP.

METHODS

This was a retrospective cohort study including patients treated for apical prolapse at a university affiliated urogynecology practice. Patients over the age of 18 who underwent abdominal SCP between 2019 and 2023 were included. The cohort was formed into two groups: (1) Patients who underwent SCP through a mini-laparotomy incision (Mini-lap group); (2) Patients who underwent laparoscopic or robotic-assisted laparoscopic SCP (Lap/Robot group).

RESULTS

A total of 116 patients were included in the final analysis. Ninety patients underwent either laparoscopic or robotic-assisted SCP, whereas 26 patients underwent SCP with a mini-laparotomy approach. Study participants exhibited a mean age of 63.1 ± 10.3 years, mean body mass index (BMI) of 25.8 ± 4.9 Kg/m2, and 77.6% of them identified as Caucasian. Upon comparison of demographic and past medical history between groups there were no statistically significant differences in age, BMI, menopausal status, race, parity or comorbid conditions. Patients in the Mini-lap group were less likely to have undergone previous abdominal surgery (11.5% vs. 50.6%, p < 0.001) and had more severe apical prolapse (stage 4 prolapse, 40% vs. 21.2%, p < 0.001) than their counterparts in the Lap/robot group. Regarding intraoperative parameters, length of surgery was significantly shorter in the Mini-lap group compared to the Lap/robot group (97.3 ± 35.0 min vs. 242.0 ± 52.6 min, p < 0.001). When focusing on the primary outcome, postoperative complications within the first 30 days after surgery, there were no differences noted between groups. Additionally, the number of unanticipated healthcare encounters, such as phone calls, clinic visits, emergency department visits, urgent care visits, readmissions and reoperations were similar between groups.

CONCLUSIONS

Mini-laparotomy approach for SCP is safe with comparable intra- and postoperative complications, and unanticipated healthcare encounters compared to conventional minimally invasive methods.

Comparison of transvaginal mesh surgery and robot-assisted sacrocolpopexy for pelvic organ prolapse

Background

Pelvic organ prolapse (POP) is greatly affecting the quality of life (QOL) of women. There are some surgical techniques for POP repair, for example, transvaginal mesh surgery (TVM), laparoscopic sacrocolpopexy (LSC), and robot-assisted sacrocolpopexy (RSC). In the United States and Europe, the number of TVM has rapidly decreased since 2011 due to complications and safety concerns and has shifted to LSC/RSC. In Japan, RSC has increased after the insurance coverage of RSC in 2020. Therefore, we compared the surgical outcomes of TVM and RSC in POP surgery.

Methods

We retrospectively collected POP surgery underwent TVM or RSC at our hospital and compared the operative time, blood loss, postoperative hospital stay, postoperative complications, and preoperative and postoperative stress urinary incontinence (SUI) of two groups. Preoperative and postoperative SUI were classified into 3 groups: “improved preoperative SUI”, “persistent preoperative SUI” and “de novo SUI”, which occurred for the first time in patients with no preoperative SUI, and compared incidence rate. The Mann–Whitney U test and Fisher’s exact test were used to compare the two groups, and P < 0.05 was considered statistically significant.

Results

From August 2011 to July 2021, 76 POP surgery was performed and they were classified into two groups: TVM group (n = 39) and RSC group (n = 37). There was no difference in patient age and BMI between the TVM and RSC groups. The median of operative time was 78.0 vs. 111.0 min (p = 0.06), blood loss was 20.0 ml vs. 5.0 ml (p < 0.05), and postoperative hospital stay was 4.0 days vs. 3.0 days (p < 0.05), with less blood loss and shorter postoperative hospital stay in the RSC group. There was no difference in postoperative complications between the TVM and RSC groups (17.9% vs. 16.2%, p = 1.00). De novo SUI was 25.6% vs. 5.4% (p < 0.05) in the TVM and RSC groups, of which 23.1% vs. 5.4% (p < 0.05) occurred within 3 months of surgery.

Conclusion

RSC is more beneficial and less invasive for patients with pelvic organ prolapse than TVM. In addition, de novo SUI as postoperative complication of RSC was lower than of TVM.

Short term complications in mesh augmented vaginal repair of pelvic organ prolapse are not higher when compared with native tissue repair

INTRODUCTION AND HYPOTHESIS

Accumulating evidence regarding the negative long-term consequences of transvaginal mesh-based procedures for pelvic organ prolapse has led to a sharp decline in mesh-based procedures. We aimed to evaluate the short-term complications of mesh-based procedures for carefully selected patients with pelvic organ prolapse after Food and Drug Administration warnings.

