Complications requiring reoperation following vaginal mesh kit procedures for prolapse

A systematic review of the surgical management of apical pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

This systematic review (PROSPERO:CRD42022275789) is aimed at comparing qualitatively the success, recurrence, and complication rates of sacrocolpopexy with concomitant hysterectomy, hysteropexy, sacrospinous fixation (SSF) with and without vaginal hysterectomy (VH) and uterosacral fixation (USF) with and without VH.

METHODS

A systematic search was performed using Embase, PubMed, Scopus, and Cochrane databases for studies published from 2011, on women with apical pelvic organ prolapse requiring surgical interventions. Risk of bias was assessed via the National Institutes of Health study quality assessment tool. The primary outcomes are the success and recurrence rate of each technique, for ≥12 months' follow-up. Findings were summarised qualitatively.

RESULTS

A total of 21 studies were included. Overall significant findings for a high success and low recurrence rate are summarised as: minimally invasive sacrocolpopexy (MISC) is superior to abdominal sacrocolpopexy (ASC); sacrospinous hysteropexy (SSHP) is superior to USF + VH, which is superior to uterosacral hysteropexy and mesh hysteropexy (MHP). Significant findings related to complications include: MISC recorded a lower overall complication rate than ASC except in mesh exposure; USF + VH tends to perform better than SSHP and SSF, with SSHP performing better than MHP in faecal incontinence and overactive bladder rates.

CONCLUSION

There is no evidence to conclude that hysterectomy is superior to uterine-sparing approaches. MISC should be considered over ASC given similar efficacy and reduced complications. Superiority of MHP is unproven against native tissue hysteropexy. Further studies under standardised settings are required for direct comparisons between the surgical management methods.

Are anterior mesh arms necessary in Japanese-style transvaginal mesh surgery for cystocele?

AIM

In this study, we retrospectively analyzed the medium-term efficacy and safety of surgery with transobturator two-arm transvaginal mesh for cystocele and to verify whether the anterior arms are necessary for Japanese-style transvaginal mesh surgery.

METHODS

The study included 203 patients with cystocele who underwent transobturator two-arm transvaginal mesh at our hospital between August 2015 and June 2017 and received appropriate follow-up care for at least 48 months after surgery.

RESULTS

The Pelvic Organ Prolapse Quantification stage was III in all the patients. Intraoperative complications included two cases of bladder injury and one case of more than 200 mL of blood loss. The mean observation period was 51.9 months, and prolapse recurred in the operated compartment in nine patients (4.4%). No cases of mesh exposure were observed. In comparing the preoperative characteristics of the 9 patients with prolapse recurrence at the surgical site with those of the other 194 patients, we found that the recurrence rate was significantly higher among patients in whom point Ba being 3.5 cm or more and among patients younger than 66 years.

CONCLUSIONS

Transobturator two-arm transvaginal mesh for cystocele was as good and safe as the procedure previously reported with four-arm mesh; thus, it was possible to omit the anterior mesh arms in Japanese-style transvaginal mesh surgery. Patients should be informed preoperatively that prolapse recurs at a significantly higher rate among younger patients and in those whose point Ba being 3.5 cm or more.

Perianal abscess as a manifestation of vaginocutaneous fistula after pelvic floor reconstruction

We present a case of vaginocutaneous fistula 10 years after pelvic floor reconstruction using transvaginal mesh implantation. The female patient in her mid-60s presented with typical symptoms of perianal abscess. After undergoing three surgical operations, the perianal infection was shown to be due to the implanted mesh as a late complication of the reconstruction. The patient was successfully managed with limited removal of the mesh tails. The case highlights one of the late complications of pelvic floor reconstruction using synthetic meshes.

Ten-year surgical complications and mesh erosion of transvaginal Elevate™ mesh for management of pelvic organ prolapse

This study aims to review the surgical complications and mesh erosion with a cohort of patients who underwent Elevate™ mesh repair. This was a single-centre, retrospective study of women undergoing Elevate™ mesh reconstruction between 2006 and 2016. Women who presented with symptomatic prolapse of stage II or above were enrolled. The study outcomes were intra-operative and peri-operative complications (including mesh complications) at six weeks, one year and five years reporting with a standardised communicable method-the International Urogynecological Association (IUGA)/International Continence Society (ICS) scale and the Clavien and Dindo Classification. A total number of 350 women had Elevate™ mesh insertion. The mesh exposure rate was 1.1% and the surgical complication rate in our series was low and self-limiting (2% were Dindo grade 3). With the low morbidity and mesh-related complications, Elevate™ mesh should be at least kept as an alternative treatment of pelvic organ prolapse. Impact statementWhat is already known on this subject? Transvaginal mesh repair surgery was popular to treat advanced pelvic organ prolapse 10 years ago. However, after announcement of the Food and Drug Administration (FDA) public notification regarding mesh-related complications, particularly mesh exposure, use of transvaginal mesh and its safety have been scrutinised. Despite the increasing challenging and difficult medico-legal climate, several studies on second generation mesh kits, such as Elevate™ have shown favourable outcomes with low complication rates including our group.What do the results of this study add? In this paper, the surgical complications and mesh erosion of Transvaginal mesh was reported in a quantified communicable method-the International Urogynecological Association (IUGA)/International Continence Society (ICS) scale and the Clavien and Dindo Classification. This is significant because it is the largest case studies from a single centre with 350 patients.What are the implications of these findings for clinical practice and/or further research? This study well demonstrated using a standardised way to classify mesh exposure and peri-operative complications which is lacking in the past, while majority studies only focus to discuss on surgical outcome instead of complications. This may make a spark for future research analysis.

