Complications related to use of mesh implants in surgical treatment of stress urinary incontinence and pelvic organ prolapse: infection or inflammation?

Distinct impacts of aging on the immune responses to extracellular matrix-based versus synthetic biomaterials

All implanted materials inevitably trigger an acute inflammatory response. The long-term outcome, however, is dependent on the trajectory of this response. This study investigates the effects of aging on the immune response to two commercially available biomaterials. Extracellular matrix-based urinary bladder matrix (UBM) and synthetic polypropylene mesh (PPM) were implanted in young (4 months) and aged (18 months) C57BL/6J mice. Overall, PPM led to a sustained inflammatory response regardless of the age of the mice. In contrast, UBM induced an initial inflammatory response that matured into a pro-regenerative/remodeling response with time, though aged mice exhibited a delayed resolution of inflammation. The PPM-induced response was predominantly pro-inflammatory with consistently higher M1-like macrophage phenotype, whereas the response to UBM was characterized by an anti-inflammatory M2-like phenotype, especially in young mice. RNA sequencing revealed marked age-related differences in gene transcription. At day 7 post-implantation, the young mice with UBM showed a robust upregulation of both pro- and anti-inflammatory pathways as compared to young mice implanted with PPM, however, by day 14, the gene expression profile transitioned into an anti-inflammatory profile. Intriguingly, in aged mice, the response to UBM was distinct with consistent downregulation of inflammatory genes compared to PPM, while the response to PPM in both young and aged animals was largely consistent. Upstream analysis identified cytokines as key drivers of the host response, with IL-4 and IL-13 in young mice, and TNF-α and IL-1β driving chronic inflammation in aged mice. These findings highlight the importance of host age in biomaterial outcome, and the potential of ECM-based materials to mount a favorable response even in the presence of age-related immune dysregulation.

[Management of complications in reconstructive pelvic floor surgery]

Reconstructive pelvic floor surgery offers a wide range of surgical options for treating urinary incontinence, organ prolapse and other pelvic floor disorders. The aim is always to choose the safest and most effective procedure to improve the quality of life of those affected. In addition to expertise in making the appropriate diagnosis and surgical experience, knowledge of how to deal with complications is always essential. When categorising complications, a distinction is made between early and late complications, intraoperative and postoperative complications, and general and procedure-specific complications. If complications arise, conservative and surgical treatment options should be known. The starting point here is adequate diagnostics, which may include basic examinations, sonography, endoscopy and imaging techniques. The aim is to be able to accurately assess the extent of the complication in order to choose the appropriate therapy-preferably conservative methods. Particular challenges in the management of complications in reconstructive pelvic floor surgery are posed by complications with foreign materials. Surgical complication management can be very complex, requires a high level of surgical expertise and may also require an interdisciplinary approach. Gaining expertise in managing complications, whether conservative or surgical methods, can be challenging, especially when aiming to avoid causing those complications yourself. Thus, the best complication management is preventive: knowing the patient well, diagnosing the disease precisely and knowing one's own limits!

Comparison of short-term clinical efficacy and safety between biological and synthetic meshes in laparoscopic hiatal hernia repair: a single-center randomized controlled trial

BACKGROUND

The optimal choice of mesh material in laparoscopic hiatal hernia repair (LHHR) is debated. This study aimed to compare the short-term clinical efficacy and safety of biological versus synthetic meshes in LHHR.

METHODS

In a prospective, single-center randomized controlled trial conducted from January 2020 to December 2022, 124 patients undergoing LHHR were enrolled and randomly assigned to either the biological mesh group (n = 62) or the synthetic mesh group (n = 62). The biological mesh group received non-crosslinked biological mesh, while the synthetic mesh group received polypropylene anti-adhesion mesh for hiatal closure reinforcement. Randomization was computer-generated. Baseline characteristics were collected, and patients were followed up at 6, 12, and 18 months postoperatively through telephone interviews or outpatient visits. The primary outcome was the recurrence rate of hiatal hernia, assessed by gastroscopy and upper gastrointestinal contrast radiography. Secondary outcomes included symptom improvement evaluated using the Visual Analog Scale (VAS) and the Short Form-36 (SF-36) Health Survey Questionnaire, as well as quality of life improvements. The safety of mesh was assessed by recording mesh-related complications.

RESULTS

Baseline characteristics were comparable between the two groups. At 18 months, the recurrence rate was 1.92% in the synthetic mesh group and 9.26% in the biological mesh group (P = 0.225). At 6 months, the biological mesh group reported significantly less early satiety compared to the synthetic mesh group (0.35 ± 1.09 vs. 0.95 ± 1.99; P = 0.046). Conversely, at 18 months, early satiety was lower in the synthetic mesh group compared to the biological mesh group (0.31 ± 1.35 vs. 1.04 ± 2.21; P = 0.043). No significant differences were observed between the groups for other symptoms or SF-36 domains at any time point (all P > 0.05). Both groups showed significant improvements in some symptoms and quality of life from preoperative to postoperative assessments (P < 0.05). No mesh-related complications were reported in either group throughout the 18-month follow-up period.

CONCLUSIONS

Both biological and synthetic meshes are effective and safe for use in LHHR, demonstrating similar recurrence rates and improvements in symptoms and quality of life over an 18-month period. The choice of mesh may influence early satiety at different postoperative intervals, suggesting that individualized mesh selection based on patient-specific factors may enhance postoperative outcomes.

Infection-Resistant Polypropylene Hernia Mesh: Vision & Innovations

The surgical repair of hernias, a prevalent condition affecting millions worldwide, has traditionally relied on polypropylene (PP) mesh due to its favorable mechanical properties and biocompatibility. However, postoperative infections remain a significant complication, underscoring the need for the development of infection-resistant hernia meshes. This study provides a comprehensive analysis of current advancements and innovative strategies aimed at enhancing the infection resistance of PP mesh. It presents an overview of various research efforts focused on the integration of antimicrobial agents, surface modifications, and the development of bioactive coatings to prevent bacterial colonization and biofilm formation. Additionally, the synergistic effects of novel material designs and the role of nanotechnology in optimizing the anti-infective properties of PP mesh are explored. Recent clinical outcomes and in vitro studies are critically examined, highlighting challenges and potential future directions in the development of next-generation hernia meshes. Emphasis is placed on the importance of interdisciplinary approaches in advancing surgical materials with the ultimate goal of improving patient outcomes in hernia repair.

Gelatin Multiwalled Carbon Nanotube Composite 3D Printed Semi Biological Mesh for Abdominal Hernia Treatment

Hernia is characterized by the protrusion of organs or tissue through weakened areas in the abdominal cavity wall. A common treatment for hernia involves the implantation of a mesh which promotes the growth of new tissue around or within the implanted material in the damaged area. The mesh is typically made from synthetic materials like polypropylene. However, such meshes have safety concerns like biofilm and scar tissue formation, foreign body reactions, and chronic pain. These concerns gave rise to the development of biological meshes. Owing to mechanical weakness, biological meshes fail due to migration and rapid degradation. This study is aimed to develop a mechanically viable biopolymer-based composite degradable mesh. A gelatin-MWCNT composite 3D printed mesh has been developed with different pore sizes and filament sizes. Adding MWCNTs improved the composite's ductility, printability, hydrophilicity, and modulus, and reduced its degradation rate. The 3D-printed mesh also showed signs of cell attachment and proliferation representing non-toxicity of MWCNTs within the composite materials. The data showed improved cell adherence due to the incorporation of MWCNTs within the composite materials. Among the various material compositions tested, the composite material with gelatin with 0.01 g MWCNTs gave the optimum mechanical strength and biocompatibility results.

Long-term outcomes of transvaginal mesh surgery for pelvic organ prolapse at a single center in Japan

OBJECTIVES

This study aimed to investigate the long-term effectiveness and safety of transvaginal mesh surgery for pelvic organ prolapse at a high-volume center in Japan.

METHODS

Patients who underwent transvaginal mesh surgery between March 2010 and August 2015 were included and followed up for 5 years. As no mesh kits were available in our country, we used a self-cut polypropylene mesh (Japanese-style transvaginal mesh) for the procedures. Objective anatomical restoration and complications were evaluated during outpatient examinations.

