Clinical predictors and risk factors for vaginal mesh extrusion

Dysregulated wound healing in the pathogenesis of urogynecologic mesh complications

To test the hypothesis that dysregulated wound healing is associated with Urogynecologic mesh complications, we collected vaginal cell secretions using vaginal swabs after polypropylene mesh implantation in patients with (N = 39) and without (N = 40) complication. A customized multiplex immunoassay measured markers of inflammation (MCP-1, IGFBP-1, IL-2, IL-10, IL-17, PDGF-BB, bFGF, IL-1b, IL-6, IL-12p70, TNF-α), neuroinflammation (IL-1RA, TGF-β, IL-15, IL-18, IL-3, M-CSF), angiogenesis (VEGF), and matrix proteins (fibronectin, tenasin c, thrombospondin-2, lumican) between groups. Patients with complications were younger, heavier, implanted with mesh longer, and more likely to be ever smokers. A 5 kg/m2 BMI increase and ever-smoking were associated with a 2.4-fold and sixfold increased risk of complication, respectively. Patients with the highest tertile of bFGF, fibronectin, thrombospondin-2, TNF-β, or VEGF had an odds ratio (OR) of 11.8 for having a mesh complication while ≥ 3 elevated had an OR of 237 while controlling for age, BMI, and smoking. The highest tertile of bFGF, thrombospondin-2, and fibronectin together perfectly indicated a complication (P < 0.0001). A receiver-operator curve for high bFGF, thrombospondin-2, and fibronectin showed excellent discrimination between complications and controls (AUC 0.87). These data provide evidence of dysregulated wound healing in mesh complications. Modifiable factors provide potential targets for patient counseling and interventions.

Review of Vaginal Approaches to Apical Prolapse Repair

PURPOSE OF REVIEW

To review recent literature and provide up-to-date knowledge on new and important findings in vaginal approaches to apical prolapse surgery.

RECENT FINDINGS

Overall prolapse recurrence rates following transvaginal apical prolapse repair range from 13.7 to 70.3% in medium- to long-term follow-up, while reoperation rates for prolapse recurrence are lower, ranging from 1 to 35%. Subjective prolapse symptoms remain improved despite increasing anatomic failure rates over time. The majority of studies demonstrated improvement in prolapse-related symptoms and quality of life in over 80% of patients 2-3 years after transvaginal repair, with similar outcomes with and without uterine preservation. Contemporary studies continue to demonstrate the safety of transvaginal native tissue repair with most adverse events occurring within the first 2 years. Transvaginal apical prolapse repair is safe and effective. It is associated with long-term improvement in prolapse-related symptoms and quality of life despite increasing rates of prolapse recurrence over time. Subjective outcomes do not correlate with anatomic outcomes.

Predictors of Clinical Outcome in Women with Pelvic Organ Prolapse Who Underwent Transvaginal Mesh Reconstruction Surgery

Background and Objectives: To identify the predictors of clinical outcomes in women with pelvic organ prolapse (POP) who underwent transvaginal reconstruction surgery, especially with transobturator mesh fixation or sacrospinous mesh fixation. Materials and Methods: All women with POP who underwent transvaginal reconstruction surgery, especially with transobturator mesh fixation or sacrospinous mesh fixation, were reviewed. Results: Between January 2011 and May 2019, a total of 206 consecutive women were reviewed, including 68 women receiving POP reconstruction with transobturator mesh fixation and 138 women who underwent POP reconstruction with sacrospinous mesh fixation. The least experienced surgeon (hazard ratio = 804.6) and advanced stage of cystocele (hazard ratio = 8.80) were the predictors of POP recurrence, especially those women with stage 4 of cystocele. Young age (hazard ratio = 0.94) was a predictor for mesh extrusion, especially those women with age ≤67 years. Follow-up interval (odds ratio = 1.03, p = 0.02) was also an independent predictor of mesh extrusion. High maximum flow rate (Qmax, hazard ratio = 1.03) was the sole predictor of postoperative stress urinary incontinence, especially those women with Qmax ≥19.2 mL/s. Preoperative overactive bladder syndrome (hazard ratio = 3.22) were a predictor for postoperative overactive bladder syndrome. In addition, overactive bladder syndrome rate improved after surgery in the sacrospinous group (p = 0.0001). Voiding dysfunction rates improved after surgery in both sacrospinous and transobturator groups. Conclusions: Predictors of clinical outcome in women who underwent transvaginal POP mesh reconstruction are identified. The findings can serve as a guide for preoperative consultation of similar procedures.