Surgical treatment of advanced anterior wall and apical vaginal prolapse using the anchorless self-retaining support implant: long-term follow-up

INTRODUCTION AND HYPOTHESIS

Following health notification by the FDA in 2008 of serious complications with transvaginal mesh for anterior pelvic organ prolapse, there has been a return to native tissue repairs. Earlier work with a self-retaining support (SRS) implant showed a high anatomical success rate with minimal implant-related complications over a medium-term follow-up. It is proposed that post-implant complications are more a consequence of the method of mesh anchoring rather than the implant itself. Our system incorporates an ultralight mesh with a frame that provides level I, II, and III support without the need for fixation. The first long-term outcomes of SRS implantation are presented.

METHODS

A prospective multicenter trial was conducted using two consecutive identical protocols of the use of the SRS implant in women with symptomatic anterior compartment prolapse extending their follow-up to 36 months. Anatomical success (Pelvic Organ Prolapse Quantification stage 0 or 1 or a Ba ≤ -2) was recorded along with subjective success as defined by regular quality-of-life (PFDI-20 and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire) assessments.

RESULTS

Sixty-seven patients completed 36 months of follow-up. Mean Ba measurements improved from 3.1 (-1 to 6) cm to -2.8 (-1 to -3) cm and C point from 0.4 (-8 to 6) cm to -6.9 (-10 cm to 1) cm. accumulating to a significant anatomical success rate of 94.3%. Subjective success based on question #3 of the PFDI-20, analyzed for the index surgical compartment, reached 95.7%. Post-operative complications included 2 cases of urinary retention, 1 minor frame exposure, 1 case of delayed voiding dysfunction, and 2 cases of de novo stress urinary incontinence. Untreated pre-operative second-degree Bp measurements had increased in 27% at follow-up.

CONCLUSION

The long-term outcome of the SRS implant shows an excellent subjective and objective success with minimal risk of complications or need for reintervention.

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,...

Improvement in dyspareunia after vaginal mesh removal measured by a validated questionnaire

INTRODUCTION AND HYPOTHESIS

The objective was to examine the effect of the surgical removal of vaginally placed prolapse and incontinence mesh on sexual function. We hypothesize that patients with painful complications of mesh will experience improvement in dyspareunia and sexual function after mesh removal.

METHODS

The eligible cohort consisted of 133 women who presented with a new onset of pain attributed to mesh-augmented incontinence or prolapse surgery and who elected to undergo mesh removal between 1 August 2012 and 1 July 2013. Sexual function symptoms were assessed before and after mesh removal surgery using the Pelvic Organ Prolapse and Urinary Incontinence Sexual Function Questionnaire short form (PISQ-12). Multivariate analysis was performed to identify predictors of improvement in dyspareunia.

RESULTS

Ninety-four patients undergoing mesh removal completed a pre-operative questionnaire, 63 of whom also completed a post-operative questionnaire. After mesh removal, there was a nearly 50% reduction in the proportion of women reporting always experiencing post-operative pain with intercourse among those experiencing pre-operative pain. There was a statistically significant quantitative improvement in pain with intercourse after mesh removal based on mean change score of PISQ-12 question 5 "How often do you experience pain with intercourse?". In multivariate analysis, only history of vaginal delivery was associated with symptom improvement.

CONCLUSION

Removal of transvaginal prolapse mesh is associated with improvement in self-reported dyspareunia based on a standardized question on a validated instrument in a small cohort of women. Although larger studies are needed to confirm the relationship between mesh-augmented surgeries and post-procedural dyspareunia, these data suggest that consideration of mesh removal is a reasonable step for patients with painful intercourse attributed to mesh-augmented prolapse and incontinence surgeries.

Endometrial SUSD2+ Mesenchymal Stem/Stromal Cells in Tissue Engineering: Advances in Novel Cellular Constructs for Pelvic Organ Prolapse

Cellular therapy is an emerging field in clinical and personalised medicine. Many adult mesenchymal stem/progenitor cells (MSC) or pluripotent derivatives are being assessed simultaneously in preclinical trials for their potential treatment applications in chronic and degenerative human diseases. Endometrial mesenchymal stem/progenitor cells (eMSC) have been identified as clonogenic cells that exist in unique perivascular niches within the uterine endometrium. Compared with MSC isolated from other tissue sources, such as bone marrow and adipose tissue, eMSC can be extracted through less invasive methods of tissue sampling, and they exhibit improvements in potency, proliferative capacity, and control of culture-induced differentiation. In this review, we summarize the potential cell therapy and tissue engineering applications of eMSC in pelvic organ prolapse (POP), emphasising their ability to exert angiogenic and strong immunomodulatory responses that improve tissue integration of novel surgical constructs for POP and promote vaginal tissue healing.

[Pelvic and perineal pain after genital prolapse: A literature review]

INTRODUCTION

Pelvic and perineal pain after genital prolapse surgery is a serious and frequent post-operative complication which diagnosis and therapeutic management can be complex.

MATERIALS ET METHODS

A literature review was carried out on the Pubmed database using the following words and MeSH : genital prolapse, pain, dyspareunia, genital prolapse and pain, genital prolapse and dyspareunia, genital prolapse and surgery, pain and surgery.

RESULTS

Among the 133 articles found, 74 were selected. Post-operative chronic pelvic pain persisting more than 3 months after surgery according to the International Association for the Study of Pain. It can be nociceptive, neuropathic or dysfunctional. Its diagnosis is mainly clinical. Its incidence is estimated between 1% and 50% and the risk factors are young age, the presence of comorbidities, history of prolapse surgery, severe prolapse, preoperative pain, invasive surgical approach, simultaneous placement of several meshes, less operator experience, increased operative time and early post-operative pain. The vaginal approach can cause a change in compliance and vaginal length as well as injury to the pudendal, sciatic and obturator nerves and in some cases lead to myofascial pelvic pain syndrome, whereas the laparoscopic approach can lead to parietal nerve damage. Therapeutic management is multidisciplinary and complex.

CONCLUSION

Pelvic pain after genital prolapse surgery is still obscure to this day.

