Changes in tissue composition of the vaginal wall of premenopausal women with prolapse

The difference in extracellular matrix metabolism in women with and without pelvic organ prolapse: A systematic review and meta-analysis

BACKGROUND

Studies on the changes of extracellular matrix (ECM) in pelvic organ prolapse (POP) are still controversial.

OBJECTIVE

To identify the changes in the ECM in POP patients.

SEARCH STRATEGY

Comprehensive searching in Embase, PubMed, Web of Science and the Cochrane Library was carried out until 23 February 2023.

SELECTION CRITERIA

Studies comparing the protein levels of ECM-related components between women with and without POP.

DATA COLLECTION AND ANALYSIS

Quality and risk of bias were assessed using the Agency for Healthcare Research and Quality assessment. Indicators were pooled with random or fixed effect meta-analysis based on heterogeneity and sub-grouped analysed by the biopsy site.

MAIN RESULTS

Thirty cross-sectional studies were included, comprising 840 POP cases and 755 controls. Overall results showed that the expression of type III collagen (COLIII) and several matrix metalloproteinases (MMP-1, -2 and -9) were increased, whereas those of type I collagen (COLI), and tissue inhibitor of matrix metalloproteinase-1 (TIMP-1) were decreased in patients with POP. Subgroup analysis showed that the expression of COLIII in the anterior vaginal wall (AVW) and COLIII, MMP-2 and -9 in the uterosacral ligament (USL) were consistent with the overall results. However, the expression of COLI and MMP-1 in the AVW showed no difference and the expression of COLI and MMP-1 in the USL is still controversial based on current studies.

CONCLUSIONS

Patients with POP have lower expression of COLI and TIMP-1 and higher expression of COLIII and MMPs compared with non-POP cases, but further studies are required to investigate in specified anatomical sites.

An Improved Understanding of the Pathophysiology of Pelvic Organ Prolapse: A 3D In Vitro Model under Static and Mechanical Loading Conditions

The suboptimal outcomes of pelvic organ prolapse (POP) surgery illustrate the demand for improved therapies. However, their development is hampered by the limited knowledge on the cellular pathophysiology of POP. Current investigations, that are limited to tissues and 2D in vitro models, provide highly inconclusive results on how the extracellular matrix (ECM) metabolism and fibroblasts are affected in POP. This study uses a physiologically relevant 3D in vitro model to investigate the cellular pathophysiology of POP by determining the differences between POP and non-POP fibroblasts on ECM metabolism, proliferation, and fibroblast-to-myofibroblast (FMT) transition. This model, based on the synthetic and biomimetic polyisocyanide hydrogel, enables the incorporation of mechanical loading, which simulates the forces exerted on the pelvic floor. Under static conditions, 3D cultured POP fibroblasts are less proliferative, undergo FMT, and exhibit lower collagen and elastin contents compared to non-POP fibroblasts. However, under mechanical loading, the differences between POP and non-POP fibroblasts are less pronounced. This study contributes to the development of more comprehensive models that can accurately mimic the POP pathophysiology, which will aid in an enhanced understanding and may contribute to improved therapies in the future.

Flat Magnetic Stimulation for Urge Urinary Incontinence

Background and Objectives: Strategies for overactive bladder syndrome (OAB) management involve, among others, strengthening the bladder outlet to suppress urgency and neuromodulating the sacral roots. Magnetic stimulation (MS) is a technology that involves an extracorporeal device that is able to provide an electromagnetic field specifically designed to interact with pelvic floor neuromuscular tissue. The resulting tissue electrical activity induces contraction of the pelvic muscle and neuromodulation of the S2-S4 sacral roots. Flat Magnetic Stimulation (FMS) is a relevant advancement involving homogeneous electromagnetic fields, which are able to optimize the effect on the entire pelvic area. However, the benefits of this new technology for OAB syndrome are poorly known. Consequently, the aim of our study is to analyze the outcomes and quality of life (QoL) impact of FMS with Dr. Arnold (DEKA, Calenzano, Italy) in women suffering from OAB syndrome associated with urinary incontinence. Materials and Methods: This prospective study included patients with OAB, urge urinary incontinence, and no ongoing OAB treatments. At baseline (T0), the Incontinence Impact Questionnaire (IIQ-7), the Female Sexual Function Index (FSFI-19), and the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) were collected. Patients underwent 8 FMS sessions of 25 min each in one month. At the termination of the therapy (T1), women repeated the ICIQ-UI SF, FSFI-19, and IIQ-7 tools. Moreover, the Patient Global Impression of Improvement (PGI-I) questionnaire was collected to evaluate the cure rate. Results: Our study enrolled a total of 57 consecutive patients. Most women had at least one second- or third-line treatment before FMS, while the remaining naive patients had contraindications to pharmacological treatments. No women reported adverse effects during the treatment. After the treatment, we observed a decrease in the IIQ-7 (p < 0.001) and ICIQ-UI SF scores (p < 0.001) and an improvement in sexual function (p < 0.001) evaluated with FSFI-19. According to PGI-I scores, 42 (73.7%) women referred to some kind of improvement, scoring ≤ 3 points. Specifically, 8.7% of patients considered themselves very much improved, 29.8% much improved, 35.1% minimally improved, and 26.3% found no changes. FMS was effective in treating OAB symptoms without any adverse effects. The mechanism is supposed to be related to suppressing the initiation of micturition. This makes FMS a promising device for treating naive and refractory urge urinary incontinence. Conclusions: The new FMS represents a promising non-pharmacological option for the treatment of naive and refractory OAB.

Morphological changes in the anterior vaginal wall caused by aging: a scanning electron microscopy study

INTRODUCTION AND HYPOTHESIS

Collagen is a protein that confers robustness and resilience to several tissues. In the female reproductive system, collagen plays a critical role in maintaining the health and function of the vaginal walls. Aging leads to collagen reduction, which may cause vaginal dryness, irritation, and prolapse. We aim to analyze the structure and profile of collagen in the anterior vaginal wall of healthy pre-menopausal (pre-M) and post-menopausal (post-M) women under a scanning electron microscope (SEM).

METHODS

Fragments of the anterior vaginal wall were collected and processed for light and scanning electron microscopy. Histological preparations were performed at first with Weigert's resorcin-fuchsin stain. Decellularized preparations were conducted, and the specimens were placed under an SEM to allow observation of the 3D organization of collagen.

RESULTS

Decellularized preparations of the pre-M specimens showed a vaginal wall with an irregular subepithelial layer, organized with ECM projections. The subepithelium evidenced the network of collagen fibrils, which seemed to support the epithelium as a basal layer. In specimens of post-M, a fusion of a network of fibrils from different direction axes was evidenced, with plate formation observed in the subepithelial plane, disfiguring the structural organization of fibrils.

CONCLUSIONS

Older specimens showed a remodeling of collagen organization in comparison with younger samples of the anterior vaginal wall.