RESULTS

Overall, 711 patients were included in this study. Over 5 years, the recurrence rate of stage 2 or higher prolapse at the operated compartment was 8.6% (61 cases), whereas that at the other compartments was 12.8% (91 cases). The frequency of recurrence was highest at 3 months and decreased with each passing year in both compartments. During the follow-up period, 28 patients (three at the operated compartment and 25 at the other compartments) required reoperation owing to recurrence. Overall, there were 13 cases of mesh exposure (1.8%), including two (0.28%) in the bladder, 10 (1.4%) in the vagina, and one (0.14%) in the rectum. Urinary incontinence surgery was performed in 69 patients (9.7%) during the follow-up period.

CONCLUSIONS

The frequencies of recurrence requiring reoperation and mesh-related complications were low, and vaginal mesh exposure was mostly asymptomatic. Therefore, the Japanese-style transvaginal mesh is safe and effective.

Cytokine modulation in pelvic organ prolapse and urinary incontinence: from molecular insights to therapeutic targets

Pelvic organ prolapse (POP) and urinary incontinence (UI) are common disorders that significantly impact women's quality of life. Studies have demonstrated that cytokines, including pro- and anti-inflammatory immune mediators, play a role in illness genesis and progression. Research on the inflammatory milieu of the pelvic floor has shown that POP patients have increased inflammation in vaginal tissues. This evidence revealed that significant changes in the inflammatory milieu of the pelvic floor are an aspect of the pathogenesis of POP. POP patients exhibit increased levels of inflammatory cytokines (IL-1, TNF, IFN, and others) in the front vaginal wall, which may alter collagen metabolism and contribute to POP. Studies indicate that cytokines such as IL-6, IL-10, and TGF, which are involved in inflammation, remodelling, and repair, have dual effects on POP and UI. They can promote tissue healing and regeneration but also exacerbate inflammation and fibrosis, contributing to the progression of these conditions. Understanding the dual roles of these cytokines could help us improve the vaginal microenvironment of women and treat POP and UI. Given the considerable changes in these cytokines, this review addresses studies published between 2000 and 2024 on the molecular mechanisms by which pro- and anti-inflammatory cytokines affect women with POP and UI. Furthermore, we explain novel therapeutic strategies for cytokine regulation, emphasizing the possibility of personalized treatments that address the underlying inflammatory milieu of the vagina in POP and UI patients. This thorough analysis aims to establish a foundation for future research and clinical applications, ultimately improving patient outcomes via designed cytokine-based therapies.

Debridement, antibiotics and implant retention (DAIR) following hip and knee arthroplasty: results and findings of a multidisciplinary approach from a non-specialist prosthetic infection centre

INTRODUCTION

Prosthetic joint infection (PJI) is a catastrophic complication following arthroplasty surgery. Recently a debridement, antibiotics and implant retention (DAIR) procedure has gained popularity for PJI where a thorough debridement, irrigation and modular component exchange is undertaken.

METHOD

We present the outcome for DAIR, data collected prospectively, in a busy orthopaedic unit but not one specialising in PJI. All patients with PJI were included without loss of data or patients from 2012 to 2018 with a minimum follow-up of 5 years.

RESULTS

Four total knee replacements, 17 total hip replacements, one revision total hip replacement and three hip hemiarthroplasties are included with an average duration from onset of symptoms to the DAIR procedure of 11 days (range 1-22 days). Staphylococcus aureus (24%) and Staphylococcus epidermidis (32%) were the most common causative organisms, and the most common antibiotic regimens included intravenous teicoplanin and flucloxacillin. Average follow-up was 67 months (range 9-104 months). Only four patients went on to require revision surgery. An analysis of midterm patient outcome measures for 6 of the total hip replacement (THR) DAIR patients were compared with a database of 792 THRs (with a minimum two-year follow-up) carried out by the same surgeon revealed no significant difference in Oxford hip scores at one-year post-surgery (OHS DAIR 36.2 vs 39 for control group).

CONCLUSION

This study includes 25 consecutive patients treated with DAIR with only one reinfection, with a mean follow-up period of 5 years. Using a strict protocol, DAIR appears to offer a successful treatment strategy for the management of early PJI.

The long-term impact of vaginal surgical mesh devices on pain clinic and psychological service referrals, anti-inflammatory testing and pelvic scans in UK primary care: A cohort study with the Clinical Practice Research Datalink

OBJECTIVE

To examine long-term complications in women with stress urinary incontinence (SUI) and pelvic organ prolapse (POP), with and without surgical mesh implants.

DESIGN

Longitudinal open cohort study from 1 April 2006 (or 1 April 2012) to 30 November 2018.

SETTING

The Clinical Practice Research Datalink (CPRD) Gold database, which is linked to Hospital Episodes Statistics (HES) inpatient data, the HES Diagnostic Imaging Dataset (DID), Office for National Statistics mortality data and Index of Multiple Deprivation socio-economic status data.

SAMPLE

Women aged ≥18 years with a diagnostic SUI/POP Read code.

METHODS

Rates are estimated using negative binomial regression.

MAIN OUTCOME MEASURES

Rates of referrals for: psychological and pain services; urinalysis, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) testing; and pelvic ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) scans.

RESULTS

A cohort of 220 544 women were eligible for inclusion; 74% (n = 162 687) had SUI, 37% (n = 82 123) had POP and 11% (n = 24 266) had both. Rates of psychological referrals and CT scans were lower in women with SUI mesh surgery, but this was offset by higher rates of CRP testing in women with SUI or POP mesh, MRI scans in women with SUI mesh, and urinalysis testing and referrals to pain clinics for women with POP mesh.

CONCLUSIONS

Our results suggest a higher burden of morbidity in women with SUI/POP mesh surgery, and that these women may require ongoing follow-up in the primary care setting.

Emerging materials and technologies for advancing bioresorbable surgical meshes

Surgical meshes play a significant role in the treatment of various medical conditions, such as hernias, pelvic floor issues, guided bone regeneration, and wound healing. To date, commercial surgical meshes are typically made of non-absorbable synthetic polymers, notably polypropylene and polytetrafluoroethylene, which are associated with postoperative complications, such as infections. Biological meshes, based on native tissues, have been employed to overcome such complications, though mechanical strength has been a main disadvantage. The right balance in mechanical and biological performances has been achieved by the advent of bioresorbable meshes. Despite improvements, recurrence of clinical complications associated with surgical meshes raises significant concerns regarding the technical adequacy of current materials and designs, pointing to a crucial need for further development. To this end, current research focuses on the design of meshes capable of biomimicking native tissue and facilitating the healing process without post-operative complications. Researchers are actively investigating advanced bioresorbable materials, both synthetic polymers and natural biopolymers, while also exploring the performance of therapeutic agents, surface modification methods and advanced manufacturing technologies such as 4D printing. This review seeks to evaluate emerging biomaterials and technologies for enhancing the performance and clinical applicability of the next-generation surgical meshes. STATEMENT OF SIGNIFICANCE: In the ever-transforming landscape of regenerative medicine, the embracing of engineered bioabsorbable surgical meshes stands as a key milestone in addressing persistent challenges and complications associated with existing treatments. The urgency to move beyond conventional non-absorbable meshes, fraught with post-surgery complications, emphasises the necessity of using advanced biomaterials for engineered tissue regeneration. This review critically examines the growing field of absorbable surgical meshes, considering their potential to transform clinical practice. By strategically combining mechanical strength with bioresorbable characteristics, these innovative meshes hold the promise of mitigating complications and improving patient outcomes across diverse medical applications. As we navigate the complexities of modern medicine, this exploration of engineered absorbable meshes emerges as a promising approach, offering an overall perspective on biomaterials, technologies, and strategies adopted to redefine the future of surgical meshes.