Vaginal posterior isthmic sling: A report of 53 cases

INTRODUCTION

Sacrospinofixation is used for fundic vaginal vault's prolapse or to prevent mid-level or posterior prolapse. It can lead to complications such as dyspareunia, chronic pain, and quality of life impairment. Anchoring a posterior isthmic sling to the two sacrospinous ligaments is an alternative to classic Richter's sacrospinofixation. Objective of this study is to report the first cases of vaginal posterior isthmic slings.

METHODS

This study is retrospective and unicentric. It includes women who had posterior isthmic sling at the time of a surgery with a mesh for anterior prolapse by vaginal way between 2010 and 2016 in the gynecologic department of a teaching hospital. Report of efficacy and tolerance was performed.

RESULTS

Between 2010 and 2016, 53 women were included with a posterior isthmic sling and a mesh for an anterior prolapse. POP-Q evolution during the follow-up in the posterior isthmic sling group assess of a good efficacy of the sling. Four women (7.5%) required second surgery in 28 months following initial surgery (only 1 for excision). Four women (7.5%) had a prolapse recurrence in a mean time of 30 months without recurrent surgery. Women's satisfaction level was high (8.0/10 [7,1-8,8]).

CONCLUSION

Efficacy and tolerance of the posterior isthmic sling seems good. It might then be an option for mid-level prolapses in case of vaginal surgery with mesh for anterior prolapse. A non-inferiority trial should be performed to be able to conclude on the place of this alternative to Richter's sacrospinofixation.

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.

Pelvic Organ Prolapse: ACOG Practice Bulletin, Number 214

Pelvic organ prolapse (POP) is a common, benign condition in women. For many women it can cause vaginal bulge and pressure, voiding dysfunction, defecatory dysfunction, and sexual dysfunction, which may adversely affect quality of life. Women in the United States have a 13% lifetime risk of undergoing surgery for POP (). Although POP can occur in younger women, the peak incidence of POP symptoms is in women aged 70-79 years (). Given the aging population in the United States, it is anticipated that by 2050 the number of women experiencing POP will increase by approximately 50% (). The purpose of this joint document of the American College of Obstetricians and Gynecologists and the American Urogynecologic Society is to review information on the current understanding of POP in women and to outline guidelines for diagnosis and management that are consistent with the best available scientific evidence.

Feasibility and safety of self-expandable metal stent in nonmalignant disease of the lower gastrointestinal tract

In recent years, self-expandable metal stents (SEMSs) have been employed to treat benign gastrointestinal strictures secondary to several conditions: Acute diverticulitis, radiation colitis, inflammatory bowel disease (IBD), and postanastomotic leakages and stenosis. Other applications include endometriosis and fistulas of the lower gastrointestinal tract. Although it may be technically feasible to proceed to stenting in the aforementioned benign diseases of the lower gastrointestinal tract, the outcome has been reported to be poor. In fact, in some settings (such as complicated diverticulitis and postsurgical anastomotic strictures), stenting seems to have a limited evidence-based benefit as a bridge to surgery, while in other settings (such as endometriosis, IBD, radiation colitis, etc.), even society guidelines are not able to guide the endoscopist through decisional algorithms for SEMS placement. The aim of this narrative paper is to review the scientific evidence regarding the use of SEMSs in nonmalignant diseases of the lower gastrointestinal tract, both in adult and pediatric settings.

Abnormal vaginal microbiome associated with vaginal mesh complications

Aims

To identify differences in the vaginal microbiomes of women after transvaginal mesh (TVM) surgery for pelvic organ prolapse with and without mesh‐associated complications.

Methods

Patients with complications were eligible as cases, patients without as controls. DNA was isolated and the V1‐2 region of the 16S ribosomal RNA gene was amplified and sequenced. Overall richness was quantified using Chao1. Overall diversity was expressed as Shannon diversity and screened for group differences using analysis of variance. Multivariate differences among groups were evaluated with functions from R.

Results

We recruited 14 patients after mesh exposure, 5 after contraction, and 21 as controls. The average number of operational taxonomic unit was 74.79 (SD ± 63.91) for controls, 57.13 (SD ± 58.74) after exposures, and 92.42 (SD ± 50.01) after contractions. Total 89.6% of bacteria in controls, 86.4% in previous exposures, and 81.3% in contractions were classified as either Firmicutes, Proteobacteria, or Actinobacteria (P < .001). Veillonella spp. was more abundant in patients after contraction (P = .045). The individual microbiomes varied, and we did not detect any significant differences in richness but a trend towards higher diversity with complications.

Conclusions

The presence of Veillonella spp. could be associated with mesh contraction. Our study did not identify vaginal microbiotic dysbiosis as a factor associated with exposure. Larger cohort studies would be needed to distinguish the vaginal microbiome of women predisposed to mesh‐related complications for targeted phenotyping of patients who could benefit from TVM surgery.

Management of vaginal mesh exposure: A systematic review

Objectives: To identify various predisposing factors, the clinical presentation, and the management of vaginal mesh-related complications, with special emphasis on mesh exposure and the indications for and results of vaginal mesh removal.

Methods: A systematic literature review was performed using a search strategy based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria. PubMed was queried for studies regarding aetiology, risk factors, and management of vaginal mesh exposure from 1 January 2008 to June 2018. Full-text articles were obtained for eligible abstracts. Relevant articles were included, and the cited references were used to identify relevant articles not previously included.

Results: A total of 102 abstracts were identified from the PubMed search criteria. An additional 45 studies were identified based on review of the cited references. After applying eligibility criteria and excluding impertinent articles, 58 studies were included in the final analysis.