A comprehensive evaluation of spontaneous pelvic organ prolapse in rhesus macaques as an ideal model for the study of human pelvic organ prolapse

Pelvic organ prolapse (POP) seriously affects a woman's quality of life, and the treatment complications are severe. Although new surgical treatments are being developed, the host tissue responses and safety need to be evaluated in preclinical trials. However, there is a lack of suitable animal models, as most quadrupeds exhibit different structural and pathological changes. In this study, 72 elderly rhesus macaques (Macaca mulatta) were physically examined, and the incidence of spontaneous POP was similar to that in humans. The vaginal wall from five control monkeys and four monkeys with POP were selected for further analysis. Verhoeff-van Gieson staining showed that elastin content decreased significantly in monkeys with POP compared with control samples. Immunohistological staining revealed that the smooth muscle bundles in monkey POP appeared disorganized, and the number of large muscle bundles decreased significantly. The collagen I/III ratio in monkey POP also significantly decreased, as revealed by Sirius Red staining. These histological and biochemical changes in monkeys with POP were similar to those in humans with POP. Moreover, we generated a single-cell transcriptomic atlas of the prolapsed monkey vagina. Cross-species analysis between humans and monkeys revealed a comparable cellular composition. Notably, a differential gene expression analysis determined that dysregulation of the extracellular matrix and an immune disorder were the conserved molecular mechanisms. The interplay between fibroblasts and macrophages contributed to human and monkey POP. Overall, this study represents a comprehensive evaluation of spontaneous POP in rhesus macaques and demonstrates that monkeys are a suitable animal model for POP research.

PEOPLE: Lifestyle and comorbidities as risk factors for pelvic organ prolapse-a systematic review and meta-analysis PEOPLE: PElvic Organ Prolapse Lifestyle comorbiditiEs

INTRODUCTION AND HYPOTHESIS

The literature is scarce regarding the effects of comorbidities, clinical parameters, and lifestyle as risk factors for pelvic organ prolapse (POP). This study was performed to systematically review the literature related to body mass index (BMI), waist circumference, diabetes mellitus (DM), hypertension (HT), dyslipidemia, chronic constipation, smoking, chronic cough, occupation, and striae and varicose veins as determinants for POP.

METHODS

Search terms in accordance with Medical Subject Headings were used in PubMed, Embase, LILACS, and the Cochrane Library. Clinical comparative studies between women with and without POP and containing demographic and/or clinical raw data related to lifestyle and/or comorbidities were included. The ROBINS-I (risk of bias in non-randomized studies of interventions) instrument was used. Fixed-effects and random-effects models were used for homogeneous and heterogeneous studies, respectively.

RESULTS

Forty-three studies were included in the meta-analysis. BMI < 25 kg/m2 was found to be a protective factor for POP [OR 0.71 (0.51, 0.99); p = 0.04], and BMI > 30 kg/m2 was a risk factor for POP [OR 1.44 (1.37, 1.52); p < 0.00001]. Waist circumference (≥ 88 cm) was reported as a risk factor for POP [OR 1.80 (1.37, 2.38); p < 0.00001], along with HT [OR 1.18 (1.09, 1.27); p = 0.04], constipation [OR 1.77 (1.23, 2.54); p < 0.00001], occupation [OR 1.86 (1.21, 2.86); p < 0.00001], persistent cough [OR 1.52 (1.18, 1.94); p < 0.0001]), and varicose veins [OR 2.01 (1.50, 2.70); p = 0.12].

CONCLUSIONS

BMI < 25 kg/m2 is protective while BMI > 30 kg/m2 is a risk factor for POP. Large waist circumference, dyslipidemia, HT, constipation, occupation, persistent cough, and varicose veins are also determinants for POP.

The Effect of Growth Factors on Vaginal Wound Healing: A Systematic Review and Meta-analysis

Surgical outcomes of pelvic organ prolapse (POP) surgery are poor, resulting in a 20% recurrence risk. Following the hypothesis that impaired wound healing is the main determinant of recurrent POP, growth factors have the potential to promote wound healing and may improve surgical outcomes. In this study, we systematically reviewed the effect of growth factors on vaginal wound healing in both in vitro and animal studies. For each independent comparison, the standardized mean difference and 95% CI were calculated using the Hedges' g correction. Of the 3858 retrieved studies, seven studies were included, of which six were included in meta-analysis (three in vitro studies and four in vivo studies). In vitro, basic fibroblast growth factor (bFGF) promotes proliferation, differentiation, and collagen types I and III production. Epidermal growth factor stimulates proliferation and connective tissue growth factor promotes Tenascin-C expression. These effects, however, are less pronounced in vivo; only bFGF slightly promotes collagen production. The review shows that growth factors, particularly bFGF, are able to promote vaginal wound healing in vitro. The uncertain in vivo findings suggest that preclinical models should be improved. The ultimate goal is to develop effective growth factor-supplemented therapies that improve surgical outcomes for POP.

The female urethra: urethral function throughout a woman's lifetime

INTRODUCTION AND HYPOTHESIS

The objective of this narrative review is to describe changes in urethral function that occur during a woman's lifetime. Evaluation of urethral function includes measurements of urethral closure pressure, at rest and during stress, leak point pressure, and the detailed study of anatomical and histological changes of the urethral sphincteric mechanism.

METHODS

A literature search in MEDLINE, PubMed, and relevant journals from 1960 until 2020 was performed for articles dealing with urethral function and the impact of aging, pregnancy, and childbirth, female hormones, and menopausal transition on the urethral sphincteric mechanism. Longitudinal and cross-sectional epidemiological surveys, studies on histological changes in urethral anatomy during aging, and urodynamic data obtained at different points in a woman's lifetime, during pregnancy, after childbirth, as well as the effects of female hormones on urethral sphincter function are reviewed. Relevant studies presenting objective data are analyzed and briefly summarized.

RESULTS AND CONCLUSIONS

The findings lead one to conclude that a constitutional or genetic predisposition, aging, and senescence are the most prominent etiological factors in the development of urinary incontinence and other pelvic floor disorders. Vaginal childbirth dilates and may damage the compressed pelvic supportive tissues and is invariably associated with a decline in urethral sphincter function. Pregnancy, hormonal alterations, menopausal transition, weight gain, and obesity are at best of secondary influence on the pathology of lower urinary tract dysfunction. The decline of circulating estrogens during menopausal transition may play a role in the transition of fibroblasts to cellular senescence.

Electrospun Silk Fibroin-CNT Composite Fibers: Characterization and Application in Mediating Fibroblast Stimulation

Electrospinning is a simple, low-cost, and highly efficient technique to generate desirable nano/microfibers from polymer solutions. Silk fibroin (SF), a biopolymer found in Bombyx mori cocoons, has attracted attention for various biomedical applications. In this study, functionalized CNT was incorporated in SF to generate biocomposite fibers by electrospinning. The electrospun (E-spun) fibers were well aligned with morphology mimicking the locally oriented ECM proteins in connective tissues. While as-spun fibers dissolved in water in just two minutes, ethanol vapor post-treatment promoted β-sheet formation leading to improved fiber stability in an aqueous environment (>14 days). The addition of a minute amount of CNT effectively improved the E-spun fiber alignment and mechanical strength while retained high biocompatibility and biodegradability. The fibers’ electrical conductivity increased by 13.7 folds and 21.8 folds, respectively, in the presence of 0.1 w% and 0.2 w% CNT in SF fibers. With aligned SF-CNT 0.1 % fibers as a cell culture matrix, we found electrical stimulation effectively activated fibroblasts from patients of pelvic organ prolapse (POP), a connective tissue disorder. The stimulation boosted the fibroblasts’ productivity of collagen III (COLIII) and collagen I (COLI) by 74 folds and 58 folds, respectively, and reduced the COLI to COLIII ratio favorable for tissue repair. The developed material and method offer a simple, direct, and effective way to remedy the dysfunctional fibroblasts of patients for personalized cell therapeutic treatment of diseases and health conditions associated with collagen disorder.

