Use of vaginal mesh in the face of recent FDA warnings and litigation

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.

Elastin homeostasis is altered with pelvic organ prolapse in cultures of vaginal cells from a lysyl oxidase-like 1 knockout mouse model

Pelvic organ prolapse (POP) decreases quality of life for many women, but its pathophysiology is poorly understood. We have previously shown that Lysyl oxidase‐like 1 knockout (Loxl1 KO) mice reliably prolapse with age and increased parity, similar to women. Both this model and clinical studies also indicate that altered elastin metabolism in pelvic floor tissues plays a role in POP manifestation, although it is unknown if this is a cause or effect. Using Loxl1 KO mice, we investigated the effects of genetic absence of Loxl1, vaginal parity, and presence of POP on the expression of genes and proteins key to the production and regulation of elastic matrix. Cultured cells isolated from vaginal explants of mice were assayed with Fastin for elastic matrix, as well as RT‐PCR and Western blot for expression of genes and proteins important for elastin homeostasis. Elastin synthesis significantly decreased with absence of LOXL1 and increased with parity (p < .001), but not with POP. Cells from prolapsed mice expressed significantly decreased MMP‐2 (p < .05) and increased TIMP‐4 (p < .05). The results suggest changes to elastin structure rather than amounts in prolapsed mice as well as poor postpartum elastin turnover, resulting in accumulation of damaged elastic fibers leading to abnormal tropoelastin deposition. POP may thus, be the result of an inability to initiate the molecular mechanisms necessary to clear and replace damaged elastic matrix in pelvic floor tissues after vaginal birth.

Medical Malpractice Litigation in Non-Mesh-Related Pelvic Organ Prolapse Surgery: An Analysis of 91 Cases

INTRODUCTION

Malpractice litigations have significant implications for patients and physicians. Studies have investigated mesh litigations in female pelvic reconstructive surgery, but none on nonmesh pelvic organ prolapse (POP) surgery. Our purpose is to determine the reasons for and outcomes of medical malpractice after nonmesh POP surgery.

METHODS

Westlaw (Thompson Reuters, New York, New York) is a legal research database of US court records. We identified completed POP litigations from 1987 to 2018 using the following: "pelvic organ prolapse," "enterocele," "rectocele," "cystocele," "uterine prolapse," and "vaginal wall prolapse." Mesh-related cases were excluded. Outcomes included reasons for litigation, verdict, injury, and payments. Statistical analysis was performed with nonparametric tests and χ2 independence test.

RESULTS

Ninety-one litigations were included. The median plaintiff age was 53 years (range, 36-85 years). The leading allegation was negligence of surgery (n = 59; 65%). The jury sided with the defendant physician in 67% of cases (n = 61). There was no association between case verdict and patient age (P = 0.781), geographic region (P = 0.824), or allegation (P = 0.904). The primary complications were urinary tract injury (n = 24; 26%), need for additional surgery (n = 22; 24%), and new postoperative urinary symptoms (n = 22; 24%). The median payout was $280,000 (interquartile range, $137,250-$1,300,000), with no difference between plaintiff awards or settlements (P = 0.659).

CONCLUSION

The leading allegation of malpractice litigations for nonmesh POP surgery is negligence of surgery, whereas the most common complication was urinary tract injury. A verdict in favor of the physician defendant was the most likely outcome. Plaintiff awards and settlements were not statistically different with no variation by region or time.

Comparison of synthetic mesh erosion and chronic pain rates after surgery for pelvic organ prolapse and stress urinary incontinence: a systematic review

BACKGROUND

The aim of this study is to systematically compare rates of erosion and chronic pain after mesh insertion for pelvic organ prolapse (POP) and stress urinary incontinence (SUI) surgery.

METHODS

A systematic electronic search was performed on studies that evaluated the incidence of erosion and chronic pain after mesh insertion for POP or SUI. The primary outcome measurement was to compare mesh erosion rates for POP and SUI surgery. Secondary outcome measurements were incidence of de novo pain and a comparison of patient demographics for both surgeries.

RESULTS

Twenty-six studies on 292,606 patients (n = 9077 for POP surgery and n = 283,529 for SUI surgery) met the inclusion criteria. Median follow-up was 26.38 ± 22.17 months for POP surgery and 39.33 ± 27.68 months for SUI surgery. Overall, the POP group were older (p < 0.0001) and had a lower BMI (p < 0.0001). Mesh erosion rates were significantly greater in the POP group compared to the SUI group (4% versus 1.9%) (OR 2.13; 95% CI 1.91-2.37; p < 0.0001). The duration from surgery to onset of mesh erosion was 306.84 ± 183.98 days. There was no difference in erosion rates between abdominal and transvaginal mesh for POP. There was no difference in erosion rates between the transobturator and retropubic approach for SUI. The incidence of chronic pain was significantly greater in the POP group compared to the SUI group (6.7% versus 0.6%) (OR 11.02; 95% CI 8.15-14.9; p < 0.0001). The duration from surgery to onset of chronic pain was 325.88 ± 226.31 days.