'I have no life and neither do the ones watching me suffer': women's experiences of transvaginal mesh implant surgery

Objective: Many women are affected by pelvic floor disorders, such as stress urinary incontinence and pelvic organ prolapse. In recent years, these disorders have been treated with transvaginal mesh implant surgeries involving the vaginal insertion of woven netting. We explored women's experiences of transvaginal mesh implant surgery through a biopsychosocial lens. Design: We analysed women's submissions to an Australian Parliament Senate Inquiry on transvaginal mesh implant surgery using thematic analysis. Main Outcome Methods: One-hundred and fifty-three publicly available submissions detailing women's experiences of transvaginal mesh implant surgery to an Australian Parliament Senate Inquiry were analysed. Adverse and positive accounts were eligible for inclusion. Results: We generated nine themes in three categories relating to the Biopsychosocial Model: Physical Health - comprising three themes; Psychological Health - comprising two themes; and Social Wellbeing - comprising four themes. Physical, psychological and social experiences interacted, resulting in reduced quality of life for women. Conclusion: Most women who made submissions to an Australian government inquiry about transvaginal mesh implant surgery described devastating impacts on physical, psychological, and social wellbeing. We provide recommendations to guide psychologists in assisting women with adverse transvaginal mesh-related outcomes. Further research should explore women's long-term experiences of the various transvaginal mesh procedures.

Complications of Pelvic Prolapse Surgery Using Mesh: A Systematic Review

BACKGROUND

Pelvic organ prolapse (POP) is a public health problem that influences millions of women around the globe, and it has a significant impact on the quality of life. From the FDA statement regarding the complications of using mesh implants in POP surgery to studies that have shown the benefits and side effects, we conducted a systematic review investigating the complications associated with surgical mesh implantation for POP repair.

METHODS

Relevant studies were identified through a comprehensive search of scientific databases. Studies evaluating the use of mesh in POP surgery and reporting on associated complications were included.

RESULTS

Among 2816 studies, 28 studies met the research criteria, with a total number of 8958 patients, revealing that in laparoscopic mesh surgery, the rate of mesh exposure was lower compared to vaginal mesh surgery, among other complications.

CONCLUSIONS

Laparoscopic mesh surgery is superior as a long-term approach for POP repair compared to vaginal mesh surgery, offering lower complication rates and potentially better anatomical success. However, vaginal mesh surgery remains a valuable option for patients who are unsuitable for laparoscopy due to specific factors. Future research should explore alternative techniques, like pectopexy with or without mesh, to further improve surgical outcomes and patient experience.

Patient-Reported Outcome Measures in High-Risk Medical Device Registries: A Scoping Review

Little is known about the methods and outcomes of patient-reported outcome measure (PROM) use among high-risk medical device registries. The objective of this scoping review was to assess the utility and predictive ability of PROMs in high-risk medical device registries. We searched Ovid Medline, Embase, APA PsychINFO, Cochrane Library, and Scopus databases for published literature. After searching, 4323 titles and abstracts were screened, and 262 full texts were assessed for their eligibility. Seventy-six papers from across orthopedic (n = 64), cardiac (n = 10), penile (n = 1), and hernia mesh (n = 1) device registries were identified. Studies predominantly used PROMs as an outcome measure when comparing cohorts or surgical approaches (n = 45) or to compare time points (n = 13) including pre- and postintervention. Fifteen papers considered the predictive ability of PROMs. Of these, 8 treated PROMs as an outcome, 5 treated PROMs as a risk factor through regression analysis, and 2 papers treated PROMs as both a risk factor and as an outcome. One paper described PROMs to study implant survival. To advance methods of PROM integration into clinical decision-making for medical devices, an understanding of their use in high-risk device registries is needed. This scoping review found that there is a paucity of studies using PROMs to predict long-term patient and clinical outcomes in high-risk medical device registries. Determination as to why PROMs are rarely used for predictive purposes in long-term data collection is needed if PROM data are to be considered suitable as real-world evidence for high-risk device regulatory purposes, as well as to support clinical decision-making.

Level of Evidence 4

Evaluating Non-ablative Erbium Yttrium Aluminium Garnet (YAG) Laser Treatment for Polypropylene Mesh-Induced Vaginal Erosion: A Case Series

Background Vaginal erosion caused by the polypropylene mesh is a serious side effect, and the development of effective treatment methods is required. This study explored the potential of non-ablative vaginal erbium yttrium aluminum garnet (YAG) laser treatment (VEL) as a novel treatment approach. Methods In this study, VEL was performed on nine women who experienced vaginal erosion after undergoing treatment for pelvic organ prolapse (POP) with polypropylene mesh. These patients visited our hospital between April and December 2020. Using the Renovalase (SP Dynamis Fotona d.o.o., Ljubljana, Slovenia), the laser was applied to the entire vagina, with intensive irradiation focused on the erosion areas. Detailed analyses of symptoms before and after treatment, as well as histopathological changes, were conducted one year post-treatment. Results Nine women were referred to our hospital due to vaginal erosion caused by polypropylene mesh. The participants' average age was 73.2 years (range: 69-81 years), with four patients having undergone transvaginal mesh (TVM) surgery and five undergoing laparoscopic sacrocolpopexy (LSC). The average time from mesh insertion to treatment initiation was 7.2 years (range: 3-15 years), with eight patients having previously attempted mesh removal. Post-treatment, significant improvements were observed in managing vaginal erosion and related bleeding, corroborated by histopathological analysis confirming cell regeneration and tissue repair. These improvements also resulted in significant improvements in bleeding management and quality of life (QoL). Conclusion VEL suggests the possibility of being an effective treatment method for vaginal erosion caused by a polypropylene mesh. However, further research is needed because of the small sample size and the limitations inherent in the retrospective case series design.

Injectable Decellularized Extracellular Matrix-Based Bio-Ink with Excellent Biocompatibility for Scarless Urethra Repair

In recent years, decellularized extracellular matrices (dECM) derived from organs have attracted much attention from researchers due to their excellent biocompatibility, capacity to promote cell proliferation and migration, as well as pro-vascularization. However, their inferior mechanical properties, slow cross-linking, weak strengths, and poor supporting properties remain their inevitable challenges. In our study, we fabricated a novel dECM hydrogel with better crosslinking strength and speed, stronger support properties, and better mechanical properties. The hydrogel, which we named gelatin-based dECM powder hydrogel (gelatin-dECM hydrogel), was prepared by mixing dECM microparticles in gelatin solution and adding certain amount of 1-Ethyl-3-(3-dimethyl-aminopropyl-1-carbodiimide) (EDC) and N-hydroxysuccinimide (NHS). We evaluated the utility of this hydrogel by assessing the degradation rate, mechanical properties, and biocompatibility. The results showed that the gelatin-dECM hydrogel has high mechanical properties and biocompatibility and also has the ability to promote cell proliferation and migration. After injection of this hydrogel around the surgical sites of urethras in rabbits, the incorporation of dECM powder was demonstrated to promote angiogenesis as well as scarless repair by histological sections after surgery. The application of this novel hydrogel provides a new perspective for the treatment of post-traumatic urethral stricture.

Neorectal prolapse following proctectomy: a novel application of mesh sacral pexy

Neorectal prolapse following proctectomy for cancer has seldom been reported and treatment has mostly consisted in the resection of the prolapse via a perineal approach. Management of a patient with neorectal J-pouch prolapse using mesh sacral pexy via an abdominal approach is reported. By analogy with native rectal prolapse due to pelvic static disorders, laparoscopic mesh sacral pexy is likely to afford the same advantages of low morbidity and durability when applied to neorectal prolapse following rectal cancer surgery.

Fabrication and in vitro investigation of hyperbranched poly-lysine-grafted warp knitted polypropylene sling for potential treatment of stress urinary incontinence

Polypropylene (PP) sling implantation is the most commonly performed procedure for women with stress urinary incontinence (SUI). However, concerns have arisen regarding complications caused by slings, including the common issue of erosion, which can be attributed to various factors such as the body's response and bacterial contamination. To address these concerns, we have developed a rectangular mesh self-locking edge sling with a large pore size and lightweight design. Promising results have been obtained from preliminary in vivo mechanical reliability tests, including uniaxial tensile tests. In comparative in vitro fixed load tensile tests and simulated Tension-free Vaginal Tape (TVT) and Transobturator Vaginal Tape inside-out (TVT-O) technique tests using commercial slings, our sling demonstrated less transverse wrinkling. Both slings achieved an effective porosity of over 45% under the TVT technique. However, the commercial sling experienced a significant reduction in effective porosity during the TVT-O technique, whereas our sling maintained a stable effective porosity with minimal wrinkling. Furthermore, we successfully developed cationic hydration rejection-driven antibacterial-anti-fouling coatings on the surface of our sling by grafting hyperbranched poly-lysine (HBPL) mediated by polynorepinephrine. The HBPL coating imparts a positive charge and hydrophilicity to the sling, resulting in elevated bactericidal activity and reducing protein adhesion. An optimal grafting concentration of 20 mg mL-1 was selected, confirming the stability and biocompatibility of the sling coating. This coating is expected to reduce the likelihood of postoperative erosion. Overall, our research represents significant advancements in improving the safety and performance of PP slings for stress urinary incontinence, potentially leading to a reduction in complications following surgery.