Conclusion: Numerous studies have found at least some degree of symptomatic improvement regardless of the amount of mesh removed. Focal areas of exposure or pain can be successfully managed with partial mesh removal with low rates of complications. With partial mesh removal, many patients will ultimately require subsequent mesh removal procedures. For this reason, complete mesh excision is an alternative for patients with diffuse vaginal pain, large mesh exposure, and extrusion of mesh into adjacent viscera. However, when considering complete mesh removal, it is important to counsel patients regarding possible complications of removal and the increased risk of recurrent stress urinary incontinence and pelvic organ prolapse postoperatively.

Abbreviations: MUS: midurethral sling; OR: odds ratio; POP: pelvic organ prolapse; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-analyses; SUI: stress urinary incontinence; TOT: transobturator; TVT: tension-free vaginal tape

The challenge of stress incontinence and pelvic organ prolapse: revisiting biologic mesh materials

PURPOSE OF REVIEW

The present article reviews the history of mesh-related complications and regulations in SUI and POP repair settings, clinical outcomes associated with the use of biologic and synthetic mesh materials, and novel approaches using modified mesh materials.

RECENT FINDINGS

Treatment of pelvic floor disorders, such as stress urinary incontinence (SUI) and pelvic organ prolapse (POP) commonly involves implantation of synthetic surgical mesh materials like polypropylene. Many synthetic mesh materials, however, are associated with a foreign body response upon implantation, which is characterized by fibrotic encapsulation. Complications, including erosion, infections, bleeding, and chronic pain, have led to warnings by regulatory agencies and the recall of several mesh products. To mitigate such complications, biologic mesh materials have been proposed as alternatives for SUI and POP repair.

SUMMARY

Clinical outcomes of surgical repair of POP/SUI are similar between biologic and synthetic meshes, but biologic meshes have a lower incidence of adverse effects. Several strategies for modifying or functionalizing biological and synthetic meshes have shown promising results in preclinical studies.

Experimental study of a new original mesh developed for pelvic floor reconstructive surgery

INTRODUCTION AND HYPOTHESIS

Most synthetic meshes used in transvaginal surgery are made of polypropylene, which has a stable performance, but does not easily degrade in vivo. However, mesh-related complications are difficult to address and have raised serious concerns. A new biomaterial mesh with good tissue integration and few mesh-related complications is needed. To evaluate the effect of a new bacterial cellulose (BC) mesh on pelvic floor reconstruction following implantation in the vagina of sheep after 1 and 12 weeks.

METHODS

The meshes were implanted in the submucosa of the posterior vagina wall of sheep. At 1 and 12 weeks after surgery, mesh-tissue complex (MTC) specimens were harvested for histological studies and biomechanical evaluation. At 12 weeks after surgery, MTC specimens were biomechanically assessed by a uniaxial tension "pulley system".

RESULTS

The BC mesh elicited a higher inflammatory response than Gynemesh™PS at both 1 and 12 weeks after implantation. Twelve weeks after implantation, the BC mesh resulted in less fibrosis than Gynemesh™PS. Compared with the Gynemesh™PS group, the BC mesh group had increased mRNA expression of MMP-1, MMP-2, and MMP-9 (P < 0.05), but decreased expression of the anti-inflammatory factor IL-4 (P < 0.05). Twelve weeks after implantation, the ultimate load and maximum elongation percentage of the BC mesh were significantly lower than those of Gynemesh™PS.

CONCLUSIONS

The BC mesh could not be a promising biomaterial for pelvic floor reconstructive surgery unless the production process and parameters were improved.

Stress Urinary Incontinence and Pelvic Organ Prolapse Correction by Single Incision and Using Monoprosthesis: Three-year Follow-up

Background:

The aim was to study the effectiveness and safety of a modified technique that employs a four-arm polypropylene (PP) mesh (NAZCA-TC) to treat pelvic organ prolapse (POP) and concurrent stress urinary incontinence (SUI) simultaneously.

Materials and Methods:

This prospective follow-up study was conducted on fifty SUI women with concurrent high-grade (greater than Stage 2) anterior vaginal wall and/or uterine prolapse who were referred to Al-Zahra and Noor Hospitals in Isfahan and underwent surgery using the NAZCA-TC, Promedon, Argantina kit. The POP-Quantification system was employed for staging POP before and after surgery. To evaluate lower urinary tract symptoms (LUTS) and patients’ quality of life, a stress test and the short form of International Consultation on Incontinence Questionnaire of Female Lower Urinary Tract Symptom were used. Patients were followed up and assessed at 6 weeks, 6 months, and 1, 2, and 3 years after surgery.

Results:

The mean age of patients was 58.2 ± 10.2 years. There was a great reduction (88.6%) in POP staging after surgery. The success rate of SUI treatment was significantly high (83.5%). During 3 years of postoperative follow-up, mesh erosion occurred in 18%, 5 patients (10%) presented with mesh erosion in the first years after operation, 16% reported significant groin or pelvic pain, and 10% required sling release.

Conclusion:

A single vaginal incision and using two less percutaneous access sites with the PP meshes were effective for treating patients with concurrent POP and SUI but have a high rate of postsurgery erosion rate.

Treatment of Anterior Vaginal Wall Prolapse Using Transvaginal Anterior Mesh With Apical Fixation: A Prospective Multicenter Study With up to 2 Years of Follow-up

Purpose

To evaluate the safety and efficacy of a surgical polypropylene mesh for correction of anterior vaginal prolapse, with or without apical defects, by providing simultaneous reinforcement at the anterior and apical aspects of the vagina with a single-incision approach.

Methods

This was a prospective, multicenter, single-arm study involving women with baseline stage ≥2 anterior and/or apical vaginal wall prolapse according to the Pelvic Organ Prolapse Quantification (POP-Q) system. The primary endpoint was defined as achievement of POP-Q stage ≤1 status. Additionally, patient-reported outcomes were assessed using the International Consultation on Incontinence Questionnaire-Vaginal Symptoms (ICIQ-VS). The device under evaluation was Calistar A, which is fixed posteriorly to the sacrospinous ligaments with a novel tissue-anchoring system (TAS) and anteriorly to the obturator internus muscles. Postoperative follow-ups were scheduled at 7 days and at 6, 12, and 24 months.