Wound dehiscence prevalence and relationship with prosthetic material extrusion in women underwent anterior colpotomy

AIM

To assess the prevalence of anterior vaginal wall dehiscence in women who underwent anterior vaginal wall colpotomy for pelvic organ prolapse or stress urinary incontinence and to evaluate the influence of suture materials and techniques on wound dehiscence.

MATERIALS AND METHODS

This multicenter, prospective study enrolled naïve women for urogynecological surgery affected by anterior vaginal wall defect or stress urinary incontinence. Performed surgical procedures were anterior vaginal wall repair (AVWR) with native tissue (N-AVWR) or polypropylene mesh (M-AVWR), trans-obturator polypropylene in-out middle urethral sling (MUS). Used suture materials were Vicryl 2-0, Vicryl Rapide 2-0, and Monocryl 3-0. Suture techniques were running interlocking or interrupted. Follow-up was performed daily during hospitalization and in outpatient clinic after 10-14, 30 days, and after 3 months.

RESULTS

A total of 1139 patients were enrolled. AVWR were 790: 89.1% N-AVWR, and 10.9% M-AVWR. Polypropylene MUS were 349. Women with prosthetic implantation were 38.2%, while 61.8% had native tissue repair. Overall Vicryl was used in 53.9%, Vicryl Rapide in 37.4%, and Monocryl in 8.7%. Overall running interlocking sutures were 66.5%, while interrupted were 33.5%. Overall wound dehiscence prevalence was 0.9% (10/1139). Wound dehiscence rate of 0.6% (5/790) was documented in AVWR: 0.3% (2/704) in N-AVWR, and 3.5% (3/86) in M-AVWR. Among women underwent MUS, 1.4% (5/349) showed wound dehiscence. In patients who underwent prosthetic surgery, the overall dehiscence prevalence was 1.8% (8/435). A statistically significant higher rate of wound dehiscence was found in women with implanted prosthetic materials.

DISCUSSION

We reported for the first time the prevalence of wound dehiscence in females who underwent colpotomy for AVWR or MUS. Wound dehiscence occurrence was low, but non-negligible. We found that this complication was poorly associated to the suture methods and materials, while prosthetic material represented a risk factor for wound healing.

Comparison of the efficiency of partial versus subtotal mesh removal on urogenital distress and sexual functions after stress urinary incontinence surgery

OBJECTIVE

To compare the efficiency of the partial mesh removal (PMR) versus subtotal mesh removal (SMR) on urogenital distress and sexual functions in patients who experienced vaginal mesh extrusion.

MATERIAL AND METHODS

Between June 2014 and January 2018, 45 patients who experienced vaginal mesh extrusion following midurethral sling surgeries and therefore underwent mesh excision were evaluated retrospectively. The effectiveness of PMR and SMR was compared using the "Urinary Distress Inventory-6 (UDI-6)" and "Female Sexual Function Index (FSFI)" forms, at the 6th month postoperatively.

RESULTS

Fourteen PMR-patients and 21 SMR-patients who met the study criteria were evaluated for the study. There was a significant improvement in UDI-6 scores and FSFI scores in both PMR and SMR groups at the 6^th month postoperatively (p=0.001, p=0.001, p=0.001, and p=0.001, respectively). When the two groups were compared in terms of improvement rates, there was no significant difference in UDI-6 scores [(-)30.21±6.56% vs. (-)26.33±9.01%, p=0.222]. However, there was a statistically significant improvement in the FSFI scores in the SMR group [(+)83.71±14.81% vs. (+)124.42±36.82%, p=0.001]. There was no significant difference in overactive bladder symptoms between the two groups, with a decrease of 75% in the PMR group and 71.42% in the SMR group (p=0.721). Recurrent stress urinary incontinence was observed in two (14.2%) patients in the PMR group and four (19.1%) patients in the SMR group at the 6th month postoperatively (p=0.544).

CONCLUSION

In cases where extrusion is developed, subtotal/total mesh removal provides a significant improvement in patients' complaints of sexual dysfunction related to extrusion.