Transobturator Tension-Free Vaginal Flap Operation versus Synthetic Transobturator Tape for Treatment of Female Stress Urinary Incontinence: A Prospective Randomized Study

INTRODUCTION

Synthetic mid-urethral slings (MUSs) are the gold standard treatment for female stress urinary incontinence (SUI). Recently, there have been reports of serious adverse events with synthetic tapes such as urethral erosion, vaginal erosion, and mesh infection. Tension-free vaginal flap (TVF) operation has been proven to be successful as a natural alternative to synthetic slings. We propose our novel technique, the transobturator tension-free vaginal flap (TO-TVF), utilizing native vaginal tissue and being suspended via transobturator route.

METHODS

This prospective study was conducted on 72 female patients with SUI, presenting at Alexandria University Hospital. Patients were randomized into 2 groups, group 1: 37 patients subjected to TO-TVF and group 2: 35 patients to conventional transobturator tape (TOT). In TO-TVF, a rectangular vaginal wall flap is created. A polypropylene monofilament mesh is sutured to each edge of the vaginal flap. This is inserted like conventional outside-in TOT. Patients were subjected to PGI and UDI-6 questionnaires and urodynamic study before and 6 months postoperatively.

RESULTS

Both groups showed comparable and significant improvements in questionnaires. Mean operative time for TO-TVF and conventional TOT was 26.31 ± 5.2 min and 21.8 ± 3.1 min, respectively. Cure rate was 89% in group 1 and 91.4% in group 2, which was not statistically significant. No significant intraoperative complications were encountered. We had no cases of vaginal or urethral erosion in both groups.

CONCLUSIONS

TO-TVF is a cost-effective, feasible, safe, and effective surgical alternative to synthetic MUS. Synthetic mesh tissue anchoring properties are maintained for better adjustment of tension. However, long-term follow-up on a large cohort of patients is still needed.

Transvaginal Mesh-related Complications and the Potential Role of Bacterial Colonization: An Exploratory Observational Study

STUDY OBJECTIVE

This study aimed to investigate the potential role of transvaginal mesh bacterial colonization in the development of mesh-related complications (MRCs).

DESIGN

An observational and exploratory study.

SETTING

Tertiary referral center (Amsterdam UMC, location AMC, Amsterdam, The Netherlands). PATIëNTS: 49 patients indicated for mesh removal and 20 women of whom vaginal tissue was retrieved during prolapse surgery as a reference cohort.

INTERVENTIONS

collection of mesh-tissue complex (patient cohort) or vaginal tissue (reference cohort) MEASUREMENTS AND MAIN RESULTS: Homogenized samples were used for quantitative microbiological culture. Inflammation and fibrosis were semiquantitatively histologically scored; Gram staining and fluorescence in situ hybridization were used to detect bacteria and bacterial biofilms. Of the 49 patients, 44 samples (90%) were culture positive, with a higher diversity of species and more Gram-negative bacteria and polymicrobial cultures in the MRC cohort than the reference cohort, with mostly staphylococci, streptococci, Actinomyces spp., Cutibacterium acnes, and Escherichia coli. Patients with clinical signs of infection or exposure had the highest bacterial counts. Histology demonstrated moderate to severe inflammation in most samples. Gram staining showed bacteria in 57% of culture-positive samples, and in selected samples, fluorescence in situ hybridization illustrated a polymicrobial biofilm.

CONCLUSION

In this study, we observed distinct differences in bacterial numbers and species between patients with MRCs and a reference cohort. Bacteria were observed at the mesh-tissue interface in a biofilm. These results strongly support the potential role of bacterial mesh colonization in the development of MRCs.

Aging of Industrial Polypropylene Surfaces in Detergent Solution and Its Consequences for Biofilm Formation

The performance of plastic components in water-bearing parts of industrial and household appliances, often in the presence of harsh environments and elevated temperatures, critically relies on the mechanical and thermal polymer stability. In this light, the precise knowledge of aging properties of polymers formulated with dedicated antiaging additive packages as well as various fillers is crucial for long-time device warranty. We investigated and analysed the time-dependent, polymer-liquid interface aging of different industrial performance polypropylene samples in aqueous detergent solution at high temperatures (95 °C). Special emphasis was put on the disadvantageous process of consecutive biofilm formation that often follows surface transformation and degradation. Atomic force microscopy, scanning electron microscopy, and infrared spectroscopy were used to monitor and analyse the surface aging process. Additionally, bacterial adhesion and biofilm formation was characterised by colony forming unit assays. One of the key findings is the observation of crystalline, fibre-like growth of ethylene bis stearamide (EBS) on the surface during the aging process. EBS is a widely used process aid and lubricant enabling the proper demoulding of injection moulding plastic parts. The aging-induced surface-covering EBS layers changed the surface morphology and promoted bacterial adhesion as well as biofilm formation of Pseudomonas aeruginosa.

Abdominal Sacrohysteropexy using Proline mesh versus Mersilene tape in apical prolapse: A randomized clinical trial

IMPORTANCE

uterine preservation is increasingly a common demand in surgical management of pelvic organ prolapse. Using Proline mesh in surgical repair of prolapse may have negative drawbacks.

OBJECTIVE

compare between using Polyproline mesh and Mersilene tape in abdominal Sacrohysteropexy repairing apical prolapse stage ӀӀ or more.

STUDY DESIGN

This RCT study was conducted at the Department of Obstetrics and Gynecology (Menoufia and Ain Shams university hospitals, Egypt). Eligible population included women planned Sacrohysteropexy for uterine prolapse ≥ stage 2 assigned to two groups: Mesh group (n = 38), underwent Sacrohysteropexy with polyproline mesh, and Tape group (n = 38), underwent Sacrohysteropexy using Mersilene tape.

RESULTS

High statistically significant difference between TAPE group and MESH group concerning hysteropexy time was 50.4 min in TAPE group vs 90.6 min in MESH group (p < 0.001), need for post operative analgesia was14 in TAPE group vs 27 in MESH group (p < 0.005). The mean hospital stay was 2.8 days in TAPE group vs 5.2days in MESH group (p < 0.001).

CONCLUSIONS

Using Mersilene tape in Sacrohysteropexy is a safe alternative to Polyproline Mesh with comparable efficacy with less complications. Tape is easier as it needs less dissection area for sacral fixation so less injury incidence.

Prussian Blue Nanoparticle-Entrapped GelMA Gels Laden with Mesenchymal Stem Cells as Prospective Biomaterials for Pelvic Floor Tissue Repair

Pelvic organ prolapse (POP) seriously affects elderly patients' quality of life, and new repair materials are urgently needed. To solve this problem, we synthesized methacrylated gelatin (GelMA) hydrogels and incorporated photothermally active Prussian blue nanoparticles (PBNPs) to synthesize PBNP@GelMA. Then, MSCs were encapsulated in the PBNP@GelMA and exposed to a 1.0 W/cm² of 808 nm laser for 10 min to perform heat shock pretreatment for the implantation of mesenchymal stem cells (MSCs). Next, we tested the repair efficacy of scaffold-cell complexes both in vitro and in vivo. Our results reveal that the heat shock treatment induced by PBNP@GelMA improved the viability of MSCs, and the underlying mechanism may be related to HSP70. Furthermore, 2 weeks after implantation in the SD rat model, the collagen content increased in the MSC implantation group and PBNP@GelMA implantation group. However, the muscle regeneration at the implanting position was mostly enhanced after the implantation of the heat-shock-pretreated MSCs, which illustrates that heat shock treatment can further promote the MSC-mediated muscle regeneration. Therefore, manipulating the cell environment and providing proper heat stimulus by using PBNP@GelMA with NIR is a novel strategy to enhance the regenerative potential of MSCs and to promote pelvic tissue repair.