Distinctive structure, composition and biomechanics of collagen fibrils in vaginal wall connective tissues associated with pelvic organ prolapse

Collagen is the predominant structural protein within connective tissues. Pelvic organ prolapse (POP) is characterized by weakening of the pelvic floor connective tissues and loss of support for pelvic organs. In this study, we examined the multiscale structure, molecular composition and biomechanics of native collagen fibrils in connective tissues of the posterior vaginal fornix collected from healthy women and POP patients, and established the correlation of these properties with clinical POP quantification (POP-Q) scores. The collagen characteristics, including collagen amount, ratio of Collagen I and Collagen III, collagen fibril d-period, alignment and stiffness, were found to change progressively with the increase of the clinical measurement of Point C, a measure of uterine descent and apical prolapse. The results imply that a severe prolapse is associated with stiffer collagen fibrils, reduced collagen d-period, increased fibril alignment and imbalanced collagen synthesis, degradation and deposition. Additionally, prolapse progression appears to be synchronized with deterioration of the collagen matrix, suggesting that a POP-Q score obtained via a non-invasive clinical test can be potentially used to quantitatively assess collagen abnormality of a patient's local tissue. STATEMENT OF SIGNIFICANCE: Abnormal collagen metabolism and deposition are known to associate with connective tissue disorders, such as pelvic organ prolapse. Quantitative correlation of the biochemical and biophysical characteristics of collagen in a prolapse patient's tissue with the clinical diagnostic measurements is unexplored and unestablished. This study fills the knowledge gap between clinical prolapse quantification and the individual's cellular and molecular disorders leading to connective tissue failure, thus, provides the basis for clinicians to employ personalized treatment that can best manage the patient's condition and to alert pre-symptomatic patients for early management to avoid unwanted surgery.

Cost-Effectiveness of perioperative Vaginally Administered estrogen in postmenopausal women undergoing prolapse surgery (EVA trial): study protocol for a multicenter double-blind randomized placebo-controlled trial

BACKGROUND

Surgery for pelvic organ prolapse (POP) is associated with high recurrence rates. The costs associated with the treatment of recurrent POP are huge, and the burden from women who encounter recurrent POP, negatively impacts their quality of life. Estrogen therapy might improve surgical outcome for POP due to its potential beneficial effects. It is thought that vaginal estrogen therapy improves healing and long-term maintenance of connective tissue integrity. Hence, this study aims to evaluate the cost-effectiveness of perioperative vaginal estrogen therapy in postmenopausal women undergoing POP surgery.

METHODS

The EVA trial is a multi-center double-blind randomized placebo-controlled trial conducted in the Netherlands comparing the effectiveness and costs-effectiveness of vaginal estrogen therapy. This will be studied in 300 postmenopausal women undergoing primary POP surgery, with a POP-Q stage of ≥ 2. After randomization, participants administer vaginal estrogen cream or placebo cream from 4 to 6 weeks preoperative until 12 months postoperative. The primary outcome is subjective improvement of POP symptoms at 1 year follow-up, measured with the Patient Global Impression of Improvement (PGI-I) scale. Secondary outcomes are POP-Q anatomy in all compartments, re-interventions, surgery related complications, general and disease specific quality of life, sexual function, signs and complaints of vaginal atrophy, vaginal pH, adverse events, costs, and adherence to treatment. Follow up is scheduled at 6 weeks, 6 months and 12 months postoperative. Data will be collected using validated questionnaires and out-patient visits including gynecological examination performed by an independent gynecologist.

DISCUSSION

This study investigates whether perioperative vaginal estrogen will be cost-effective in the surgical treatment of POP in postmenopausal women. It is hypothesized that estrogen therapy will show a reduction in recurrent POP symptoms and a reduction in reoperations for POP, with subsequent improved quality of life among women and cost savings. Trial registrationNetherlands Trial Registry: NL6853; registered 19-02-2018, https://www.trialregister.nl/trial/6853 . EudraCT: 2017-003144-21; registered: 24-07-2017.

Role of fibulin-5 insufficiency and prolapse progression on murine vaginal biomechanical function

The vagina plays a critical role in supporting the pelvic organs and loss of support leads to pelvic organ prolapse. It is unknown what microstructural changes influence prolapse progression nor how decreased elastic fibers contributes to vaginal remodeling and smooth muscle contractility. The objective for this study was to evaluate the effect of fibulin-5 haploinsufficiency, and deficiency with progressive prolapse on the biaxial contractile and biomechanical function of the murine vagina. Vaginas from wildtype (n = 13), haploinsufficient (n = 13), and deficient mice with grade 1 (n = 9) and grade 2 or 3 (n = 9) prolapse were explanted for biaxial contractile and biomechanical testing. Multiaxial histology (n = 3/group) evaluated elastic and collagen fiber microstructure. Western blotting quantified protein expression (n = 6/group). A one-way ANOVA or Kruskal-Wallis test evaluated statistical significance. Pearson's or Spearman's test determined correlations with prolapse grade. Axial contractility decreased with fibulin-5 deficiency and POP (p < 0.001), negatively correlated with prolapse grade (ρ = - 0.80; p < 0.001), and positively correlated with muscularis elastin area fraction (ρ = - 0.78; p = 0.004). Circumferential (ρ = 0.71; p < 0.001) and axial (ρ = 0.69; p < 0.001) vaginal wall stresses positively correlated with prolapse grade. These findings demonstrated that fibulin-5 deficiency and prolapse progression decreased vaginal contractility and increased vaginal wall stress. Future work is needed to better understand the processes that contribute to prolapse progression in order to guide diagnostic, preventative, and treatment strategies.

Expression of COX-2 and Nrf2/GPx3 in the anterior vaginal wall tissues of women with pelvic organ prolapse

PURPOSE

To evaluate COX-2 and Nrf2/GPx3 expressions in the lamina propria of the anterior vaginal wall tissues of women with and without pelvic organ prolapse (POP).

METHODS

Tissue samples of anterior vaginal wall were examined using HE staining, immuohistochemical staining and Western blot for the expressions of COX-2/PGE2, Nrf2/GPx3, MMP2, TIMP1, collagen I and collagen III (n = 35, per group).