Results

Ninety-seven women were treated and assessed for the primary outcome. They were followed for up to 2 years (n=43), with a median of 12 months. Objective cure was achieved in 86 of the 97 patients (88.7%) (P<0.0005). The mean reduction in the ICIQ-VS scores was in the range of 70%–90% for every time point (P<0.05). No bleeding or surgical revision was reported. Mesh exposure occurred in 7 patients (7.2%), urinary retention in 5 (5.2%), de novo dyspareunia in 3 (3.1%), and urinary tract infections in 7 (7.2%).

Conclusions

This midterm follow-up showed that apical and anterior vaginal reinforcement with a polypropylene implant fixed with a TAS provided good anatomical correction, with no major complications.

BIOMECHANICAL CHARACTERIZATION OF NORMAL AND PROLAPSED VAGINAL TISSUE SURROGATES

In the recent years, poorly evaluated gynecological surgeries and urogynecological mesh implantations have been affecting millions of women in the US and across the globe. These failed surgeries could be mainly attributed to the nonavailability of vaginal tissues (due to ethical and biosafety issues), which does not allow any experimental testing of operation and mesh implantation techniques before an actual surgery. A surrogate which behaves biomechanically like the human vaginal tissue would be indispensable for simulating surgical suture of vaginal tissues in prolapse surgery, hysterectomy or surgery during traumatic child births (such as Cesarean). Also, vaginal tissue surrogates simulating the various prolapse conditions (such as vaginal tissue stiffening) would be very useful to evaluate tissue modifications due to prolapse, and also mesh and vaginal tissue interactions. In the current work, a low cost four-part silicone-based material was developed, which precisely simulates the linear and nonlinear mechanical behavior of the normal human vaginal tissue. Additionally, a range of four-part silicone-based novel materials were developed which precisely mimics the mechanical behavior of stiffened vaginal tissues at different degrees of prolapse. The linear and nonlinear mechanical behavior of all such novel materials were characterized using elastic and hyperelastic formulations. Such precisely characterized normal and prolapsed vaginal tissue surrogates have not been developed anywhere to date as per the best of our knowledge and would be clinically helpful for gynecological surgical planning in the future.

Short term post-operative morphing of sacrocolpopexy mesh measured by magnetic resonance imaging

BACKGROUND

Sacrocolpopexy (SC) involves suspension of the vaginal vault or cervix to the sacrum using a mesh. Following insertion, the meshes have been observed to have undergone dimensional changes.

OBJECTIVE

To quantify dimensional changes of meshes following implantation and characterize their morphology in-vivo.

DESIGN SETTING AND PARTICIPANTS

24 patients underwent SC using PolyVinyliDeneFluoride mesh loaded with Fe₃O₄ particles. Tailored anterior and posterior mesh flaps were sutured to the respective vaginal walls, uniting at the apex. The posterior flap continued to the sacrum and was attached there. Meshes were visualized on magnetic resonance (MR) imaging at 12 [3-12] (median [range]) months postoperatively and 3D models of the mesh were generated. Dynamic MR sequences were acquired during valsalva to record mesh mobility.

OUTCOME MEASURES

The area of the vagina effectively supported by the mesh (Effective Support Area (ESA)) was calculated. The 3D models' wall thickness map was analyzed to identify the locations of mesh folding. Intraclass correlation (ICC) was calculated to test the reliability of the methods. To measure the laxity and flatness of the mesh, the curvature and the ellipticity of the sacral flap were calculated.

RESULTS

The ESA calculation methodology had ICC = 0.97. A reduction of 75.49 [61.55-78.67] % (median [IQR]) in area, 47.64 [38.07-59.81] % in anterior flap, and of 23.95 [10.96-27.21] % in the posterior flap was measured. The mesh appeared thicker near its attachment at the sacral promontory (n = 19) and near the vaginal apex (n = 22). The laxity of the mesh was 1.13 [1.10-1.16] and 60.55 [49.76-76.25] % of the sacral flap was flat. We could not reliably measure mesh mobility (ICC = 0.16).

CONCLUSION

A methodology for complete 3D characterization of SC meshes using MR images was presented. After implantation, the supported area is much lower than what is prepared prior to implantation. We propose this happened during the surgery itself.

Transobturator four arms mesh in the surgical management of stress urinary incontinence with cystocele

Objective

This study aims to evaluate safety and efficacy of four arms polypropylene mesh in the long- term follow-up in the management of stress urinary incontinence (SUI) associated with cystocele.

Material and methods

This prospective study was conducted on 50 female patients with SUI associated with cystocele. Patients underwent placement of transobturator four-arms mesh implants. Stress incontinence was evaluated using cough stress test with and without prolapse reduction, Stamey's grading of SUI, the validated Arabic version of the International Consultation on Incontinence Questionnaire-Short Form and King Health Questionnaire forms. Perioperative parameters evaluated included age, body mass index, grade of SUI, time of procedure, hospital stay after surgery, difference between pre-, and postoperative serum hemoglobin values, and need for blood transfusion. Follow- up visits were planned at 3, 9 and 18 months after surgery.

Results

The mean operative time was 37.4±10.2 (25-60) minutes. Blood transfusion was not required. The mean hospital stay was 30.5±10 (24-48) hrs. Five (10%) patients had fever and urinary tract infections were noticed in five (10%) patients. Two (4%) women had urine retention after catheter removal and vaginal mesh erosion was present in one (2%) patient. Forty (80%) patients were cured from SUI, 8 (16%) patients were improved and 2 (4%) patients failed to respond.

Conclusion

Cystocele associated with SUI can be repaired with transobturator four-arms mesh with promising results, improved quality of life, and tolerable side effects.