Six-year follow-up outcomes of the P(LLA-CL)/Fg bio-patch for anterior vaginal wall prolapse treatment

INTRODUCTION AND HYPOTHESIS

There were few data about the long-term outcomes of bio-compatible patches for pelvic organ prolapse (POP). The efficacy of poly (L-lactide-co-caprolactone) blended with fibrinogen [P(LLA-CL)/Fg] bio-patches were investigated for anterior vaginal wall prolapse treatment in a 6-year follow-up.

METHODS

The P(LLA-CL)/Fg bio-patch was fabricated through electrospinning. Nineteen patients with symptomatic anterior prolapse (Pelvic Organ Prolapse Quantification [POP-Q] stage ≥ 2) were treated with anterior pelvic reconstruction surgery using a P(LLA-CL)/Fg bio-patch and were followed up at 1, 2, 3, 6 months, and 6 years. The primary outcome was objective anatomical cure (anterior POP-Q stage ≤ 1). Secondary outcomes included complications, MRI evaluation, and scores of the Pelvic Floor Impact Questionnaire-7 (PFIQ-7) and the Pelvic Floor Distress Inventory-20 (PFDI-20).

RESULTS

The micro-morphology of the bio-patch resembled the extracellular matrix, which was suitable for the growth of fibroblasts. Sixteen (84.2%) patients were finally assessed, with a mean follow-up of 6.08 ± 0.18 years. The cure rate without anterior prolapse recurrence was 93.8% at 6 years. Compared with baseline, the POP-Q measurements of Aa, Ba, and C points and scores of PFIQ-7 and PFDI-20 manifested significant differences at all times (all p < 0.05). One (5.26%) case of bio-patch-related infection, 1 (5.26%) case of urinary retention, and no exposures and erosion occurred. MRI evaluation showed that the bio-patch gradually degraded to fragments at 1 month and was completely absorbed at 3 months.

CONCLUSIONS

Among long-term follow-ups, anterior pelvic reconstruction surgery with a P(LLA-CL)/Fg bio-patch demonstrated significant improvements in anatomical correction of anterior pelvic prolapse and pelvic function without severe morbidity.

A scoping review of tissue interposition flaps used in vesicovaginal fistulae repair

Background

Research on the use of tissue interposition flaps (TIFs) in vesicovaginal fistulae (VVF) repair is a broad area where a very wide range of natural and synthetic materials have been used. The occurrence of VVF is also diverse in the social and clinical settings, resulting in a parallel heterogeneity in the published literature on its treatment. The use of synthetic and autologous TIFs in VVF repair is not yet standardized with a lack of the most efficacious type and technique of the TIF.

Objectives

The aim of this study was to systematically review all synthetic and autologous TIFs used in the surgical repair of VVFs.

Data sources and methods

In this scoping review, the surgical outcomes of autologous and synthetic interposition flaps used in VVF treatment meeting the inclusion criteria were determined. We searched the literature using Ovid MEDLINE and PubMed databases between 1974 and 2022. Study characteristics were recorded, and data on the change in fistulae size and location, surgical approach, success rate, preoperative patient evaluation and outcome evaluation were extracted from each study independently by two authors.

Results

A total of 25 articles that met the inclusion criteria were included in the final analysis. A total of 943 and 127 patients who had received autologous and synthetic flaps, respectively, were included in this scoping review. The fistulae characteristics were highly variable with regard to their size, complexity, aetiology, location and radiation. Outcome assessments of fistulae repair in included studies were mostly based on symptom evaluation. Physical examination, cystogram and methylene blue test were the methods in order of preference. Postoperative complications, such as infection, bleeding, donor site, pain, voiding dysfunction and other complications, were reported in patients after fistulae repair in all included studies.

Conclusion

The use of TIFs in VVF repair was common especially in complex and large fistulae. Autologous TIFs appear to be the standard of care at the moment, and synthetic TIFs were investigated in prospective clinical trials in a limited number of selected cases. Evidence levels of clinical studies evaluating the effectiveness of interposition flaps were overall low.

Patients' perspectives about doctor-patient communication regarding transvaginal mesh implant surgery

OBJECTIVES

Many women experience pelvic floor disorders which may require medical intervention such as transvaginal mesh implant surgeries (TVM; the abdominal or vaginal insertion of woven netting to support pelvic tissue). We examined women's perceptions of communication with their health professionals concerning TVM.

DESIGN

We analysed 153 women's written submissions to an Australian Government Inquiry regarding their experiences of transvaginal mesh surgery to explore their perceptions of TVM-related doctor-patient communication. Data were analysed using deductive and inductive reflexive thematic analysis.

RESULTS

Women expressed several challenges in their communication with their health professionals. Three themes regarding communication were generated: Insufficient information was abundant; Normalisation and minimisation of the procedure and risks; and, Desired communication interactions.

CONCLUSIONS

According to women's accounts, doctor-patient communication was poor. Health professionals must be knowledgeable about medical procedures and their potential complications and provide their patients with adequate, accurate information to make informed choices about their health. Health professionals should also document informed consent.

PRACTICE IMPLICATIONS

Health professionals should be well-informed about TVM, including best-practice treatments for pelvic floor disorders, indications for TVM, the risks, outcomes and potential complications from various forms of TVM, and ways to adequately communicate sufficient information to women.

Features of Cell Reactions during Implantation of Biodegradable Polymer and Polypropylene in the Experiment

Quantitative and qualitative characteristics of cell infiltrates in male Wistar rats were studied from 14 days to 12 months after implantation of polypropylene and a biodegradable polymer obtained by electrospinning and consisting of 65% polycaprolactone and 35% polytrimethylene carbonate. It was found that a predominantly macrophage-giant cell reaction developed around the biodegradable polymer; it spread into the matrix and the number of cells in the infiltrate decreased, as the degradation progressed. Around polypropylene, mainly lymphocytic and leukocytic reaction was seen; it also decreased with time, but was characterized by a reverse increase in the number of lymphocytes. Immunohistochemical analysis showed that the proportion of CD38⁺ cells 12 months after implantation increased around polypropylene to a greater extent than around the biodegradable polymer, while the proportion of CD68⁺ cells decreased. These findings suggest that implantation of a biodegradable polymer caused no prolonged lymphocytic and plasma cell reaction in animals as in the case of polypropylene, which indicates that biodegradable polymer is a promising material for tissue engineering.

Application of Acellular Dermal Matrix in Gynaecology—A Current Review

The aim of our study is to draw attention to the multitude of applications of acellular dermal matrix (ADM) in the surgical treatment of urogynaecological disorders, such as reduction in the reproductive organs, and in reconstructive gynaecology. Despite the existence of numerous operational methods and materials, the effectiveness of transvaginal operation is still insufficient. Native tissue operations are often not durable enough, while operations with synthetic materials have numerous side effects, such as infections, hematomas, vaginal erosion, or dyspareunia. Hence, the search continues for a different material with a better efficacy and safety profile than those previously mentioned. It seems that ADM can meet these requirements and be a useful material for urogynaecological surgery. Key words related to the usage of ADM in gynaecological reconstructive surgery were used to search relevant databases (NCBI MedLine, Clinical Key, Clinicaltrials.gov). This manuscript is based on 43 literature sources, 28 (65.11%) of which were released after 2016. Older sources are cited for the purpose of presenting basic science, or other important issues related to the manuscript. ADM seems to be an ideal material for urogynaecological and reconstructive surgery. It has high durability, and thus high effectiveness. Moreover, it does not have the side effects typical for synthetic materials. There are no reports of material rejection, erosion or dyspareunia directly related to the presence of the mesh. Due to the difficulties in obtaining ADM and the need to perform additional tests, this material is not common in routine clinical practice. Therefore, the number of cases and the size of the research groups are insufficient to clearly define the potential of mesh from biological tissue. However, the results are so promising that it is worth considering a wider introduction to the use of this material. Our hope is that increasing clinicians’ awareness of this topic will lead to more studies comparing methods using native tissues or synthetic materials and those using ADM.