RESULTS

Compared with control group, collagen fibers of the anterior vaginal wall were disorganized and discontinuous. Expressions of Nrf2, GPx3, TIMP1, collagen I and collagen III were found significantly lower in POP group (P < 0.05); while, expressions of COX-2, PGE2, and MMP2 were found significantly higher in POP group (P < 0.05). Statistically significant correlations of COX-2 and Nrf2/GPx3 were showed (P < 0.01).

CONCLUSION

We found that the interaction between inflammation and oxidative stress was closely related to the development of POP. This study demonstrates that COX-2 and Nrf2 pathways may be involved in pathogenesis of POP, as promising potential therapeutic targets and agents.

Effects of Total Abdominal Hysterectomy and Total Laparoscopic Hysterectomy on Urinary Tract Dysfunction

Objectives:

The aim of this study is to compare the urinary tract dysfunction rates of total abdominal hysterectomy (TAH) and total laparoscopic hysterectomy.

Materials and Methods:

Turkish patients who underwent TAH and laparoscopic hysterectomy were invited to participate in this study. In this study, 140 patients were examined who underwent hysterectomy in gynecology clinic between 2013 and 2018. The post residual urine volumes of patients were measured in the preoperative period and 8^th week of the postoperative period as urodynamic evaluation (with office cystometry and Q tip test). Statistical analysis was performed using Kruskal–Wallis Mann–Whitney U test by using SPSS 22.0 statistical program.

Results:

No statistical significance (P > 0.05) was found between age, parity, menopause, and obesity in our patients who underwent TAH and laparoscopic hysterectomy with high postvoid residual values in the postoperative period.

Conclusion:

In this study, no statistical significance was found between the hysterectomy techniques on urinary tract dysfunction. It can be said that laparoscopy should be more preferable in correctly selected patients for minimal dysfunctional complications.

Validation of noninvasive focal depth measurements to determine epithelial thickness of the vaginal wall

OBJECTIVE

This study investigates whether noninvasive focal depth (FD) measurements correlate with vaginal wall epithelial thickness (ET). If FD accurately reflects ET of the vaginal wall, this would allow noninvasive longitudinal assessment of (newly developed) treatment modalities aiming to increase ET, without the need for invasive biopsies.

METHODS

Fourteen women, median age 62 years (inter quartile ranges: 57-65), undergoing vaginal prolapse surgery because of anterior and/or posterior compartment pelvic organ prolapse were included. We used the CytoCam, a handheld video microscope based on incident dark field imaging, and performed FD measurements of the vaginal wall before surgery. Histology was performed on tissue that was removed during the surgical procedure, and ET was measured in stained sections. We compared ET with FD interindividually, and determined the expected linear correlation and agreement between the two measurements.

RESULTS

Seventeen ET measurements (mean 125 μm ± 38.7, range 48-181 μm) were compared with 17 FD measurements (mean 128 μm ± 34.3, range 68-182 μm). The lineair correlation between the two measurements was strong (r = 0.902, P < 0.01). Bland-Altman analysis demonstrated a mean difference of 13.5 μm when comparing ET to FD.

CONCLUSIONS

The results demonstrate good agreement between ET and FD measurements. We consider the mean difference demonstrated with Bland-Altman analysis acceptable for these measurements. This suggests that FD accurately reflects ET, which further supports the use of FD to measure ET of the vaginal wall. For a complete assessment of the vaginal wall, FD measurements are preferably combined with the assessment of vaginal angioarchitecture.

Extracellular Matrix Stiffness and Composition Regulate the Myofibroblast Differentiation of Vaginal Fibroblasts

Fibroblast to myofibroblast differentiation is a key feature of wound-healing in soft tissues, including the vagina. Vaginal fibroblasts maintain the integrity of the vaginal wall tissues, essential to keep pelvic organs in place and avoid pelvic organ prolapse (POP). The micro-environment of vaginal tissues in POP patients is stiffer and has different extracellular matrix (ECM) composition than healthy vaginal tissues. In this study, we employed a series of matrices with known stiffnesses, as well as vaginal ECMs, in combination with vaginal fibroblasts from POP and healthy tissues to investigate how matrix stiffness and composition regulate myofibroblast differentiation in vaginal fibroblasts. Stiffness was positively correlated to production of α-smooth muscle actin (α-SMA). Vaginal ECMs induced myofibroblast differentiation as both α-SMA and collagen gene expressions were increased. This differentiation was more pronounced in cells seeded on POP-ECMs that were stiffer than those derived from healthy tissues and had higher collagen and elastin protein content. We showed that stiffness and ECM content regulate vaginal myofibroblast differentiation. We provide preliminary evidence that vaginal fibroblasts might recognize POP-ECMs as scar tissues that need to be remodeled. This is fundamentally important for tissue repair, and provides a rational basis for POP disease modelling and therapeutic innovations in vaginal reconstruction.

Postmenopausal hormone therapy is accompanied by elevated risk for uterine prolapse

OBJECTIVE

Receptors for estrogen and progesterone are present in the pelvic floor, and therefore, postmenopausal hormone therapy may affect its function. We compared the former use of estradiol-progestogen postmenopausal hormone therapy in nonhysterectomized women with a uterine prolapse surgery (N = 12,072) and control women (N = 33,704).

METHODS

The women with a history of uterine prolapse operation were identified from the Finnish National Hospital Discharge Register, and the control women from the Finnish Central Population Register. The use of hormone therapy was traced from the national drug reimbursement register, and the odd ratios with 95% CIs for prolapse were calculated by using the conditional logistic regression analysis.

RESULTS

The women with uterine prolapse had used hormone therapy more often than control women (N = 4,127; 34.2% vs N = 9,189; 27.3%; P < 0.005). The use of hormone therapy was accompanied by significant (23%-53%) elevations in the risk for prolapse, being higher with longer exposure. The risk elevations (33%-23%) were comparable between sole norethisteroneacetate-estradiol and sole medroxyprogesteroneacetate-estradiol therapy. The use of estradiol in combination with a levonorgestrel releasing intrauterine device was accompanied by a 52% elevation.

CONCLUSIONS

The postmenopausal use of estradiol in combination with various progestogen regimens may weaken the pelvic floor, resulting in uterine prolapse. This data should be incorporated into the information given to the users of estradiol-progestogen hormone therapy.