CONCLUSIONS

The risk of mesh erosion and chronic pain is significantly higher after surgery for POP compared to SUI. These significant complications occur within the first year after surgery.

Vaginal Er:YAG laser application in the menopausal ewe model: a randomised estrogen and sham-controlled trial

OBJECTIVE

To describe effects of non-ablative erbium-doped:yttrium-aluminium-garnet (Er:YAG) laser on vaginal atrophy induced by iatrogenic menopause in the ewe.

DESIGN

Animal experimental, randomised, sham and estrogen-treatment controlled study with blinding for primary outcome.

SETTING

KU Leuven, Belgium.

SAMPLE

Twenty-four ewes.

METHODS

Menopause was surgically induced, after which the ewes were randomised to three groups receiving vaginal Er:YAG laser application three times, with a 1-month interval; three sham manipulations with a 1-month interval; or estrogen replacement and sham manipulations. At given intervals, ewes were clinically examined and vaginal wall biopsies were taken. Vaginal compliance was determined by passive biomechanical testing from explants taken at autopsy.

MAIN OUTCOME MEASURES

Vaginal epithelial thickness (primary), composition of the lamina propria (collagen, elastin, glycogen and vessel content), vaginal compliance, clinical signs.

RESULTS

Animals exposed to Er:YAG laser application and sham manipulation, but not to estrogens, displayed a significant and comparable increase in vaginal epithelial thickness between baseline and 7 days after the third application (69% and 67%, respectively, both P < 0.0008). In laser-treated ewes, temporary vaginal discharge and limited thermal injury were observed. Estrogen-substituted ewes displayed a more prominent increase in epithelial thickness (202%; P < 0.0001) and higher vaginal compliance (P < 0.05). None of the interventions induced changes in the lamina propria.

CONCLUSIONS

Vaginal Er:YAG laser has comparable effect to sham manipulation in menopausal ewes.

TWEETABLE ABSTRACT

Vaginal Er:YAG laser has comparable effect to sham manipulation in menopausal ewes #LASER #GSM #RCT.

A novel antibacterial biomaterial mesh coated by chitosan and tigecycline for pelvic floor repair and its biological performance

The biomaterials composed of mammalian extracellular matrix (ECM) have a great potential in pelvic floor tissue repair and functional reconstruction. However, bacterial infection does cause great damage to the repair function of biomaterials which is the major problem in clinical utilization. Therefore, the development of biological materials with antimicrobial effect is of great clinical significance for pelvic floor repair. Chitosan/tigecycline (CS/TGC) antibacterial biofilm was prepared by coating CS/TGC nanoparticles on mammalian-derived ECM. Infrared spectroscopy, scanning electron microscopy, bacteriostasis circle assay and static dialysis methods were used to characterize the membrane. MTS assay kit and DAPI fluorescence staining were used to evaluate cytotoxicity and cell adhesion. The biocompatibility was assessed by subabdominal implantation model in goats. Subcutaneous antimicrobial test in rabbit back was used to evaluate the antimicrobial and repairing effects on the infected wounds in vivo. Infrared spectroscopy showed that the composite coating had been successfully modified. The antibacterial membrane retained the main structure of ECM multilayer fibers. In vitro release of biomaterials showed sustained release and stability. In vivo studies showed that the antibacterial biological membrane had low cytotoxicity, fast degradation, good compatibility, anti-infection and excellent repair ability.

Landmarks in vaginal mesh development: polypropylene mesh for treatment of SUI and POP

Vaginal meshes used in the treatment of stress urinary incontinence (SUI) and pelvic organ prolapse (POP) have produced highly variable outcomes, causing life-changing complications in some patients while providing others with effective, minimally invasive treatments. The risk:benefit ratio when using vaginal meshes is a complex issue in which a combination of several factors, including the inherent incompatibility of the mesh material with some applications in pelvic reconstructive surgeries and the lack of appropriate regulatory approval processes at the time of the premarket clearance of these products, have contributed to the occurrence of complications caused by vaginal mesh. Surgical mesh used in hernia repair has evolved over many years, from metal implants to knitted polymer meshes that were adopted for use in the pelvic floor for treatment of POP and SUI. The evolution of the material and textile properties of the surgical mesh was guided by clinical feedback from hernia repair procedures, which were also being modified to obtain the best outcomes with use of the mesh. Current evidence shows how surgical mesh fails biomechanically when used in the pelvic floor and materials with improved performance can be developed using modern material processing and tissue engineering techniques.