Adipose mesenchymal stem cell-based tissue engineering mesh with sustained bFGF release to enhance tissue repair

Pelvic organ prolapse (POP) harms the quality of life of elderly patients. Transvaginal polypropylene mesh repair for POP was a frequently reported complication and was banned by the FDA in 2019. New therapeutic strategies are urgently required, and tissue engineering technology could be a novel therapy. Here, we developed a tissue engineering mesh out of three components: silk fibroin (SF) knitted mesh loaded with basic fibroblast growth factor (bFGF) and adipose-derived stem cells (ADSCs). We used coaxial electrospinning technology to achieve local bFGF release to promote regeneration. Additionally, ADSCs were loaded to demonstrate their paracrine ability of immune regulation and angiogenesis. Meanwhile, knitted silk fibroin mesh provided mechanical support. In vitro, SF/bFGF/ADSC tissue engineering mesh can stably release bFGF and has good biocompatibility, promoting cell proliferation and extracellular matrix synthesis. Six months after the SF/bFGF/ADSC tissue engineering mesh was implanted in a SD rat model, extracellular matrix reorganization, angiogenesis, and immunomodulatory effect, as well as mechanical properties of the implanting position were improved. Hence, SF/bFGF/ADSC tissue engineering mesh could be regarded as a promising option with excellent collagen synthesis, low foreign body response, and early angiogenic ability, providing potential ideas for POP treatment.

The impact of bacterial contamination on the host response towards fully absorbable poly-4-hydroxybutyrate and nonabsorbable polypropylene pelvic floor implants

Polypropylene (PP) implants for the vaginal surgical correction of pelvic organ prolapse (POP) are known for adverse events, like vaginal or visceral exposures. It is hypothesized that this is a result of a prolonged inflammatory response. One of the triggering factors of prolonged inflammation might be bacterial contamination. A possible solution might lie in an absorbable biomaterial, which provides initial mechanical support while being gradually replaced by the host tissue.

With this study we aimed to compare the host response, in a subcutaneous mouse implant infection model, to delayed absorbable poly-4-hydroxybutyrate (P4HB) and a latest generation PP implant. By comparing non-infected to Staphylococcus aureus infected mice, we assessed how bacterial contamination affects the host response and its role in the development of complications. Further, we included sham surgery as a control, mimicking the wound response in native tissue repair.

Despite the higher surface area of the P4HB implants, the clearance of infection was similarly delayed in the presence of a P4HB or PP implant, as compared to sham. Further, the host response towards P4HB and PP was quite comparable, yet collagen deposition was significantly increased around infected P4HB implants at early time points. Adverse event rates were similar, though implant exposures were only seen in infected mice and more often with PP (11.1%) than P4HB implants (5.6%). Infected mice overall had significantly higher levels of infiltration of inflammatory cells and lower levels of vascularization and collagen deposition compared to non-infected mice. Thus, for both P4HB and PP, bacterial contamination negatively affected mesh integration by increased inflammation and an increased adverse event rate. Altogether, our results from this subcutaneous mouse implant infection study suggest that P4HB could be a promising degradable alternative to PP, warranting further research to study its potential as a new surgical solution for women with POP.

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Absorbable poly-4-hydroxybutyrate (P4HB) is studied as a novel pelvic floor implant.

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Comparable host response to P4HB and polypropylene in a subcutaneous mouse implant infection model.

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Implant exposures exclusively occurred upon Staphylococcus aureus infection.

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Exposures occurred less with P4HB (5.6%) compared to polypropylene (11.1%).

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S. aureus infection increased inflammation and deranged the host response.

Women’s Experiences with Compliance with Pelvic Floor Home Exercise Therapy and Lifestyle Changes for Pelvic Organ Prolapse Symptoms: A Qualitative Study

In this study, we aimed to investigate women’s experiences with compliance with prescribed pelvic floor muscle exercises (PFMEs) and lifestyle changes 6–12 months after completing an individual pelvic floor physiotherapy program. This study was targeted to understanding factors affecting adherence to PFMEs and lifestyle changes to deal with pelvic organ prolapse (POP) symptoms. We designed this research as a descriptive qualitative study. We conducted this study from December 2016 to September 2017 in Madrid, Spain. Twenty-six women with symptomatic POP selected using a purposive sampling method participated in six focus groups and three one-to-one semi-structured interviews. Three authors coded and inductively analyzed transcript contents with iterative theme development. A thematic analysis revealed three main themes: (1) symptoms change; (2) PFMEs and lifestyle changes performance; and (3) a health practitioner–patient relationship. Women identified as adherent reported improvement in physical symptoms and emotional and general state as a result of the new knowledge achieved. Fear also promoted compliance with performing PFMEs and adopting lifestyle changes. Likewise, PFMEs preference and routine, integration of PFMEs and lifestyle changes into activities of daily living, support guides, therapeutic alliance, individual supervision, follow-up, and feedback were also identified as adherence facilitators. One of the biggest barriers that we identified was responsibility. Compliance with prescribed PFMEs and lifestyle changes can be improved with effective individual, women-centered, and supervised physiotherapy programs reducing symptoms, including exercises aligned with women’s preferences that are easy to integrate in daily living, promoting knowledge and awareness of their condition, providing written or electronic guidelines, with routine follow-up visits offering both positive feedback and clear and consistent messages, and enhancing therapeutic alliance.

Small intestinal submucosa xenograft to manage lower urinary tract prostheses perforation: a new path?

INTRODUCTION AND HYPOTHESIS

Tapes for stress urinary incontinence (SUI) and meshes for pelvic organ prolapse can result in postoperative complications, such as urethral (UP) or bladder (BP) perforations. Martius fat pad (MFP) is an historic procedure, widely used to treat lower urinary tract (LUT) fistulae. We report our experience with the insertion of the biological small intestinal submucosa (SIS) xenograft as an alternative to MFP in these prosthetic complications.

METHODS

We conducted a retrospective, monocentric study which included all patients who underwent SIS insertion during surgical removal of tape/vaginal mesh for UP or BP from 2011 to 2019. Preoperative assessment was based on history, symptoms, physical examination and urethrocystoscopy. Primary outcome was successful repair defined as absence of any LUT defect. Secondary outcomes were complications, LUT symptoms, pain and additional SUI surgical procedures.

RESULTS

Thirty-eight patients were included. Twenty-six had a UP and eight a BP. In four cases, perforation involved both the bladder neck and urethra. All LUT defects were cured. Six postoperative complications were reported (five of grade ≤ 2 and one of grade 3b according to the Clavien-Dindo classification). At the mean follow-up of 37.2 (range 6-98) months, 14 patients (36.8%) presenting a postoperative SUI underwent a SUI surgical procedure and 1 patient had a laparoscopic sacrocolpopexy for cystocele recurrence.

CONCLUSION

Absorbable SIS xenograft is an effective and safe graft for the management of lower urinary tract tape and mesh perforations. The cost has to be balanced with the good results, short operative time and no fat pad complications as in MFP.

Design, mechanical and degradation requirements of biodegradable metal mesh for pelvic floor reconstruction

Pelvic organ prolapse (POP) is the herniation of surrounding tissue and organs into the vagina and or rectum, and is a result of weakening of pelvic floor muscles, connective tissue,...

Melt-extrusion 3D printing of resorbable levofloxacin-loaded meshes: Emerging strategy for urogynaecological applications

Current surgical strategies for the treatment of pelvic floor dysfunctions involve the placement of a polypropylene mesh into the pelvic cavity. However, polypropylene meshes have proven to have inadequate mechanical properties and have been associated to the arising of severe complications, such as infections. Furthermore, currently employed manufacturing strategies are unable to produce compliant and customisable devices. In this work, polycaprolactone has been used to produce resorbable levofloxacin-loaded meshes in two different designs (90° and 45°) via melt-extrusion 3D printing. Drug-loaded meshes were produced using a levofloxacin concentration of 0.5% w/w. Drug loaded meshes were successfully produced with highly reproducible mechanical and physico-chemical properties. Tensile test results showed that drug-loaded 45° meshes possessed a mechanical behaviour close to that of the vaginal tissue (E ≃ 8.32 ± 1.85 MPa), even after 4 weeks of accelerated degradation. Meshes released 80% of the loaded levofloxacin in the first 3 days and were capable of producing an inhibitory effect against S. Aureus and E. coli bacterial strains with an inhibition zone equal to 12.8 ± 0.45 mm and 15.8 ± 0.45 mm respectively. Thus, the strategy adopted in this work holds great promise for the manufacturing of custom-made surgical meshes with antibacterial properties.