METHODS

A retrospective database review of the ACS NSQIP database was completed to examine 30-day complications including re-operation, prolonged length of stay, blood transfusion, surgical site infection, urinary tract infection, readmission and wound dehiscence in mesh-augmented and native tissue-based transvaginal procedures for pelvic organ prolapse.

RESULTS

A total of 36,234 patients were included in the analysis, with only 7.1% (2574 women) having mesh-augmented repair. Using a multivariable logistical regression analysis adjusting for confounders, we found that the primary composite outcome (re-operation, hospital stay, blood transfusion and surgical site infection) was less common in the mesh group compared with the native tissue repair group (adjusted OR 0.80, CI 0.67-0.95, p = 0.009). The secondary outcomes (urinary tract infection, re-admission and wound dehiscence) were not different between the group.

CONCLUSION

These results suggest that in well-chosen patients, short-term complications are not increased when using transvaginal mesh for pelvic organ prolapse repair.

New "Wrinkle Method" for Intracorporeal Anterior Vaginal Wall Plication during Sacrocolpopexy

In this study, we introduce a new wrinkle method for intracorporeal anterior vaginal wall plication during sacrocolpopexy for pelvic organ prolapse (POP) aiming to decrease POP recurrence and postoperative vaginal wall mesh erosion. The wrinkle method was performed using robotic sacrocolpopexy (RSC) on 57 symptomatic POP patients. Sixty-six patients underwent conventional RSC before the development of the wrinkle method. Feasibility and perioperative outcomes were compared. The wrinkle method is not time consuming. The total operative time was shorter in the wrinkle group than in the non-wrinkle group; however, this was attributed to lower adhesiolysis in the wrinkle group. No differences were recorded in the mean estimated blood loss and complication rates between the two groups. In conclusion, although we were unable to confirm that the wrinkle method decreased POP recurrence and vaginal wall mesh erosion after RSC because of the short follow-up period, our preliminary findings are positive in terms of safety. Further long-term well designed randomized controlled trials are required to elucidate the benefits of the wrinkle method.

Complications of Pelvic Organ Prolapse Surgery in the 2015 Finnish Pelvic Organ Prolapse Surgery Survey Study

OBJECTIVE

To describe the major complications of pelvic organ prolapse (POP) surgery in Finland.

METHODS

The Finnish Pelvic Organ Prolapse Surgery Survey 2015 study is a prospective cohort of POP surgeries performed in Finland in 2015. Perioperative, postoperative, and late complications during 1 year of follow-up were compared among native tissue repair, transvaginal mesh, and abdominal mesh surgery. Major complications were assessed using the Clavien-Dindo grading system. Predictive factors for major complications were studied with logistic regression analysis.

RESULTS

Within 1 year after POP surgery, 396 (11.2%) of 3,515 women had at least one complication: 10.9% after native tissue, 11.7% after transvaginal mesh, and 13.5% after abdominal mesh repair. The majority of complications occurred within 2 months after surgery and postoperative infection (4.3%) and bleeding or hematoma (2.6%) were the most frequent. The incidence of organ injuries was low. Mesh-augmented surgery was associated with significantly higher rates of bladder and bowel injuries than native tissue surgery. Complication-related reoperations occurred significantly more often after abdominal mesh repair than native tissue surgery (5.2% vs 1.8%, P=.001). Mesh-related complications were diagnosed more often after transvaginal mesh repair. The overall rate of major complications (Clavien-Dindo grades III-V) was 3.3%. Abdominal mesh surgery was associated with the highest rate of major adverse events (8.8% vs native tissue repair 2.6% and transvaginal mesh 4.9%). The incidence of Clavien-Dindo grade IV or V complications was rare (less than 0.6%). Mesh surgery (transvaginal mesh adjusted odds ratio [aOR] 2.23, 95% CI 1.31-3.80, and abdominal mesh aOR 3.02, 95% CI 1.67-5.46), longer operating time (aOR 2.84, 95% CI 1.78-4.53), prior POP surgery (aOR 1.68, 95% CI 1.00-2.81) and difficult surgery (aOR 2.75, 95% CI 1.63-4.62) were associated with an increased risk for occurrence of major complications.