Development of anatomically based customizable three-dimensional finite-element model of pelvic floor support system: POP-SIM1.0

To develop an anatomically based customizable finite-element (FE) model of the pelvic floor support system to simulate pelvic organ prolapse (POP): POP-SIM1.0. This new simulation platform allows for the construction of an array of models that objectively represent the key anatomical and functional variation in women with and without prolapse to test pathomechanism hypotheses of the prolapse formation. POP-SIM1.0 consists of anatomically based FE models and a suite of Python-based tools developed to rapidly construct FE models by customizing the base model with desired structural parameters. Each model consists of anatomical structures from three support subsystems which can be customized based on magnetic resonance image measurements in women with and without prolapse. The customizable structural parameters include presence of levator ani (LA) avulsion, hiatus size, anterior vaginal wall dimension, attachment fascia length and apical location in addition to the tissue material properties and intra-abdominal pressure loading. After customization, the FE model was loaded with increasing intra-abdominal pressure (0-100 cmH2O) and solved using ABAQUS explicit solver. We were able to rapidly construct anatomically based FE models with specific structural geometry which reflects the morphology changes often observed in women with prolapse. At maximum loading, simulated structural deformations have similar anatomical characteristics to those observed during clinical exams and stress magnetic resonance images. Simulation results showed the presence of LA muscle avulsion negatively impacts the pelvic floor support. The normal model with intact muscle had the smallest exposed vaginal length of 11 mm, while the bilateral avulsion produced the largest exposed vaginal length at 24 mm. The unilateral avulsion model had an exposed vaginal length of 18 mm and also demonstrated a tipped perineal body similar to that seen in clinical observation. Increasing the hiatus size, vaginal wall length and fascia length also resulted in worse pelvic floor support, increasing the exposed vaginal length from 18 mm in the base model to 33 mm, 54 mm and 23.5 mm, respectively. The developed POP-SIM1.0 can simulate the anatomical structure changes often observed in women with prolapse. Preliminary results showed that the presence of LA avulsion, enlarged hiatus, longer vaginal wall and fascia length can result in larger prolapse at simulated maximum Valsalva.

Effects of topical estrogen therapy on the vaginal microcirculation in women with vulvovaginal atrophy

AIMS

This study aims to assess vaginal wall angioarchitecture and function in women with vulvovaginal atrophy (VVA) and determine the effect of topical estrogen on the vaginal microcirculation.

MATERIALS AND METHODS

In this prospective observational study, incident dark field imaging was used to assess the vaginal microcirculation. In patients with VVA, measurements were performed before and after treatment with topical estrogen and compared to measurements performed in women without VVA. Vaginal angioarchitecture was studied by assessing microcirculatory architecture and capillary tortuosity scores at four regions of the vaginal wall. In addition, the capillary density and microvascular flow index (MFI) were obtained.

RESULTS

Seventeen women were included in this study. Of these, eight women were diagnosed with VVA and nine women were considered healthy controls. Significant differences were observed between groups with regard to microcirculatory architecture scores. The architecture of the microvasculature in women with VVA was characterized by the appearance of a vascular network without capillary loops, whereas an array of capillary loops was predominantly seen in women without VVA. After estrogen treatment, no difference in architecture scores between patients and healthy controls was observed. Capillary tortuosity, capillary density, and MFI were similar in both groups before and after estrogen treatment.

CONCLUSIONS

The architecture of vaginal microvasculature is altered in patients with VVA. In case of similar vascular architecture, capillary tortuosity and density seem to be comparable. Treatment with topical estrogen results in restoration of the angioarchitecture.

Swine Vagina Under Planar Biaxial Loads: An Investigation of Large Deformations and Tears

Vaginal tears are very common and can lead to severe complications such as hemorrhaging, fecal incontinence, urinary incontinence, and dyspareunia. Despite the implications of vaginal tears on women's health, there are currently no experimental studies on the tear behavior of vaginal tissue. In this study, planar equi-biaxial tests on square specimens of vaginal tissue, with sides oriented along the longitudinal direction (LD) and circumferential direction (CD), were conducted using swine as animal model. Three groups of specimens were mechanically tested: the NT group (n = 9), which had no pre-imposed tear, the longitudinal tear (LT) group (n = 9), and the circumferential tear (CT) group (n = 9), which had central pre-imposed elliptically shaped tears with major axes oriented in the LD and the CD, respectively. Through video recording during testing, axial strains were measured for the NT group using the digital image correlation (DIC) technique and axial displacements of hook clamps were measured for the NT, LT, and CT groups in the LD and CD. The swine vaginal tissue was found to be highly nonlinear and somewhat anisotropic. Up to normalized axial hook displacements of 1.15, no tears were observed to propagate, suggesting that the vagina has a high resistance to further tearing once a tear has occurred. However, in response to biaxial loading, the size of the tears for the CT group increased significantly more than the size of the tears for the LT group (p = 0.003). The microstructural organization of the vagina is likely the culprit for its tear resistance and orientation-dependent tear behavior. Further knowledge on the structure–function relationship of the vagina is needed to guide the development of new methods for preventing the severe complications of tearing.

Collagen changes in pelvic support tissues in women with pelvic organ prolapse

Pelvic organ prolapse is a group of diseases caused by weakened pelvic supportive tissue, but the pathophysiology is not completely understood. Collagen is one of the most important components of the extracellular matrix in connective tissue, as it maintains the supportive functions of the pelvic floor. Collagen I and III are two major subtypes in pelvic tissues. With conflicting results of different studies, changes of their content and ratio are still disputed. The structure of collagen fibrils of pelvic organ prolapse patients become loose, disorderly and discontinuous and become stiffer than control group. Strong mechanical stress and imbalance matrix metalloproteinases /tissue-derived inhibitors of metalloproteinases can lead to collagen anabolism abnormalities causing changes of collagen content and structure. These changes are inter-influenced and are involved by multiple signaling pathways, including TGF-β/Smad, AGE/RAGE, MAPK, PI3K/AKT, and NF-κB. Collagen changes, including content, morphologic and biomechanical changes and catabolism abnormalities, can destroy the supportive function of the pelvic floor and are closely related to the development of pelvic organ prolapse. Epidemiological data also show a genetic predisposition to collagen changes. Research about collagen changes in the pelvic floor supportive tissues is limited and controversial. Small sample sizes and different recruitment criteria, biopsy sites, and research methods make comparisons between various studies difficult. More research concerning collagen changes is needed to better understand the pathogenesis of pelvic organ prolapse.

Effects of elastase digestion on the murine vaginal wall biaxial mechanical response

Although the underlying mechanisms of pelvic organ prolapse (POP) remain unknown, disruption of elastic fiber metabolism within the vaginal wall extracellular matrix has been highly implicated. It has been hypothesized that elastic fiber fragmentation correlates to decreased structural integrity and increased risk of prolapse; however, the mechanisms by which elastic fiber damage may contribute to prolapse are poorly understood. Further, the role of elastic fibers in normal vaginal wall mechanics has not been fully ascertained. Therefore, the objective of this study is to investigate the contribution of elastic fibers to murine vaginal wall mechanics. Vaginal tissue from C57BL/6 female mice were mechanically tested using biaxial extension-inflation protocols before and after intraluminal exposure to elastase. Elastase digestion induced marked changes in the vaginal geometry, and biaxial mechanical properties, suggesting that elastic fibers may play an important role in vaginal wall mechanical function. Additionally, a constitutive model that considered two diagonal families of collagen fibers with a slight preference towards the circumferential direction described the data reasonably well before and after digestion. The present findings may be important to determine the underlying structural and mechanical mechanisms of POP, and aid in the development of growth and remodeling models for improved assessment and prediction of changes in structure-function relationships with prolapse development. Keywords: vaginal wall, women's health, mechanical testing, pelvic floor disorders, elastic fibers Disclosures: none.

Recommended standardized terminology of the anterior female pelvis based on a structured medical literature review

BACKGROUND

The use of imprecise and inaccurate terms leads to confusion amongst anatomists and medical professionals.