Biomimetic implants for pelvic floor repair

BACKGROUND

Polypropylene implants are used for the reconstructive surgery of urogynaecological disorders like pelvic organ prolapse, but severe complications associated with their use have been reported. There is evidence that surface properties and a difference in mechanical stiffness between the implant and the host tissue contribute to these adverse events. Electrospinning is an innovative engineering alternative that provides a biomimetic microstructure for implants, resulting in a different mechano-biological performance.

AIM

The main objective of this review is to inform about the potential of electrospun matrices as an alternative modality for pelvic floor repair.

METHODS

Publications with the following studies of electrospun matrices were reviewed: (i) the technique; (ii) in vitro use for soft tissue engineering; (iii) in vivo use for reconstruction of soft tissues in animals; and (iv) clinical use in humans.

RESULTS

Electrospun matrices provide a synthetic mimic of natural extracellular matrix (ECM), favoring cellular attachment, proliferation and matrix deposition, through which a proper, low-inflammatory tissue-implant interaction can be established. Electrospun sheets can also be created with sufficient mechanical strength and stiffness for usage in prolapse surgery.

CONCLUSION

Electrospun matrices mimic the structural topography of the extracellular matrix and can be functionalized for better biological performance. As such, they have great potential for the next generation of urogynecological implants. However, their long-term safety and efficacy must still be established in vivo.

Trends in Mesh Use for Pelvic Organ Prolapse Repair From the Medicare Database. Urology. 2015;86:885-891. [PMID: 26344153 DOI: 10.1016/j.urology.2015.08.022]

OBJECTIVE

To investigate recent trends in mesh use for pelvic organ prolapse (POP)-related reconstruction procedures.

MATERIALS AND METHODS

Using the 2001-2011 5% Medicare claims database, we identified POP diagnoses and related procedures. Transvaginal mesh use and sacrocolpopexy were first reported in 2005 and 2004, respectively.

RESULTS

A total of 613,160 cases of vaginal and abdominal POP repair procedures were identified. The majority of procedures involved multiple compartments. The rate of mesh use increased dramatically from 2% of repairs in 2005 to 35% by 2008. After the Food and Drug Administration warning in 2008, mesh use plateaued and then decreased in 2011. Mesh was used more commonly in younger (odds ratio [OR] 0.722, P < .001), white (OR 0.712-0.791 for other races, P < .001) women in the South (OR 0.741-0.848 for non-South regions, P < .001). Starting in 2008, the rate of sacrocolpopexy procedures almost doubled yearly until 2011. Sacrocolpopexy was more common in younger patients (49% in women <70 years) and in white women (88%); the majority of sacrocolpopexies were performed in the South (60%) and laparoscopically (83%-98%).

CONCLUSION

The treatment of POP has changed over time. The use of mesh increased significantly until 2008, after which it plateaued following the Food and Drug Administration warning regarding mesh-related complications. Concurrently, the number of sacrocolpopexy procedures increased significantly starting in 2008 as the use of laparoscopic and/or robotic technique and concern regarding transvaginal mesh increased.

Attitudes toward transvaginal mesh among patients in a urogynecology practice

INTRODUCTION AND HYPOTHESIS

There has been increasing media attention regarding transvaginal mesh (TVM). We hypothesized that new urogynecology patients have limited knowledge and negative opinions of TVM.

METHODS

An anonymous survey was distributed to all new patients presenting to the Mt Auburn Hospital urogynecology practice from 1 November 2012 to 31 January 2013. A total of 146 patients completed the questionnaire. The survey was designed to elicit information on participants' knowledge and opinions about TVM and knowledge about recent FDA safety communications. All statistical tests were two-sided, and P values <0.05 were considered statistically significant.

RESULTS

Analyses were restricted to the 77 women who had either heard of TVM or were unsure if they had heard of TVM. A minority (32.5 %) of these women correctly defined TVM, and 33.8 % had a negative impression of TVM. Respondents obtained their information on TVM from the media (48.1 %), the Internet (24.7 %), family or friends (22.1 %), and health care providers (18.2 %). The majority (71.4 %) agreed that they needed more information about TVM before making any decisions about using it to treat their condition. Nearly one quarter of respondents (23.4 %) agreed that they would not want their doctor to use TVM on them for any reason. When asked about recent FDA communications, 27.3 % of patients correctly responded that the FDA had released a safety communication regarding TVM.