CONCLUSION

Serious adverse events were rare regardless of the operative approach. However, mesh-augmented surgery was associated with higher risk for major complications.

Mesh exposure after transvaginal mesh prolapse surgery: Out of permissible range?

OBJECTIVES

To investigate the prevalence of postoperative complications after transvaginal mesh prolapse surgery, and whether modified transvaginal mesh prolapse surgery (without transobturator arms or posterior mesh) has less prevalence of mesh exposure compared with conventional transvaginal mesh prolapse surgery.

METHODS

Medical charts were retrospectively examined for 2648 patients who underwent transvaginal mesh prolapse surgery in a general hospital (2006-2017). Conventional transvaginal mesh prolapse surgery (Prolift-type, n = 2258) was used, with a shift from 2015 to modified transvaginal mesh prolapse surgery (Uphold-type, n = 330). Patients were instructed to have >2 years of follow up and to report if they had problems regarding the operation.

RESULTS

The prevalence of mesh exposure was 34 out of 2648 (1.28%); 18 vagina (0.68%), 10 bladder (0.38%), two ureter (0.08%) and four rectum (0.15%). The modified transvaginal mesh prolapse surgery group had only one case with vaginal exposure. Vaginal exposure was managed transvaginally or followed by observation. Rectal exposure was managed transvaginally without colostomy. Bladder exposure was managed by transurethral resection with saline. Open ureterocystostomy was carried out to treat ureteral exposure. In the conventional transvaginal mesh prolapse surgery group, three cases of ureteral stenosis and one case with vaginal evisceration of the small intestine were managed transvaginally. The prevalence of postoperative chronic pain was 13 out of 2648 (0.49%; with one patient in the modified transvaginal mesh prolapse surgery group). The patients underwent pharmacotherapy, and one patient underwent additional surgical treatment.

CONCLUSIONS

The reoperation rate as a result of complications after transvaginal mesh prolapse surgery seems to be low. The reoperation rate as a result of prolapse recurrence is also low. A shift from conventional transvaginal mesh prolapse surgery to modified transvaginal mesh prolapse surgery might contribute to a further decrease in the risk of complications.

Sacrocolpopexy compared with transvaginal mesh surgery: a systematic review and meta-analysis

BACKGROUND

The use of mesh is controversial in the treatment of female pelvic organ prolapse.

OBJECTIVES

To systematically review the outcomes of sacrocolpopexy compared with transvaginal mesh surgery and to provide evidence-based suggestions.

SEARCH STRATEGY

The MEDLINE, EMBASE, Cochrane Library and clinicaltrials.gov databases were searched on 21 November 2018.

SELECTION CRITERIA

Randomised controlled trials and prospective and retrospective cohort studies were included.

DATA COLLECTION AND ANALYSIS

Data were extracted by one reviewer and examined by a second reviewer for accuracy. Odds ratios and 95% CI were calculated using random-effects models.

MAIN RESULTS

Twenty comparative studies were included. The meta-analysis was performed with subgroups. The summary odds ratios of the randomised controlled group were 1.84 (95% CI 0.79-4.29, I²  = 75%) for anatomical success, 1.41 (95% CI 0.47-4.24, I²  = 38%) for subjective success, 0.42 (95% CI 0.18-0.98, I²  = 0%) for mesh complications, 0.61 (95% CI 0.20-1.91, I²  = 0%) for prolapse reoperation and 0.44 (95% CI 0.23-0.88, I²  = 0%) for de novo dyspareunia. The mean differences were 0.77 (95% CI 0.31-1.23, I²  = 66%) for total vaginal length and -1.28 (95% CI -2.00 to -0.55, I²  = 66%) for point C after surgery.

CONCLUSIONS

Very-low-quality evidence indicated that the anatomical and subjective success rates of sacrocolpopexy were similar to those of transvaginal mesh surgery; sacrocolpopexy might be more beneficial than transvaginal mesh surgery in terms of mesh-related complication rates, prolapse recurrence and de novo dyspareunia. However, additional high-quality randomised trials with long-term follow-up durations are needed.

TWEETABLE ABSTRACT

Sacrocolpopexy is beneficial after surgical anatomical changes and has decreased rates of mesh-related complications and dyspareunia.