OBJECTIVE

We sought to create recommended standardized terminology to describe anatomic structures of the anterior female pelvis based on a structured review of published literature and selected text books.

STUDY DESIGN

We searched MEDLINE from its inception until May 2, 2016, using 11 medical subject heading terms to identify studies reporting on anterior female pelvic anatomy; any study type published in English was accepted. Nine textbooks were also included. We screened 12,264 abstracts, identifying 200 eligible studies along with 13 textbook chapters from which we extracted all pertinent anatomic terms.

RESULTS

In all, 67 unique structures in the anterior female pelvis were identified. A total of 59 of these have been previously recognized with accepted terms in Terminologia Anatomica, the international standard on anatomical terminology. We also identified and propose the adoption of 4 anatomic regional terms (lateral vaginal wall, pelvic sidewall, pelvic bones, and anterior compartment), and 2 structural terms not included in Terminologia Anatomica (vaginal sulcus and levator hiatus). In addition, we identified 2 controversial terms (pubourethral ligament and Grafenberg spot) that require additional research and consensus from the greater medical and scientific community prior to adoption or rejection of these terms.

CONCLUSION

We propose standardized terminology that should be used when discussing anatomic structures in the anterior female pelvis to help improve communication among researchers, clinicians, and surgeons.

Immunolocalization of Advanced Glycation End Products, Mitogen Activated Protein Kinases, and Transforming Growth Factor-β/Smads in Pelvic Organ Prolapse

Collagen and matrix metalloproteinases (MMP) play a pivotal role in the pathophysiology of Pelvic Organ Prolapse (POP) as a switch between type I and III collagen together with a simultaneous activation of MMPs have been observed in the vaginal wall. The aim of this study was to evaluate the Advanced Glycation End (AGE) products, ERK1/2 and transforming growth factor (TGF)-β/Smad pathway expression in muscularis propria in women with POP compared with control patients. We examined 20 patients with POP and 10 control patients treated for uterine fibromatosis. Immunohistochemical analysis using AGE, RAGE, ERK1/2, Smads-2/3, Smad-7, MMP-3, and collagen I-III, TIMP, and α-SMA were performed. Smad-2/3, Smad-7, AGE, ERK1/2, p-ERK, and p-Smad3 were also evaluated using Western-blot analysis. POP samples from the anterior vaginal wall showed disorganization of the normal muscularis architecture. In POP samples, AGE, ERK1/2, Smad-2/3, MMP-3, and collagen III were upregulated in muscularis whereas in controls, Smad-7 and collagen I were increased. The receptor for AGEs (RAGE) was mild or absent both in controls and prolapse. We demonstrated the involvement of these markers in women with POP but further studies are required to elucidate if the overexpression of these molecules could play a crucial role in the pathophysiology of POP disease.

Biaxial Mechanical Assessment of the Murine Vaginal Wall Using Extension-Inflation Testing

Progress toward understanding the underlying mechanisms of pelvic organ prolapse (POP) is limited, in part, due to a lack of information on the biomechanical properties and microstructural composition of the vaginal wall. Compromised vaginal wall integrity is thought to contribute to pelvic floor disorders; however, normal structure-function relationships within the vaginal wall are not fully understood. In addition to the information produced from uniaxial testing, biaxial extension-inflation tests performed over a range of physiological values could provide additional insights into vaginal wall mechanical behavior (i.e., axial coupling and anisotropy), while preserving in vivo tissue geometry. Thus, we present experimental methods of assessing murine vaginal wall biaxial mechanical properties using extension-inflation protocols. Geometrically intact vaginal samples taken from 16 female C57BL/6 mice underwent pressure-diameter and force-length preconditioning and testing within a pressure-myograph device. A bilinear curve fit was applied to the local stress-stretch data to quantify the transition stress and stretch as well as the toe- and linear-region moduli. The murine vaginal wall demonstrated a nonlinear response resembling that of other soft tissues, and evaluation of bilinear curve fits suggests that the vagina exhibits pseudoelasticity, axial coupling, and anisotropy. The protocols developed herein permit quantification of biaxial tissue properties. These methods can be utilized in future studies in order to assess evolving structure-function relationships with respect to aging, the onset of prolapse, and response to potential clinical interventions.

Advanced glycation end products decrease collagen I levels in fibroblasts from the vaginal wall of patients with POP via the RAGE, MAPK and NF-κB pathways

The present study was carried out to observe the impact of advanced glycation end products (AGEs) on collagen I derived from vaginal fibroblasts in the context of pelvic organ prolapse (POP), and explore the downstream effects on MAPK and nuclear factor-κB (NF-κB) signaling. After treating primary cultured human vaginal fibroblasts (HVFs) derived from POP and non-POP cases with AGEs, cell counting was carried out by sulforhodamine B. The expression levels of collagen I, receptor of advanced glycation end products (RAGE), matrix metalloproteinase-1 (MMP-1) and tissue inhibitor of metalloproteinase-1 (TIMP-1) were detected by western blot analysis and PCR. RAGE, MAPK and NF-κB were molecularly and pharmacologically-inhibited by siRNA, SB203580 and PDTC, respectively, and downstream changes were detected by western blot analysis and PCR. Inhibition of HVF proliferation by AGEs occurred more readily in POP patients than that noted in the controls. After treatment with AGEs, collagen I levels decreased and MMP-1 levels increased to a greater extent in the HVFs of POP than that noted in the controls. During this same period, RAGE and TIMP-1 levels remained stable. Following treatment with AGEs and RAGE pathway inhibitors by siRNA, SB203580 and PDTC, the impact induced by AGEs was diminished. The inhibition of p-p38 MAPK alone was not able to block the promoting effect of AGEs on the levels of NF-κB, which suggests that AGEs may function through other pathways, as well as p-p38 MAPK. On the whole, this study demonstrated that AGEs inhibited HVF proliferation in POP cases and decreased the expression of collagen I through RAGE and/or p-p38 MAPK and NF-κB-p-p65 pathways. Our results provide important insights into the collagen I metabolism in HVFs in POP.

Recent Advances in Understanding Pelvic-Floor Tissue of Women With and Without Pelvic Organ Prolapse: Considerations for Physical Therapists

Pelvic organ prolapse is a fairly common condition that imposes significant symptoms, diminished quality of life, social burden, financial expense, and surgical risk on women. As evidence supporting the benefit of pelvic-floor muscle training in nonsurgical management of pelvic organ prolapse grows, physical therapists are becoming a provider of choice interacting with women affected by pelvic organ prolapse. This perspective article will review recent research on tissue characteristics of 3 key components of pelvic organ support: skeletal muscle, ligament, and vaginal wall. This information will be summarized as implications for physical therapists. An improved understanding of pelvic-floor tissue in women with and without pelvic organ prolapse will provide a more comprehensive appreciation of the interaction of multiple systems in the disorder.

Does the vaginal wall become thinner as prolapse grade increases?