Self-retaining support implant: an anchorless system for the treatment of pelvic organ prolapse-2-year follow-up

INTRODUCTION AND HYPOTHESIS

The search for an improved vaginal mesh prompted the development of a new anchorless implant. The objective was to report on outcome after 2 years of a technique using a self-retaining support (SRS) implant.

METHODS

Patients with anterior vaginal wall prolapse, with/without apical prolapse, were recruited. Participants underwent surgical repair using the SRS device. Demographic data, pre-surgical Pelvic Organ Prolapse Quantification (POP-Q) scoring, quality of life (QoL) questionnaires (Pelvic Floor Distress Inventory Short Form 20 [PFDI-20], Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire 12 [PISQ-12]), and surgical data were collected. Patients were followed at 2 weeks, 2, 6, 12, and 24 months after surgery. Objective anatomical success was defined using the NIH criteria.

RESULTS

Twenty women were recruited for the study with an average age of 62.1 years and an average parity of 4.0 deliveries. Average BMI was 28. Pre-operative mean POP-Q measurements were Aa =1.40 (-1 to 3) cm, Ba = 2.3 (-1 to 6) cm and C = 0.4 (-7 to 6) cm. Surgical time averaged 31.2 min. Estimated blood loss averaged 165 ml. No intra-operative complications were observed. One case (5%) of frame erosion was documented 8 months after surgery. At 2 years' follow-up, mean POP-Q measurements were: Aa = -2.95 (-3 to -2) cm, Ba = -2.85 (-3 to -2) cm, and C point -6.90 (-10 to -3) cm. Seventeen (85%) patients had stage 0 and 3 patients (15%) had stage 1. No mesh erosions or chronic pelvic pain were documented at follow-up. The total PFDI score at follow-up was decreased by 92.8 points (p < 0.0001).

CONCLUSIONS

At 2 years' follow-up, the SRS implant was found to be safe, showing no intra-operative or immediate post-operative complications. All women presented with POP-Q measurements of the anterior and apical compartment at normal value (Ba ≤ -2 cm) and statistically significant subjective improvement.

Transvaginal Repair of Complex Rectovaginal Fistulas Using the Porcine Urinary Bladder Matrix as an Augmenting Graft

BACKGROUND

After the US Food and Drug Administration issued a safety warning concerning vaginal mesh implants in 2008, their use in correction of pelvic floor defects have decreased in the United States (http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm479732.htm). However, we are still treating patients who have had complications associated with their use, rectovaginal fistulas (RVFs) being one of them. Rectovaginal fistulas are considered complex if greater than 2.5 cm, recurrent, associated with inflammatory bowel disease, or if they are proximal in location. Various surgical techniques have been described for treating RVFs. Interposition grafts such as Martius, gracilis, omental J flaps, and rectus abdominis flaps have been used extensively in correcting RVFs (Am J Gastroenterol 2014;109(8):1141-1157). However, these techniques may increase morbidity or have poor cosmesis. Pelvic surgeons have chronicled the use of biologic grafts for fistula repair. Of the various biologic grafts in use, there have been no reports describing the use of porcine urinary bladder matrix (UBM) for fistula repair. We report on 2 cases of large, complex RVFs secondary to mesh erosion, which were effectively treated with transvaginal repair using the UBM.

CASES

An 80-year-old woman was referred by the colorectal service to our urogynecology service with complaints of rectal bleeding and vaginal spotting secondary to mesh erosion. Surgical history included hysterectomy with mesh augmented posterior repair with synthetic midurethral sling placement in 2002. Examination revealed a 3-cm mesh exposure located in the middle third of the posterior vaginal wall. On rectovaginal examination, a 3-cm full-thickness RVF with through-and-through mesh erosion was noted between the rectum and vagina.A 65-year-old woman presented to our service with complaints of passage of fecal material through the vagina. Surgical history was significant for hysterectomy in 1988 and prolapse repair with anterior and posterior vaginal mesh in 2009. Subsequently in 2011, she had part of the mesh removed because of exposure. Vaginal examination revealed mesh exposure at the right sulcus of the anterior wall consistent with evidence of prior sling and another mesh exposure on the posterior vaginal wall. Rectovaginal examination revealed palpable mesh in the rectovaginal septum with a 3-cm large and complex fistula. Both of our patients underwent transvaginal excision of mesh, RVF repair, and posterior repair with augmentation with UBM. At 6- and 10-month follow-up, they reported complete resolution of their symptoms with no fistula noted on physical examination.

CONCLUSIONS

Typically, traditional repair with use of muscular advancement flaps is performed for complex RVF closures. Recently, however, various biologic agents have been successfully used to augment RVF repair. In our cases, the use of UBM led to successful follow-up at 6 to 8 months. Despite existing literature, there remains a void in the depth of knowledge regarding the UBM grafts. Larger studies utilizing it for repair of RVFs are warranted to further understand the success and effectiveness of the UBM grafts for RVF repair.

In Vivo Ultrasound Characteristics of Vaginal Mesh Kit Complications

OBJECTIVE

The objective of this study was to investigate the ultrasound characteristics of vaginal mesh in women with vaginal mesh complications.

METHODS

This was a cross-sectional study of women presenting with extrusion complications from vaginal mesh kit for prolapse at our tertiary care center between years 2009 and 2014. We included women who concurrently underwent a 3-dimensional endovaginal ultrasound (EVUS) as part of the clinical evaluation. We excluded women with incomplete charts and poor imaging quality. Subjects were categorized by the presence or absence of associated pelvic pain. Based on ultrasound findings, we compared the location of mesh, the appearance of mesh pattern (flat, folding, prominence, convoluted), and other EVUS characteristics of mesh.