Outcomes of nerve-sparing laparoscopic sacropexy on one hundred fifteen cases

STUDY OBJECTIVE

To evaluate the postoperative anatomic and functional outcomes of patients who underwent laparoscopic nerve-sparing sacrocolpopexy or sacrocervicopexy for pelvic organ prolapse (POP) POP-Q stage III and IV apical prolapse, and to delineate the contributing factors for recurrence.

STUDY DESIGN AND CLASSIFICATION

The file records of patients who underwent sacropexy in the last five years were reviewed retrospectively and compared in terms of preoperative and postoperative anatomic findings and symptoms.

PATIENTS

Patients who underwent laparoscopic nerve-sparing surgery for treatment of POP-Q Stage III and IV/prolapse of uterine or vaginal cuff were included.

INTERVENTIONS

Postoperative anatomic and functional outcomes were evaluated using POP-Q classification and urinary/anal function by questioning during visits.

RESULTS

The mean follow-up duration was 24.2 ± 17.6 months. Anatomic recovery was achieved in 104 (90.4 %) cases. Advanced age (≥70 years), longer duration of symptoms, and low body mass index were determined as parameters related to recurrence risk.

Robotic-assisted repair of pelvic organ prolapse: a scoping review of the literature

The purpose of this article is to perform a scoping review of the medical literature regarding the efficacy, safety, and cost of robotic-assisted procedures for repair of pelvic organ prolapse in females. Sacrocolpopexy is the “gold standard” repair for apical prolapse for those who desire to maintain their sexual function, and minimally-invasive approaches offer similar efficacy with fewer risks than open techniques. The introduction of robotic technology has significantly impacted the field, converting what would have been a large number of open abdominal sacrocolpopexy (ASC) procedures to a minimally-invasive approach in the United States. Newer techniques such as nerve-sparing dissection at the sacral promontory, use of the iliopectineal ligaments and natural orifice vaginal sacrocolpopexy may improve patient outcomes. Prolapse recurrence is consistently noted in at least 10% of patients regardless of route of mesh placement. Ancillary factors including pre-operative prolapse stage, retention of the cervix, type of mesh implant, and genital hiatus (GH) size all adversely affect surgical efficacy, while trainees do not. Minimally-invasive apical repair procedures are suited to early recovery after surgery protocols but may not be appropriate for all patients. Studies evaluating longer-term outcomes of robotic sacrocolpopexies are needed to understand the relative risk/benefit ratio of this technique. With several emerging robotic platforms with improved features and a focus on decreasing costs, the future of robotics seems bright.

Laparoscopic Long Mesh Surgery with Augmented Round Ligaments: A Novel Uterine Preservation Procedure For Apical Pelvic Organ Prolapse

We aim to assess the surgical outcomes of our novel hysteropexy procedure, laparoscopic long mesh surgery (LLMS) with augmented round ligaments. Twenty-five consecutive women with stage II or greater main uterine prolapse defined by the POP quantification staging system were referred for LLMS. Long mesh is a synthetic T-shaped mesh, with the body fixed at the uterine cervix and the two arms fixed along the bilateral round ligaments. The clinical evaluations performed before and 6 months after surgery included pelvic examinations, urodynamic studies, and questionnaires for urinary and sexual symptoms. After a follow-up time of 12 to 24 months, the anatomical reduction rate was 92% (23/25) for the apical compartment. The average operative time was 65.4  ±  28.8 minutes. No major complications were recognized during LLMS. The lower urinary tract symptoms and scores on the questionnaires improved significantly after the surgery, except urgency urinary incontinence and nocturia. Neither voiding nor storage dysfunction was observed after the operations. All of the domains and total Female Sexual Function Index (FSFI) scores of the 15 sexually active women did not differ significantly after LLMS. The results of our study suggest that LLMS is an effective, safe, and time-saving hysteropexy surgery for the treatment of apical prolapse.