CONCLUSIONS

The majority of participants had limited knowledge of TVM; however, only a minority had negative opinions. Given our findings, it is important that providers spend more time during the consent process explaining TVM and its risks and benefits as a treatment option.

Implications of the FDA statement on transvaginal placement of mesh: the aftermath

The release of the U.S. Food and Drug Administration (FDA) safety communication on the use of transvaginal mesh (TVM) for pelvic organ prolapse (POP) has resulted in changes in the pelvic reconstruction community. This monograph reviews the implications of the FDA statements over the last 18-24 months. Recent findings show that there have been significant developments in the areas of regulatory mandates, media and medico-legal activity, and statements from surgical societies. In summary, well-publicized communications from the FDA and major medical organizations are defining a change in the use of TVM for POP.

An appraisal of the Food and Drug Administration warning on urogynecologic surgical mesh

Currently, there is no consensus on the use of mesh in transvaginal surgical repairs for the treatment of pelvic organ prolapse. This review recapitulates and assesses the recent U. S. Food and Drug Administration (FDA) warnings about the use of surgical mesh in transvaginal pelvic organ prolapse repair and summarizes the responses of the national organizations that represent the health care providers most invested in treating patients with transvaginal surgical mesh. Mesh exposure or extrusion through the vaginal wall, true mesh erosion into viscera, and infection are the major complications that are currently used to define the safety of synthetic mesh use. Other potential adverse postsurgical outcomes that can affect quality of life, sexual function, and patient satisfaction include dyspareunia, "hispareunia" (ie, complaints of a sexual partner), prosthetic contraction or prominence, vaginal shortening, pelvic pain, urinary dysfunction, and failure of the repair. These outcomes are frequently attributed to mesh use, and can result in expense, frustration, and the need for further medical and surgical interventions for patients undergoing treatment for pelvic floor disorders. Information regarding the FDA's reports on the use of surgical mesh in pelvic organ prolapse repair should be made available to patients at the time of surgical planning and should be used as an adjunct in the process of obtaining informed consent.

Informed consent and the use of transvaginal synthetic mesh

In 2008 and again in July of this year, the U.S. Food and Drug Administration (FDA) issued safety communications regarding the use of transvaginally placed surgical mesh. These FDA communications have been the subject of much discussion in the literature. One issue raised by these communications and in the medical literature is the matter of informed consent. Informed consent is an established bioethical principle in modern health care, but it is evolving. The legal interpretations of informed consent are also in flux. A review of contemporary ethical and legal elements of informed consent is presented as it relates to the use of medical innovation, with a focus on transvaginally placed surgical mesh.

One-year objective and functional outcomes of a randomized clinical trial of vaginal mesh for prolapse

OBJECTIVE

The purpose of this study was to show 12-month outcomes of a randomized trial that compared vaginal prolapse repair with and without mesh.

STUDY DESIGN

Women with stage ≥2 prolapse were assigned randomly to vaginal repair with or without mesh. The primary outcome was prolapse stage ≤1 at 12 months. Secondary outcomes included quality of life and complications.

RESULTS

All 65 evaluable participants were followed for 12 months after trial stoppage for mesh exposures. Thirty-two women had mesh repair; 33 women had traditional repair. At 12 months, both groups had improvement of pelvic organ prolapse-quantification test points to similar recurrence rates. The quality of life improved and did not differ between groups: 96.2% mesh vs 90.9% no-mesh subjects reported a cure of bulge symptoms; 15.6% had mesh exposures, and reoperation rates were higher with mesh.

CONCLUSION

Objective and subjective improvement is seen after vaginal prolapse repair with or without mesh. However, mesh resulted in a higher reoperation rate and did not improve 1-year cure.

Is mesh becoming more popular? Dilemmas in urogynecology: a national survey

The use of vaginal mesh in pelvic organ prolapse (POP) repair surgery has become more common in recent years. The purpose of the current study was to evaluate the common practice of Israeli urogynecologists, and to determine whether surgical practice has changed over the last two years. Methods. In 2009 and again in 2011, a survey was mailed to all urogynecologists affiliated with an academic institute in Israel. The survey consisted of 7 Likert-scale items and 3 open questions; the latter inquired about preferred type of surgery in three clinical scenarios. Results. Of 22 practitioners, 15 responded to the survey. The number of urogynecologists who reported using vaginal mesh for the repair of primary POP increased from 47 to 67% from 2009 to 2011. The number who would not use vaginal mesh in POP repair of elderly patients dropped from 60 to 3%. Finally, for the treatment of a 35-year-old patient with stage III uterine prolapse who desired to preserve fertility, 13% recommended the used vaginal mesh in 2009 compared with 47% in 2011. Conclusion. A survey of practitioners shows that the use of vaginal mesh for the repair of primary and recurrent pelvic organ prolapse has become more common among Israeli urogynecologists.