Host-biomaterial interactions in mesh complications after pelvic floor reconstructive surgery

Polypropylene (PPL) mesh is widely used in pelvic floor reconstructive surgery for prolapse and stress urinary incontinence. However, some women, particularly those treated using transvaginal PPL mesh placement for prolapse, experience intractable pain and mesh exposure or extrusion. Explanted tissue from patients with complications following transvaginal implantation of mesh is typified by a dense fibrous capsule with an immune cell-rich infiltrate, suggesting that the host immune response has a role in transvaginal PPL mesh complications through the separate contributions of the host (patient), the biological niche within which the material is implanted and biomaterial properties of the mesh. This immune response might be strongly influenced by both the baseline inflammatory status of the patient, surgical technique and experience, and the unique hormonal, immune and microbial tissue niche of the vagina. Mesh porosity, surface area and stiffness also might have an effect on the immune and tissue response to transvaginal mesh placement. Thus, a regulatory pathway is needed for mesh development that recognizes the roles of host and biological factors in driving the immune response to mesh, as well as mandatory mesh registries and the longitudinal surveillance of patients.

Long-term postoperative follow-up results of transobturator autologous rectus fascial sling versus transobturator tension-free vaginal tapes for female stress urinary incontinence: Randomized controlled clinical trial

AIMS

To evaluate the outcomes of a new surgical technique for the treatment of stress urinary incontinence (SUI).

METHODS

This randomized study included 132 index patients from January 2017 to May 2021, 60 applied with autologous facia and 60 with transobturator tension-free vaginal tape (TVT-O). The primary endpoint was dryness (negative stress test and 0 pad use per day) and this was assessed at 3, 6, 12, and 24 months. The secondary endpoints were the International Consultation on Incontinence Questionnaire short form (ICIQ-SF) and the urinary incontinence quality of life (QoL) at 3, 6, 12, and 24 months.

RESULTS

The dryness rate at 24 months was 92.4% (49/53) for patients with transobturator autologous rectus fascial sling (TO-AFS) and 94.6% (53/56) for those with TVT-O (p = 0.47). No difference was determined between the TO-AFS and TVT-O groups in respect of the ICIQ-SF and QoL scores at 2 years postoperatively (p = 0.87). There were five postoperative complications in the TO-AFS group (one urinary retention, one hematoma at suprapubic incision line, and three intermittent groin pains) and four in the TVT-O group (four persistent groin pain) (p = 0.98).

CONCLUSIONS

The objective cure rates of the 24-month outcomes of TO-AFS indicate that this novel surgical technique seems to be a highly effective, safe, and feasible procedure for the treatment of SUI, but further studies including long-term follow-up are mandatory to confirm these preliminary data.

Tissue engineering: recent advances and review of clinical outcome for urethral strictures

PURPOSE OF REVIEW

Urethrotomy remains the first-line therapy in the treatment of a urethral stricture despite data showing no real chance of a cure after repeated urethrotomies. An anastomotic or an augmentation urethroplasty using oral mucosa can be offered to patients following failed urethrotomy. The potential for a tissue engineered solution as an alternative to native tissue has been explored in recent years and is reviewed in this article.

RECENT FINDINGS

More than 80 preclinical studies have investigated a tissue-engineered approach for urethral reconstruction mostly using decellularized natural scaffolds derived from natural extracellular matrix with or without cell seeding. The animal models used in preclinical testing are not representative of disease processes seen with strictures in man. The available clinical studies are based on small noncontrolled series.

SUMMARY

There is a potential role for tissue engineering to provide a material for substitution urethroplasty and work has demonstrated this. Further work will require a rigorous basic science programme and adequate evaluation of the material prior to its introduction into clinical practice. The research with tissue engineering applied to the urethra has not yet been resulted in a widely available material for clinical use that approaches the efficacy seen with the use of autologous grafts.

Sacrospinous hysteropexy with an autologous rectus fascia sling for treatment of advanced apical pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

There is a great interest in avoiding mesh usage in vaginal surgeries. We propose using the autologous rectus fascia to repair apical vaginal prolapse in a similar way it has been successfully used in urinary stress incontinence surgery. This study aims to demonstrate the technique of sacrospinous hysteropexy using autologous rectus fascia for apical pelvic organ prolapse (POP) treatment.

METHODS

We present a video of a 63-year-old female with stage IV pelvic organ prolapse and urinary obstruction. A rectus fascia sling of approximately 90 × 10 mm was harvested through a Pfannenstiel incision. It was used in vaginal surgery to suspend the cervix and fix the apical POP.

RESULTS

The patient resumed her usual activities after 1 week and waited 2 months to resume physical activities and sexual intercourse. She is satisfied at 6 months follow-up, without complications or prolapse recurrence.

CONCLUSION

The sacrospinous hysteropexy using autologous rectus fascia is a feasible technique with excellent results and low risk of complication. Further studies are required to compare POP repair using autologous rectus fascia and polypropylene meshes.

Expression of Inflammatory Factors in Critically Ill Patients with Urosepticemia and the Imaging Analysis of the Severity of the Disease

Urine sepsis is a complex inflammatory response of the body to infection with a high fatality rate. It is one of the main causes of death in noncardiovascular intensive care units. Nevertheless, in daily clinical practice, early sepsis is often not detected. In this paper, discharged cases of urinary sepsis from the Department of Urology and Critical Care Medicine of a university hospital were collected as the observation group, and common urinary tract infection cases were selected as the control group. We sorted and summarized the discharged case information of the observation group and the control group. The results of the study showed that, after renal pelvis perfusion, the expression of HMGB1 protein and mRNA increased, and the expression of TLR4 increased; inhibiting HMGB1 can reduce the expression of inflammatory factors caused by perfusion and reduce the infiltration of neutrophils and macrophages caused by perfusion. In addition, r HMGB1 treatment can promote the expression of inflammatory factors caused by perfusion and aggravate the infiltration of neutrophils and macrophages caused by perfusion. We found that inhibition of HMGB1 can inhibit the expression of TLR4/My D88 signaling molecules and r HMGB1 treatment can enhance the expression of TLR4/My D88 signaling molecules.

Next-generation surgical meshes for drug delivery and tissue engineering applications: materials, design and emerging manufacturing technologies

Abstract

Surgical meshes have been employed in the management of a variety of pathological conditions including hernia, pelvic floor dysfunctions, periodontal guided bone regeneration, wound healing and more recently for breast plastic surgery after mastectomy. These common pathologies affect a wide portion of the worldwide population; therefore, an effective and enhanced treatment is crucial to ameliorate patients’ living conditions both from medical and aesthetic points of view. At present, non-absorbable synthetic polymers are the most widely used class of biomaterials for the manufacturing of mesh implants for hernia, pelvic floor dysfunctions and guided bone regeneration, with polypropylene and poly tetrafluoroethylene being the most common. Biological prostheses, such as surgical grafts, have been employed mainly for breast plastic surgery and wound healing applications. Despite the advantages of mesh implants to the treatment of these conditions, there are still many drawbacks, mainly related to the arising of a huge number of post-operative complications, among which infections are the most common. Developing a mesh that could appropriately integrate with the native tissue, promote its healing and constructive remodelling, is the key aim of ongoing research in the area of surgical mesh implants. To this end, the adoption of new biomaterials including absorbable and natural polymers, the use of drugs and advanced manufacturing technologies, such as 3D printing and electrospinning, are under investigation to address the previously mentioned challenges and improve the outcomes of future clinical practice. The aim of this work is to review the key advantages and disadvantages related to the use of surgical meshes, the main issues characterizing each clinical procedure and the future directions in terms of both novel manufacturing technologies and latest regulatory considerations.