Laparoscopic management of pelvic organ prolapse recurrence after open sacrocervicopexy

In this narrated video we present a case of pelvic organ prolapse (POP) recurrence 12 years after sacrocervicopexy, outline our management and suggest an optimal laparoscopic surgical technique that may reduce the risk of future recurrence. A 71-year-old patient, who had undergone an open sub-total hysterectomy with sacrocervicopexy 12 years previously, complained of a bulging sensation in her vagina, of 12 months' duration. On physical examination, a Pelvic Organ Prolapse Quantification (POP-Q) stage III prolapse was diagnosed, with marked apical, anterior and posterior compartment prolapse. On laparoscopy we identified the old mesh attached to the promontory and to the vaginal apex, without any fixation of the vaginal walls. Complete mesh excision was performed, followed by vaginal dissection to facilitate implantation of two new meshes and performing a new sacrocolpopexy. No postoperative complications occurred. Over 6 weeks of post-operative follow-up, there was no pelvic pain, dysuria or dyschezia. A good anatomical result was noted without any prolapse. Laparoscopy appears to be an effective approach to complete mesh excision. For the treatment of prolapse recurrence, complete excision of the old mesh with new pelvic mesh-augmented reconstruction is recommended. Thorough dissection of the vesico-vaginal and recto-vaginal spaces followed by mesh fixation to the relevant vaginal walls may reduce recurrence.

Current Treatments for Female Pelvic Floor Dysfunctions

As global population aging, the issue of pelvic floor dysfunctions becomes increasingly. Millions of women were affected every year. The treatment of pelvic floor dysfunction has evolved in the past decade. This review aims to provide the current information on the treatment for female pelvic floor dysfunction, including pelvic organ prolapse (POP), urinary, fecal incontinence (FI), and myofascial pelvic pain among women. We used PubMed, Embase, and Web of Science to search for studies that were related to pelvic floor dysfunction regarding the POP, urinary, FI, and treatments. The development of laparoscopic surgery and synthetic and biological materials for pelvic floor reconstructive surgery were summarized. The surgical outcomes and complications of different pelvic floor reconstructive surgeries were compared. New devices for FI and the potential modified pelvic floor reconstructive surgery were also discussed here. Female pelvic medicine will continue to evolve for better treatment in the future. The pelvic floor reconstructive surgery tends to be minimally invasive approach with synthetic graft use.

Long-term mesh erosion rate following abdominal robotic reconstructive pelvic floor surgery: a prospective study and overview of the literature

Introduction and hypothesis

The use of synthetic mesh in transvaginal pelvic floor surgery has been subject to debate internationally. Although mesh erosion appears to be less associated with an abdominal approach, the long-term outcome has not been studied intensively. This study was set up to determine the long-term mesh erosion rate following abdominal pelvic reconstructive surgery.

Methods

A prospective, observational cohort study was conducted in a tertiary care setting. All consecutive female patients who underwent robot-assisted laparoscopic sacrocolpopexy and sacrocolporectopexy in 2011 and 2012 were included. Primary outcome was mesh erosion. Preoperative and postoperative evaluation (6 weeks, 1 year, 5 years) with a clinical examination and questionnaire regarding pelvic floor symptoms was performed. Mesh-related complications were assessed using a transparent vaginal speculum, proctoscopy, and digital vaginal and rectal examination. Kaplan–Meier estimates were calculated for mesh erosion. A review of the literature on mesh exposure after minimally invasive sacrocolpopexy was performed (≥12 months’ follow-up).

Results

Ninety-six of the 130 patients included (73.8%) were clinically examined. Median follow-up time was 48.1 months (range 36.0–62.1). Three mesh erosions were diagnosed (3.1%; Kaplan–Meier 4.9%, 95% confidence interval 0–11.0): one bladder erosion for which mesh resection and an omental patch interposition were performed, and two asymptomatic vaginal erosions (at 42.7 and 42.3 months) treated with estrogen cream in one. Additionally, 22 patients responded solely by questionnaire and/or telephone; none reported mesh-related complaints. The literature, mostly based on retrospective studies, described a median mesh erosion rate of 1.9% (range 0–13.3%).

Conclusions

The long-term rate of mesh erosion following an abdominally placed synthetic graft is low.

Electronic supplementary material

The online version of this article (10.1007/s00192-019-03990-1) contains supplementary material, which is available to authorized users

Methods of surgery for pelvic organ prolapse in a nationwide cohort (FINPOP 2015)

INTRODUCTION

The management of pelvic organ prolapse (POP) varies significantly between countries. The objective of this study was to describe the methods used for POP surgery in Finland and to identify the factors that affect clinicians' choice to use either a native tissue repair (NTR) or a mesh repair method.

MATERIAL AND METHODS

This prospective cohort study included 3535 surgeries covering 83% of all POP operations performed in Finland in 2015. The operative details and patient characteristics, including the Pelvic Floor Distress Inventory (PFDI-20), were compared between three selected surgical methods: NTR, transvaginal mesh (TVM) and abdominal mesh (AM). The predictive factors for the use of mesh augmentation were also studied with logistic regression analysis.