Minimally invasive urogynecology

Laparoscopic and other forms of minimally invasive pelvic floor defect repair represent alternative approaches to performing established procedures; laparoscopy can offer benefits to the surgeon (improved visualization, access for multiple procedures) and patient (decreased pain, scar formation, recuperation, and improved cosmesis). Many practitioners prefer the term “minimal access surgery” to the more prevalent “minimally invasive surgery,” as, ideally, only the route of access, not the procedure itself, is changed. Similarly, dialogue and debate about the merits and concerns of trocar-based mesh prolapse repair kits continue. While gynecology will benefit from further investigations of outcomes of minimally invasive pelvic reconstruction,there is evidence already that these techniques are feasible and offer options and advantages in the treatment of patients with pelvic floor disorders.

Traditional native tissue versus mesh-augmented pelvic organ prolapse repairs: providing an accurate interpretation of current literature

The objective of this paper was to review the literature on pelvic organ prolapse (POP) and compare the success of traditional/native tissue versus mesh-augmented repairs. A comprehensive literature review was performed using PubMed and bibliography searches to compare the anatomic success rates of native tissue (NT) and mesh-augmented (MA) prolapse repairs and to analyze outcome measures used to report success rates. Articles were included if anatomic outcomes were stated for the specific compartment of interest and included both prospective and retrospective studies. The published success rates for NT repairs versus MA repairs by anterior, posterior, or apical compartments are reported. When continence is used as the primary outcome measure, anterior NT has a success rate of 54%. Anterior NT success is as low as 30% in some studies, but generally is 88-97% when prolapse is the primary outcome particularly if apical support is included. This compares to the 87-96% success reported for anterior MA. Posterior NT success is 54-81%, which is lower than the 92-97% reported for posterior MA when prolapse is the outcome measure. The success rates for apical NT are 97-98% for uterosacral ligament suspension and 96% for sacrospinous ligament suspension, which compare favorably to sacrocolpopexy (91-100%). There are some differences in the complications reported for NT and MA. The rate of complications is approximately 8% for NT and is reported at 0-19% for MA. The higher rate for MA is largely due to mesh erosion/exposure. When similar outcome measures are compared, the published anatomic success rates of POP of anterior and apical compartmental surgery are similar for NT and MA repairs. There may be a higher rate of complications noted for mesh implantation. POP surgery is complex, and both NT and MA techniques require skills to perform proper compartmental reconstruction. An understanding of the published literature and knowledge of individual surgeon factors are important in deciding which surgical approach to use and how to best counsel patients during informed consent.

Shifts in national rates of inpatient prolapse surgery emphasize current coding inadequacies

OBJECTIVE

: This study aimed to assess national rates, types, and routes of inpatient surgery for pelvic organ prolapse in the United States in 1998 compared to those in 2007.

METHODS

: We used the 1998 and 2007 Nationwide Inpatient Sample, which represents a stratified, random sample of discharge data from US hospitals. We included women 20 years and older who underwent surgery for prolapse based on diagnosis and procedure codes of the International Classification of Disease, 9th Revision, Clinical Modification. We calculated the number of women undergoing surgery each year and incidence rates.

RESULTS

: The total number of women undergoing prolapse surgeries was 92,503 in 1998 versus 113,646 in 2007. The incidence rate of surgery increased slightly, from 90.8 to 100.9 per 100,000 women, respectively. The most common procedure was hysterectomy, representing approximately half of prolapse surgeries in 1998 and 2007. Suspension procedures accounted for 18.8% of procedures in 2007, an increase from 6.1% in 1998. Surgeries performed via a minimally invasive route increased from 4.8% in 1998 to 9.4% in 2007. However, it was difficult to determine the route for many procedures based on current ICD-9 codes. There were also no codes that specifically designated mesh kit procedures or minimally invasive sacrocolpopexies.

CONCLUSIONS

: During the last decade, the rate of inpatient prolapse surgery has slightly increased. The proportion of suspension procedures has increased; however, it is difficult to determine the route of these procedures based on current ICD-9 codes. These findings emphasize that ICD-9 procedure codes have not kept up with changes in clinical practice.