INTRODUCTION AND HYPOTHESIS

The pathophysiology of prolapse is not well understood. However, two main theories predominate: either the fibromuscular layer of the vagina develops a defect/tears away from its supports, or its tissues are stretched and attenuated. The aim of this study was to assess how vaginal wall thickness (VWT) is related to vaginal prolapse.

METHODS

The study group comprised 243 women with symptomatic prolapse recruited from the Outpatient Department of a tertiary referral centre for urogynaecology. A history was taken and women were examined to determine their POP-Q score. Using a previously validated technique, ultrasonography was used to measure the mean VWT at three anatomical sites on the anterior and posterior walls. Scores were then compared using t tests, the Kruskal-Wallis test and the Friedman test.

RESULTS

The mean age of the patients was 59.7 years (SD 12.0 years range 38 - 84 years). For each measurement VWT reduced as prolapse grade increased until the prolapse extended beyond the hymen. Women with grade 3 prolapse had a significantly higher mean VWT than women with grade 1 or 2 contained prolapse. Menopause status did not have a significant effect on the VWT.

CONCLUSIONS

VWT is lower in women with vaginal prolapse until the prolapse extends beyond the hymen and then VWT is thicker and comparable with women without prolapse. This may be explained by changes in the vaginal tissue including reduction of collagen, elastin and smooth muscle, as well as fibrosis in exposed tissues, rather than by defects in the vagina.

Vaginal Fibroblastic Cells from Women with Pelvic Organ Prolapse Produce Matrices with Increased Stiffness and Collagen Content

Pelvic organ prolapse (POP) is characterised by the weakening of the pelvic floor support tissues, and often by subsequent prolapse of the bladder outside the body, i.e. cystocele. The bladder is kept in place by the anterior vaginal wall which consists of a dense extracellular matrix rich in collagen content that is maintained and remodelled by fibroblastic cells, i.e. fibroblasts and myofibroblasts. Since altered matrix production influences tissue quality, and myofibroblasts are involved in normal and pathological soft tissue repair processes, we evaluated matrix production of cells derived from pre- and post-menopausal POP and non-POP control anterior vaginal wall tissues. Results showed that cells from postmenopausal POP women deposited matrices with high percentage of collagen fibres with less anisotropic orientation and increased stiffness than those produced by controls. There was a transient increase in myofibroblastic phenotype that was lost after the peak of tissue remodelling. In conclusion, affected fibroblasts from postmenopausal prolapsed tissues produced altered matrices in vitro compared to controls. Such aberrant altered matrix production does not appear to be a consequence of abnormal phenotypical changes towards the myofibroblastic lineage.

Changes in muscularis propria of anterior vaginal wall in women with pelvic organ prolapse

The objective of this study was to evaluate the morphological and immunohistochemical alterations of tissue removed from the upper third of anterior vaginal wall in a sample group of the female population presenting homogenous risk factors associated with Pelvic Organ Prolapse (POP). The case study consisted of 14 patients with POP and there were 10 patients in the control group. Patient selection was carried on the basis of specific criteria and all of the patients involved in the study presented one or more of the recognized POP risk factors. Samples were taken from POP patients during vaginal plastic surgery following  colpohysterectomy, and from control patients during closure of the posterior fornix following hysterectomy. Samples were processed for histological and  immunohistochemical analyses for Collagen I and Collagen III, α-Smooth Muscle Actin (α-SMA), Platelet-Derived-Growth-Factor (PDGF), matrix metalloproteinase 3 (MMP3), Caspase3. Immunofluorescence analyses for Collagen I and III and PDGF were also carried out. In prolapsed specimens our results show a disorganization of smooth muscle cells that appeared to have been displaced by an increased collagen III deposition resulting in rearrangement of the muscularis propria architecture. These findings suggest that the increase in the expression of collagen fibers in muscularis could probably due to a phenotypic switch resulting in the dedifferentiation of smooth muscle cells into myofibroblasts. These alterations could be responsible for the compromising of the dynamic functionality of the pelvic floor.

Versican and vascular endothelial growth factor expression levels in peritoneal metastases from colorectal cancer are associated with survival after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) can increase survival of colorectal cancer (CRC) patients with peritoneal metastases (PM). This treatment is associated with high morbidity and mortality rates. Therefore, improvement of patient selection is necessary. Assuming that the clinical phenotype is dictated by biological mechanisms, biomarkers could play a crucial role in this process. Since it is unknown whether and to what extent angiogenesis influences the course of disease in patients with PM, we investigated the expression of two angiogenesis-related markers and their relation to overall survival (OS) in CRC patients after CRS and HIPEC. Clinicopathological data and tissue samples were collected from 65 CRC patients with isolated metastases to the peritoneum that underwent CRS and HIPEC. Whole tissue specimens from PM were evaluated for versican (VCAN) expression, VEGF expression and microvessel density (MVD) by immunohistochemistry. The relation between these markers and OS was assessed using univariate and multivariate analysis. Associations between VEGF expression, VCAN expression, MVD and clinicopathological data were tested. High stromal VCAN expression was associated with high MVD (p = 0.001), better resection outcome (p = 0.003) and high T-stage (p = 0.027). High epithelial VCAN expression was associated with MVD (p = 0.007) and a more complete resection (p < 0.001). In multivariate analysis, simplified peritoneal cancer index (p = 0.001), VEGF expression levels (p = 0.012), age (p = 0.030), epithelial VCAN expression levels (p = 0.042) and lymph node status (p = 0.053) were associated with OS. Concluding, VCAN and VEGF were associated with survival in CRC patients with PM after CRS and HIPEC. Independent validation in a well-defined patient cohort is required to confirm the putative prognostic role of these candidate biomarkers.

Static Mechanical Loading Influences the Expression of Extracellular Matrix and Cell Adhesion Proteins in Vaginal Cells Derived From Premenopausal Women With Severe Pelvic Organ Prolapse

INTRODUCTION

Primary human vaginal cells derived from women with severe pelvic organ prolapse (POP-HVCs) demonstrate altered cellular characteristics as compared to cells derived from asymptomatic women (control-HVCs). Using computer-controllable Flexcell stretch unit, we examined whether POP-HVCs react differently to mechanical loading as compared to control-HVCs by the expression of extracellular matrix (ECM) components, cell-ECM adhesion proteins, and ECM degrading and maturating enzymes.

METHODS

Vaginal tissue biopsies from premenopausal patients with Pelvic Organ Prolapse Quantification System stage ≥3 (n = 8) and asymptomatic controls (n = 7) were collected during vaginal hysterectomy or repair. Human vaginal cells were isolated by enzymatic digestion, seeded on collagen (COLI)-coated plates, and stretched (24 hours, 25% elongation). Total RNA was extracted, and 84 genes were screened using Human ECM and Adhesion Molecules polymerase chain reaction array; selected genes were verified by quantitative reverse transcription-polymerase chain reaction. Stretch-conditioned media (SCM) were collected and analyzed by protein array, immunoblotting, and zymography.