RESULTS

The most common method was NTR (n = 2855, 81%), followed by TVM (n = 429, 12%) and AM (n = 251, 7%). Approximately 92% of the patients who underwent primary prolapse surgery underwent NTR, and mesh surgery was used mainly for recurrent prolapse. The strongest predictor of mesh surgery was previous POP surgery for the same vaginal compartment (adjusted odds ratio [OR] = 56, 95% confidence interval [CI] = 38-84 for TVM; adjusted OR = 22, 95% CI = 14-34 for AM). Other predictive factors for mesh surgery were previous hysterectomy, healthcare district, severe bulge symptoms and advanced prolapse. TVM was associated with advanced anterior prolapse and older age. AM surgery was associated with advanced apical and/or posterior compartment prolapse. PFDI-20 scores were the highest in the AM group (108 vs 103 in the TVM group and 98 in the NTR group, P = 0.012), which indicates more bothersome symptoms than in the other groups.

CONCLUSIONS

The Finnish practices follow international guidelines that advocate NTR as the principal surgical method for POP. Synthetic mesh augmentation was mainly used in patients with recurrent and advanced prolapse with severe symptoms. The variation in the rates of mesh augmentation for POP surgery in different hospitals implies a lack of sufficient evidence of the most suitable treatment method and indicates a need for national guidelines.

[LSC (LAPAROSCOPIC SACROCOLPOPEXY) VERSUS UPHOLD TYPE TVM: A CASE CONTROL STUDY]

(Objective) The comparative analysis of post-surgery condition of lower urinary tract symptoms of LSC and Uphold-type TVM. (Methods) Since August 2015, our hospital introduced LSC and launched Uphold-type TVM in May 2017. 25 cases were examined by December 2017. In comparison with 37 cases of LSC conducted simultaneously, OABSS, IPSS, ICIQ-SF as well as uroflowmetry and residual urine measurement were performed with focus on perioperative complications and postoperative (3 months) lower urinary tract symptoms. As can be observed from the patient background, the average age of subject patients were close to 77 years old for TVM group, 70 years old for LSC group. LSC group showed a tendency to be observed among younger patients. (Result) In Stage II of Pelvic organ prolapse quantification (POP-Q) most of the mild cases (8 cases in TVM group and 3 cases in LSC group) existied. The type of pelvic organ prolapse (most protruding part) was bladder. Many cystoceles in the TVM group (15 cases in the TVM group and 10 cases in the LSC group) were observed. The average operation time was 115 minutes in the TVM group and 214 minutes in the LSC group which was longer. The average bleeding amount was 54 ml in the TVM group and 10 ml in the LSC group, which was quite small. For the intraoperative complication, in 2 cases bleeding volume 100 ml or more were observed in the TVM group. Bladder injury was found in 1 case. (Conclusion) Regarding postoperative complications, one case of vaginal erosion in TVM group, one case of port suture failure in LSC group, one case of de novo OAB were observed respectively. OABSS, total urinary urgency, IPSS, residual urine were improved in both groups. Both types of surgery are expected to improve lower urinary symptoms and considered to be a useful tool for treatment of pelvic organ prolapse.

Pelvic Pain and Apical Prolapse Surgery: A Population-Based Retrospective Cohort Study

OBJECTIVES

The aims of this study were to evaluate the association of preoperative pelvic pain with operative characteristics and the association of patient and operative characteristics with postoperative pain.

METHODS

This is a retrospective cohort study utilizing Clinformatics DataMart, a large national commercial insurance database. We collected data for patients older than 18 years who underwent apical prolapse surgery between January 2005 and December 2014. We stratified data by preoperative (prior) pain and analyzed for associations of prior and postoperative pain. Logistic regression analysis was performed using SAS software.

RESULTS

A total of 14,440 patients met inclusion criteria and were analyzed. Patients with prior pain were more likely to have an abdominal (open or laparoscopic) approach, a concomitant hysterectomy, but less likely to have additional repairs or a mesh insertion (P < 0.001). Postoperative pain was less with a concomitant hysterectomy, whether they had prior pain (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.41-0.77) or not (OR, 0.68; 95% CI, 0.56-0.82). Additional vaginal repairs were associated with more postoperative pain for those without prior pain (OR, 1.63; 95% CI, 1.3-2.04). Age older than 45 years was associated with less pain. Length of hospital stay of more than 2 days was associated with more pain.