RESULTS

Forty-six women with vaginal mesh complications and good image quality were included. When comparing mesh length between posterior and anterior compartments, the posterior meshes were significantly longer than the anterior meshes (42.1 [SD, 11.9] mm vs 25.8 [SD, 9] mm; P < 0.0001) and more often associated with pain. In the posterior compartment, the mean mesh length seen on EVUS was significantly longer in women with pain than in women without pain (46.5 [SD, 9] mm vs 31.8 [SD, 12.1] mm; P = 0.0001). There was also a higher proportion of a "flat" mesh pattern, 14 (58.3%) of 25, in the posterior compartment associated with the presence of pain (P = 0.013). In the posterior compartment, a smaller distance between the distal edge of the mesh and the anal sphincter was significantly associated with the presence of pain (8 mm [0-37] vs 21 mm [8-35], P = 0.024). In both compartments, the EVUS had 100% sensitivity for detection of mesh extrusions.

CONCLUSIONS

In this population of patients presenting with mesh complications, the posterior meshes were more often visualized as a "flat" pattern with a higher frequency of pain. Mesh complications of the anterior compartment had a higher frequency of folding and shrinkage.

Biomechanical, Topological and Chemical Features That Influence the Implant Success of an Urogynecological Mesh: A Review

Synthetic meshes are normally used to treat several diseases in the field of urogynecological surgery. Not-optimal selection of mesh and/or its not-correct implant may increase patient's pain and discomfort. The knowledge of mechanical behaviour and topological and chemical properties of a mesh plays a fundamental role to minimize patient's suffering and maximize the implant success. We analysed several papers reporting the meshes application for urogynecological pathologies, to extrapolate the principal parameters that normally are used to characterise the biomechanical, topological, and chemical properties, and to verify their influence on implant success. In this way we want demonstrate that, knowing these features, it is possible to foresee the success of a mesh implant. This review shows that the application of a mesh strictly depends on elastic modulus, failure load, porosity and pore size, filament diameter, polymer weight, and crystallinity. To increase the success of the implant and to help choice of optimal mesh for a clinical need, two indexes have been proposed for comparing, in an easier way, the mechanical performance of different commercially available meshes.

Pain Scores and Exposure Rates after Polypropylene Mesh for Pelvic Organ Prolapse

OBJECTIVES

To characterize pain and exposure after Prolift placement and identify risk factors.

METHODS

A case series of women who underwent Prolift vaginal mesh were surveyed. Pain was assessed using a visual analog scale. Exposure was evaluated clinically.

RESULTS

Of 183 eligible patients, 160 completed the survey, and 45 returned for examination. Mean preoperative pain score was 0.97 and postoperative was 1.35 (P = 0.12). Pre- and postoperative pain scores by compartment were: anterior (1.34 vs 1.25, mean change -0.09, P = 0.84), posterior (1.30 vs 1.56, mean change 0.26, P = 0.72), and total (0.63 vs 1.34, mean change 0.71, P = 0.05). Graft exposure was confirmed in 23 of 183 patients (12.6%); however, because asymptomatic patients were not examined, the true exposure rate may be underestimated. Hematoma formation is independently associated with mesh exposure, adjusted odds ratio 18.4 (95% confidence interval 3.4-147.4, P = 0.01).

CONCLUSIONS

Although pain scores did not increase overall, there was a trend toward increased pain score in the patients with total (anterior and posterior) Prolift. Hematoma formation was significantly associated with mesh exposure.

Incidence and risk factors for mesh erosion after laparoscopic repair of pelvic organ prolapse by lateral suspension with mesh

INTRODUCTION AND HYPOTHESIS

The objective of our study was to estimate the incidence and identify the risk factors for mesh erosion after laparoscopic repair of pelvic organ prolapse (POP) by lateral suspension with mesh.

METHODS

We conducted a nested case-control study among 480 women who underwent POP repair by laparoscopic lateral suspension with mesh from January 2004 to October 2012. Cases (n = 18) were women who showed mesh erosion following the first intervention through December 2014. Controls (n = 133) were women randomly selected from the same cohort who did not have any erosion.

RESULTS

The risk of mesh erosion was 3.8 % with a mean follow-up of 82.3 months (range 28.2 - 130.6 months). The main risk factor was the use of a type 3 mesh (macroporous with either multifilamentous or microporous components) rather than a type 1 mesh (macroporous and monofilamentous; adjusted OR 13.0, 95 % CI 1.5 - 110.6; P = 0.02). Risk factors included smoking (adjusted OR 10.4, 95 % CI 2.3 - 46.5; P < 0.01) and posterior mesh placement (adjusted OR 5.1, 95 % CI 1.2 - 21.8 P = 0.03).

CONCLUSIONS

The risk of mesh erosion is low and may be further reduced by using the appropriate mesh material, and by identifying specific patient characteristics such as tobacco use. As conventional vaginal surgery is effective for the treatment of the posterior compartment, the use of posterior mesh during laparoscopic pelvic floor repair needs to be questioned.

Management of apical pelvic organ prolapse

Pelvic organ prolapse is a prevalent condition, with up to 12 % of women requiring surgery in their lifetime. This manuscript reviews the treatment options for apical prolapse, specifically. Both conservative and surgical management options are acceptable and should be based on patient preferences. Pessaries are the most commonly used conservative management options. Guided pelvic floor muscle training is more beneficial than self-taught Kegel exercises, though may not be effective for high stage or apical prolapse. Surgical treatment options include abdominal and vaginal approaches, the latter of which can be performed open, laparoscopically, and robotically. A systematic review has demonstrated that sacrocolpopexy has better long-term success for treatment of apical prolapse than vaginal techniques, but vaginal surgery can be considered an acceptable alternative. Recent data has demonstrated equal efficacy between uterosacral ligament suspension and sacrospinous ligament suspension at 1 year. To date, two randomized controlled trials have demonstrated equal efficacy between robotic and laparoscopic sacrocolpopexy. Though abdominal approaches may have increased long-term durability, when counseling their patients, surgeons should consider longer operating times and increased pain and cost with these procedures compared to vaginal surgery.