RESULTS

In mechanically stretched control-HVCs, transcript levels of integrins (ITGA1, ITGA4, ITGAV, and ITGB1) and matrix metalloproteinases (MMPs) 2, 8, and 13 were downregulated (P < .05); in POP-HVCs, MMP1, MMP3, and MMP10, ADAMTS8 and 13, tissue inhibitor of metalloproteinases (TIMPs) 1 to 3, ITGA2, ITGA4, ITGA6, ITGB1, contactin (CNTN1), catenins (A1 and B1), and laminins (A3 and C1) were significantly upregulated, whereas COLs (1, 4, 5, 6, 11, and 12) and LOXL1 were downregulated. Human vaginal cells massively secrete MMPs and TIMPs proteins; MMP1, MMP8, MMP9 protein expression and MMP2 gelatinase activity were increased, whereas TIMP2 decreased in SCM from POP-HVCs compared to control-HVCs.

CONCLUSIONS

Primary human vaginal cells derived from women with severe pelvic organ prolapse and control-HVCs react differentially to in vitro mechanical stretch. Risk factors that induce stretch may alter ECM composition and cell-ECM interaction in pelvic floor tissue leading to the abatement of pelvic organ support and subsequent POP development.

Comparative Characterization of Vaginal Cells Derived From Premenopausal Women With and Without Severe Pelvic Organ Prolapse

BACKGROUND

This study tested a hypothesis that primary human vaginal cells derived from tissue of premenopausal women with severe pelvic organ prolapse (POP-HVCs) would display differential functional characteristics as compared to vaginal cells derived from asymptomatic women with normal pelvic floor support (control-HVCs).

METHODS

Vaginal tissue biopsies were collected from premenopausal patients with POP (n = 8) and asymptomatic controls (n = 7) during vaginal hysterectomy or repair. Primary vaginal cells were isolated by enzymatic digestion and characterized by immunocytochemistry. Cell attachment and proliferation on different matrices (collagen I, collagen II, collagen IV, fibronectin, laminin, tenascin, and vitronectin) were compared between POP-HVCs and control-HVCs. RNA was extracted, and the expression of 84 genes was screened using Human Extracellular Matrix and Adhesion Molecules RT(2) Profiler PCR array. The expression of selected genes was verified by quantitative reverse transcription-polymerase chain reaction.

RESULTS

(1) Control-HVCs attached to collagen IV more efficiently than POP-HVCs; (2) control-HVCs and POP-HVCs show a similar proliferation rate when plated on proNectin and collagen I; (3) when seeded on collagen I, resting POP-HVCs expressed significantly (P < .05) increased transcript levels of collagen VII, multiple matrix metalloproteinases (MMP3, MMP7, MMP10, MMP12, MMP13, and MMP14), integrins (ITGA1, ITGA4, ITGA6, ITGA8, ITGB1, ITGB2, and ITGB3), and cell adhesion molecules as compared to control-HVCs. Collagen XV and tissue inhibitors of MMPs (TIMP1 and TIMP2) as well as genes involved in the biogenesis and maturation of collagen and elastin fibers (LOX, LOXL1-LOXL3, BMP1, and ADAMTS2) were significantly downregulated in POP-HVCs versus control-HVCs (P < .05).

CONCLUSIONS

Resting primary POP-HVCs in vitro show altered cellular characteristics as compared to control-HVCs, which may influence their dynamic responses to external mechanical or hormonal stimuli.

Angiogenesis-Related Markers and Prognosis After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Metastatic Colorectal Cancer

BACKGROUND

Patients presenting with peritoneal metastases (PM) of colorectal cancer (CRC) can be curatively treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Angiogenesis is under control of multiple molecules of which HIF1a, SDF1, CXCR4, and VEGF are key players. We investigated these angiogenesis-related markers and their prognostic value in patients with PM arising from CRC treated with CRS and HIPEC.

PATIENTS AND METHODS

Clinicopathological data and tissue specimens were collected in 2 tertiary referral centers from 52 patients who underwent treatment for isolated PM of CRC. Whole tissue specimens were subsequently analyzed for protein expression of HIF1a, SDF1, CXCR4, and VEGF by immunohistochemistry. Microvessel density (MVD) was analyzed by CD31 immunohistochemistry. The relationship between overall survival (OS) and protein expression as well as other clinicopathological characteristics was analyzed.

RESULTS

Univariate analysis showed that high peritoneal cancer index (PCI), resection with residual disease and high expression of VEGF were negatively correlated with OS after treatment with CRS and HIPEC (P < 0.01, P < 0.01, and P = 0.02, respectively). However, no association was found between the other markers and OS (P > 0.05). Multivariate analysis showed an independent association between OS and PCI, resection outcome and VEGF expression (multivariate HR: 6.1, 7.8 and 3.8, respectively, P ≤ 0.05).

CONCLUSIONS

An independent association was found between high VEGF expression levels and worse OS after CRS and HIPEC. The addition of VEGF expression to the routine clinicopathological workup could help to identify patients at risk for early treatment failure. Furthermore, VEGF may be a potential target for adjuvant treatment in these patients.

Production of ascorbic acid releasing biomaterials for pelvic floor repair

OBJECTIVE

An underlying abnormality in collagen turnover is implied in the occurrence of complications and recurrences after mesh augmented pelvic floor repair surgeries. Ascorbic acid is a potent stimulant of collagen synthesis. The aim of this study is to produce ascorbic acid releasing poly-lactic acid (PLA) scaffolds and evaluate them for their effects on extracellular matrix production and the strength of the materials.

MATERIALS AND METHODS

Scaffolds which contained either l-ascorbic acid (AA) and Ascorbate-2-Phosphate (A2P) were produced with emulsion electrospinning. The release of both drugs was measured by UV spectrophotometry. Human dermal fibroblasts were seeded on scaffolds and cultured for 2weeks. Cell attachment, viability and total collagen production were evaluated as well as mechanical properties.

RESULTS

No significant differences were observed between AA, A2P, Vehicle and PLA scaffolds in terms of fibre diameter and pore size. The encapsulation efficiency and successful release of both AA and A2P were demonstrated. Both AA and A2P containing scaffolds were significantly more hydrophilic and stronger in both dry and wet states compared to PLA scaffolds. Fibroblasts produced more collagen on scaffolds containing either AA or A2P compared to cells grown on control scaffolds.

CONCLUSION

This study is the first to directly compare the two ascorbic acid derivatives in a tissue engineered scaffold and shows that both AA and A2P releasing electrospun PLA scaffolds increased collagen production of fibroblasts to similar extents but AA scaffolds seemed to be more hydrophilic and stronger compared to A2P scaffolds.

STATEMENT OF SIGNIFICANCE

Mesh augmented surgical repair of the pelvic floor currently relies on non-degradable materials which results in severe complications in some patients. There is an unmet and urgent need for better pelvic floor repair materials. Our current understanding suggests that the ideal material should be able to better integrate into sites of implantation both biologically and mechanically. The impact of vitamin C on extracellular matrix production is well established but we in this study have undertaken a critical comparison of two derivatives of vitamin C as they are released from a biodegradable scaffold. This strategy proved to be equally useful with both derivatives in terms of new tissue production yet we observed significant differences in mechanical properties of these biomaterials.