CONCLUSIONS

Patients with prior pain were more likely to undergo an abdominal approach and have a concomitant hysterectomy. Postoperative pain was less with a concomitant hysterectomy, but more with additional vaginal repairs. There is a need to include pain as an outcome in future studies, particularly clinical trials.

The use of synthetic mesh for vaginal prolapse in the UK: a review of cases submitted to the British Society of Urogynaecology database

INTRODUCTION AND HYPOTHESIS

The use of mesh for vaginal prolapse gained popularity during the 1990s. More recently, concerns have been raised regarding the safety of mesh procedures. Mesh can be inserted vaginally, laparoscopically or via an open abdominal route, but there are few data comparing the outcomes. Most previous published data relate to small numbers of procedures.

METHODS

This was a review of data submitted to the British Society of Urogynaecology (BSUG) database of all cases reporting the use of mesh placed vaginally or abdominally (open or laparoscopic) between January 2006 and December 2016. The primary outcome was based on the reported patient global impression of improvement (PGI-I).

RESULTS

A total of 6,709 cases of mesh prolapse repair were entered during the study period. Women in the laparoscopic group had a lower BMI and were younger. Significantly more patients in the open group (96.4%) described themselves as very much better or much better compared with the laparoscopic group (91%) and the vaginal mesh group (90.7%; p < 0.001). Only 0.5% of patients reported that they were worse or very much worse.

CONCLUSIONS

This dataset suggests that the effectiveness of mesh repair might be good regardless of the route of insertion. The improvement in PGI-I seems to be greatest with open sacrocolpopexy.

[POSTOPERATIVE CHRONIC PAIN FOLLOWING MESH AND NON-MESH REPAIR OF PELPIC ORGAN PROLAPSE]

(Objective) A FDA alert in 2011 warned about postoperative chronic pain following transvaginal mesh (TVM) for pelvic organ prolapse (POP). We studied cases with chronic pain after TVM, natural tissue repair (NTR) and laparoscopic salcocopopexy (LSC). (Methods) We retrospectively reviewed medical charts of patients who underwent POP operations in our hospital or were referred to us after POP operations in other hospitals between 2006 and 2016. Postoperative chronic pain was defined as persistent pain for more than three months following the first three months from the time of POP operations.Patients' characteristics and treatments were analyzed. (Results) In patients who underwent POP operations in our hospital, the rates of chronic postoperative pain after TVM, NTR and LSC were 12/2,457 (0.49%), 1/402 (0.26%) and 0/29 (0%), respectively. Another 8 patients were referred to us after POP operations in other hospitals. Thus, a total of 21 patients (15: TVM, 6: NTR) had either medications, surgical treatment or were referred to other doctors due to postoperative chronic pain. All of them were parous women aged 53 to 81 years old. Preoperative chronic pelvic pain was found in seven patients (33%), and another four patients (19%) had orthopedic diseases with chronic pain. The main locations of pain were; vagina 11, vulva 2, urinary bladder 2, urethra 1, coccyx 1, buttocks 1, anus 1, perineum 1 and groin 1. Nineteen patients had pharmacological treatment using tricyclic antidepressants, Ca²⁺ channel α₂δ ligand and/or serotonin-noradrenalin reuptake inhibitor (SNRI); 9 (47%) of the patients showed a notable improvement. Three patients following TVM had surgical treatment; one with bladder mesh exposure was resolved with TURis, one with vaginal mesh exposure was resolved with mesh trimming, but one with tenderness on the mesh arm did not improve after a partial mesh removal. Four patients were referred to pain clinics. (Conclusions) Postoperative chronic pain can occur following both TVM and NTR therefore, attentive listening and proper medication are important as initial therapies. It is mandatory to examine the presence of mesh exposure in patients after using mesh. We should be careful about preoperative chronic pain, pelvic or elsewhere, as a risk factor for postoperative chronic pain.

Current trends and future perspectives in pelvic reconstructive surgery

Pelvic organ prolapse is a prevalent disorder with a high lifetime incidence of surgical repair. Pelvic organ prolapse surgery has greatly evolved over the past years, and pelvic floor reconstructive surgeons are faced with a vast array of treatment options for their patients. Our review article illustrates the current trends and future perspectives for the surgical treatment of pelvic organ prolapse.