KEY POINTS

• Pelvic floor physical therapy (PFPT) with a physical therapist is the best approach to conservative management of apical prolapse [10]. • Pessaries should be managed with regular follow-up care to minimize complications [14•]. • Minimally invasive sacrocolpopexy appears as effective as the gold standard abdominal sacrocolpopexy (ASC) [42•]. • Robotic assisted sacrocolpopexy (RASC) and laparoscopic assisted sacrocolpopexy (LASC) are equally effective and should be utilized by pelvic floor surgeons based on their skill level and expertise in laparoscopy [44, 45•]. • Uterosacral ligament suspension (USLS) and sacrospinous ligament suspension (SSLS) are considered equally effective procedures and can be combined with a vaginal hysterectomy. • Obliterative procedures are effective but are considered definitive surgery [24••]. • The use of transvaginal mesh has been shown in some studies to be superior to native tissue repairs with regard to anatomic outcomes, but complication rates are higher. Transvaginal mesh should be reserved for surgeons with adequate training so that complications are minimized.

Fixation of Light Weight Polypropylene Mesh with n-Butyl-2-cyanocrylate in Pelvic Floor Surgery: Experimental Design Approach in Sheep for Effectiveness Evaluation

Objective. The aim of this study was to find a proper experimental design and to evaluate n-butyl-2-cyanoacrylate (Histoacryl) as a fixation method for a light-weight and large pore PP mesh (Synthetic PP Mesh-1) using the sheep as an animal model. Methods. Posterior vaginal implantation by means of episiotomy was used to implant 8 ewes which were evaluated macroscopically and histologically at 3 months (n = 4) and 6 months (n = 4) post-surgery. In previous pilot studies anterior vaginal implantation was evaluated, as well as different synthetic mesh materials, sizes and fixation methods (n = 1 to 3) during three weeks. In all cases a clinical evaluation of the animal was performed. Results. A reduction in the mesh size (Synthetic PP Mesh-1) together with precise application of the surgical glue Histoacryl to fix the mesh yielded significantly better histocompatibility results (P < 0.01) compared to larger size or other fixation methods. Conclusion. The combination of Synthetic PP Mesh-1 with Histoacryl offered a high degree of graft integration without vaginal ulceration and a minimal foreign body reaction, being the sheep a proper animal model to test these types of medical devices.

Use and risks of surgical mesh for pelvic organ prolapse surgery in women in New York state: population based cohort study

OBJECTIVE

To assess the use of mesh in pelvic organ prolapse surgery, and compare short term outcomes between procedures using and not using mesh.

DESIGN

All inclusive, population based cohort study.

SETTING

Statewide surgical care captured in the New York Statewide Planning and Research Cooperative System.

PARTICIPANTS

Women who underwent prolapse repair procedures in New York state from 2008 to 2011.

MAIN OUTCOMES MEASURES

90 day safety events and reinterventions within one year, after propensity score matching. Categorical, time to event, and subgroup analyses (<65 and ≥ 65 year age groups) were conducted.

RESULTS

Of 27,991 patients in total, 7338 and 20, 653 underwent prolapse repair procedures with and without mesh, respectively. Mesh use increased by 44.7%, from 1461 procedures in 2008 to 2114 procedures in 2011. Most patients in the cohort were younger than 65 years (62.3% (n=17,424/27, 991)). However, more patients were aged 65 years and older in the mesh group than in the non-mesh group (44.3% (n=3249) v 35.4% (n=7318)). Complications after surgery were not common, irrespective of the use or non-use of mesh. After propensity score matching, patients who received the surgery with mesh had a higher chance of having a reintervention within one year (mesh 3.3% v no mesh 2.2%, hazard ratio 1.47 (95% confidence interval 1.21 to 1.79)) and were more likely to have urinary retention within 90 days (mesh 7.5% v no mesh 5.6%, risk ratio 1.33 (95% confidence interval 1.18 to 1.51)), compared with those who received surgery without mesh. In subgroup analyses based on age, mesh use was associated with an increased risk of reintervention within one year in patients under age 65 years, and increased risk of urinary retention in patients aged 65 years and over.

CONCLUSIONS

Despite multiple warnings released by the US Food and Drug Administration since 2008, use of mesh in pelvic organ prolapse surgery continues to grow. In this statewide comprehensive study, mesh procedures were associated with an increased risk of reinterventions within one year and urinary retention after surgery.

To mesh or not to mesh: a review of pelvic organ reconstructive surgery

Pelvic organ prolapse (POP) is a major health issue with a lifetime risk of undergoing at least one surgical intervention estimated at close to 10%. In the 1990s, the risk of reoperation after primary standard vaginal procedure was estimated to be as high as 30% to 50%. In order to reduce the risk of relapse, gynecological surgeons started to use mesh implants in pelvic organ reconstructive surgery with the emergence of new complications. Recent studies have nevertheless shown that the risk of POP recurrence requiring reoperation is lower than previously estimated, being closer to 10% rather than 30%. The development of mesh surgery - actively promoted by the marketing industry - was tremendous during the past decade, and preceded any studies supporting its benefit for our patients. Randomized trials comparing the use of mesh to native tissue repair in POP surgery have now shown better anatomical but similar functional outcomes, and meshes are associated with more complications, in particular for transvaginal mesh implants. POP is not a life-threatening condition, but a functional problem that impairs quality of life for women. The old adage "primum non nocere" is particularly appropriate when dealing with this condition which requires no treatment when asymptomatic. It is currently admitted that a certain degree of POP is physiological with aging when situated above the landmark of the hymen. Treatment should be individualized and the use of mesh needs to be selective and appropriate. Mesh implants are probably an important tool in pelvic reconstructive surgery, but the ideal implant has yet to be found. The indications for its use still require caution and discernment. This review explores the reasons behind the introduction of mesh augmentation in POP surgery, and aims to clarify the risks, benefits, and the recognized indications for its use.