Graphic abstract

In Vitro Bacterial Adhesion and Biofilm Formation on Fully Absorbable Poly-4-hydroxybutyrate and Nonabsorbable Polypropylene Pelvic Floor Implants

Knitted polypropylene (PP) implants for the correction of pelvic organ prolapse have been associated with complications such as vaginal exposure, infection, and pain. Since certain complications may be linked to bacterial contamination and persistent inflammation, there is a rationale to develop a biocompatible implant that is less prone to bacterial adhesion and biofilm formation. Delayed absorbable materials could meet these requirements and poly-4-hydroxybutyrate (P4HB) might be such a new material for future pelvic floor implants. We studied in vitro bacterial adhesion and biofilm formation on P4HB in comparison to PP. We investigated the influence of both polymers using flat films and compared P4HB and PP implants with different knitting designs. P4HB flat films were demonstrated to be hydrophilic with significantly less Staphylococcus aureus and Escherichia coli cultured from P4HB films than from hydrophobic PP films after 24 h of incubation. On the implants, a higher number of E. coli were cultured after 1 h of incubation from the knitted P4HB implant with the highest density and smallest pore size, compared to other P4HB and PP implants. No differences were observed between the implants for E. coli at later time points or for S. aureus incubation. These results show that in flat films, the polymer influences biofilm formation, demonstrated by a reduced biofilm formation on P4HB compared with PP flat films. In addition, the knitting design may affect bacterial adhesion. Despite certain design and material characteristics that give the knitted P4HB implants a higher surface area, this did not result in more bacterial adhesion and biofilm formation overall. Collectively, these results warrant further (pre)clinical investigations of P4HB pelvic floor implants.

Urogynecological surgical mesh implants: New trends in materials, manufacturing and therapeutic approaches

Pelvic Organ Prolapse (POP) and Stress Urinary Incontinence (SUI) are two prevalent disorders affecting 30-40% of women worldwide. Current strategies to repair or improve these medical conditions are non-surgical options such as physiotherapy, or surgical options such as the use of vaginal meshes. The synthetic material polypropylene (PP), which has long been used for manufacturing these vaginal meshes, is associated with severe complications such as chronic pain, infection or mesh erosion. As a result of a widespread reporting and unacceptably high rates of complications, these issues have become a public health concern. Regulatory bodies have recently deemed the transvaginal placement of PP mesh in the pelvic floor (PF) no longer a suitable treatment method for PF repair, leading to the need for a novel approach to the manufacture and selection of materials for urogynecological meshes. Medical devices, such as vaginal meshes can be manufactured using a variety of techniques including injection moulding, electrospinning, hot-melt extrusion (HME) or more recently 3D printing. Over the past decade, the use of 3D printing within the medical device industry has expanded and offers a promising approach to manufacture patient-specific surgical mesh when combined with imaging tools. This review will summarise the current strategies to treat POP and SUI, the issues and use of current meshes for the treatment of these pelvic floor disorders (PFDs), and the future directions for the manufacture of more suitable urogynecological meshes, as well as their potential materials.

Stress Urinary Incontinence and Pelvic Organ Prolapse: Biologic Graft Materials Revisited

Symptomatic stress urinary incontinence (SUI) and pelvic organ prolapse (POP) refractory to conservative management with pelvic floor muscle training or vaginal pessaries may warrant surgical intervention with different forms of biologic or synthetic material. However, in recent years, several global regulatory agencies have issued health warnings and recalled several mesh products due to an increase in complications such as mesh erosion, infection, chronic pain, and perioperative bleeding. At present, current surgical treatment strategies for SUI and POP are aimed at developing biological graft materials with similar mechanical properties to established synthetic meshes, but with improved tissue integration and minimal host response. This narrative review aims to highlight recent studies related to the development of biomimetic and biologic graft materials as alternatives to traditional synthetic materials for SUI/POP repair in female patients. We also investigate complications and technical limitations associated with synthetic mesh and biological biomaterials in conventional SUI and POP surgery. Our findings demonstrate that newly developed biologic grafts have a lower incidence of adverse events compared to synthetic biomaterials. However there remains a significant disparity between success in preclinical trials and long-term clinical translation. Further characterization on the optimal structural, integrative, and mechanical properties of biological grafts is required before they can be reliably introduced into clinical practice for SUI and POP surgery. Impact statement Our review article aims to outline the clinical history of developments and controversies associated with the use of synthetic mesh materials in the surgical treatment of stress urinary incontinence and pelvic organ prolapse, as well as highlighting recent advancements in the area of biological graft materials and their potential importance in an area that remains an enduring issue for patients and clinicians alike. This article aims to provide a concise summary of previous controversies in the field of urinary incontinence, while evaluating the future of potential biomaterials in this field.

3D Printing of Drug-Loaded Thermoplastic Polyurethane Meshes: A Potential Material for Soft Tissue Reinforcement in Vaginal Surgery

Current strategies to treat pelvic organ prolapse (POP) or stress urinary incontinence (SUI), include the surgical implantation of vaginal meshes. Recently, there have been multiple reports of issues generated by these meshes conventionally made of poly(propylene). This material is not the ideal candidate, due to its mechanical properties leading to complications such as chronic pain and infection. In the present manuscript, we propose the use of an alternative material, thermoplastic polyurethane (TPU), loaded with an antibiotic in combination with fused deposition modelling (FDM) to prepare safer vaginal meshes. For this purpose, TPU filaments containing levofloxacin (LFX) in various concentrations (e.g., 0.25%, 0.5%, and 1%) were produced by extrusion. These filaments were used to 3D print vaginal meshes. The printed meshes were fully characterized through different tests/analyses such as fracture force studies, attenuated total reflection-Fourier transform infrared, thermal analysis, scanning electron microscopy, X-ray microcomputed tomography (μCT), release studies and microbiology testing. The results showed that LFX was uniformly distributed within the TPU matrix, regardless the concentration loaded. The mechanical properties showed that poly(propylene) (PP) is a tougher material with a lower elasticity than TPU, which seemed to be a more suitable material due to its elasticity. In addition, the printed meshes showed a significant bacteriostatic activity on both Staphylococcus aureus and Escherichia coli cultures, minimising the risk of infection after implanting them. Therefore, the incorporation of LFX to the TPU matrix can be used to prepare anti-infective vaginal meshes with enhanced mechanical properties compared with current PP vaginal meshes.

Observational analysis of mesh related complications in urogynecologic procedures

Since the 1990s, the use of mesh has expanded in gynecologic surgeries in the aim of correcting pelvic organ prolapse. Because there has been a lot of complications that were reported, the U.S. Food and Drug Administration has requested the withdrawal of many products from the market. Recently, many countries have called for the suspension of vaginal mesh products from the market. The objective of this review is to analyze the incidence of the complications that arise after vaginal mesh surgeries with an insight to the American College of Obstetricians and Gynecologists recommendations on the management of those complications.

Laparoscopic complete sacrocolpopexy mesh removal for right-sided gluteal pain and recurrent mesh erosion

AIM OF VIDEO

The aim was to demonstrate laparoscopic complete excision of sacrocolpopexy mesh from a 65-year-old woman who had presented with delayed onset of persistent right-sided gluteal pain.

METHOD

The patient was referred to our unit, having undergone a laparoscopic sacrocolpopexy for vault prolapse 7 years earlier, with a type 1 polypropylene mesh. Four years after the primary surgery, she first noticed symptoms of spontaneous vaginal pain together with deep dyspareunia, and right-sided gluteal pain. Clinical examination revealed mesh erosion at the vaginal vault. This was managed at her local hospital, with excision of the small exposed portion of the mesh and over sewing, from a vaginal approach. She continued to be symptomatic following this procedure. When her symptoms still failed to improve 3 years later, a tertiary referral was made to our unit. At laparoscopy, minimal adhesions between the bowel and the mesh were noted and divided. After carefully dissecting the right ureter and reflecting the bladder, the entire sacrocolpopexy mesh was removed with its ProTack fasteners. The entire specimen was retrieved in one piece through the open vault and the vagina was sutured with 2.0 <monocryl laparoscopically. Surgical steps begin with laparoscopic survey of the anatomy. Adhesions need to be released carefully, after developing proper surgical planes. On follow-up in clinic 12 weeks later, there was complete resolution of her symptoms, with minimal vault descent.

CONCLUSION

This video demonstrates the steps needed to undertake complete laparoscopic sacrocolpopexy mesh excision, which should be feasible for skilled laparoscopists. This approach has advantages over the open approach, with good access and visualisation of the entire course of the mesh, and more rapid recovery for the patient.