Surgical repair of vaginal prolapse: A gynaecological hernia

Prevalence and surgical outcomes of stage 3 and 4 pelvic organs prolapse in Jimma university medical center, south west Ethiopia

BACKGROUND

Pelvic organ prolapse (POP) affects about half of the women and affects their quality of life. The current study is, therefore, aimed at determining the prevalence and surgical outcomes of severe stage POP at Jimma University medical center from November 2016 to May 2018.

METHOD

A Hospital-based cross-sectional study was conducted on all patients with stage 3 and 4 POP, who were admitted, and had surgery. Data were collected from the patient's chart, and logbooks, which were filled up from entry till her discharge. A Simplified POPQ(S-POPQ) was used to stage the prolapse at admission, at discharge, and three months follow-ups.

RESULTS

Among 92 patients who were analyzed, POP accounts for 10.6% of all gynecologic admissions, and 43.8% of all gynecologic surgeries. The mean age of patients is 46 (± 12) years, and nearly 34% of the patients had stage 3 and 66% had stage 4 POP. Based on the type of prolapse, 93.5% of patients had stage 3 and more anterior vaginal wall prolapse (AVWP) and apical prolapse, while 57.6% had stage 3 or more posterior vaginal wall prolapse. Out of 72 patients who had anterior colporrhaphy, 58.7% had anterior colporrhaphy with colposuspension. Out of 83 patients who had apical suspension, 48.2%, 39.8%, and 12% had uterosacral, sacrospinous, and Richardson respectively. Ninety-seven patients had stage 0 or 1 POP at discharge while 90% of 20 patients who returned for follow-up at three months had stage 0 or 1 POP. Eight patients had surgery-related complications; bladder injury, urinary retention, Hemorrhage during SSLF, and rectal injury.

CONCLUSION

The prevalence of pelvic organ prolapse is high and the majority of patients presented with advanced-stage pelvic organ prolapse, with a long duration of symptoms and associated problems. The surgical techniques used have resulted in a high immediate success rate of 97% and 90% at discharge and three months follow up respectively. Therefore, awareness creation activities are important to facilitate an early presentation for treatment to improve the quality of life and the current surgical technique; native tissue vaginal repair (NTVR), being practiced in the setup has had better success.

Using a pessary during radiotherapy in reducible pelvic organ prolapse and vaginal cancer: a case report and review of the literature

Purpose

Primary vaginal cancer and pelvic organ prolapse (POP) combination is extremely rare. Although definitive chemoradiotherapy (CRT) and brachytherapy (BT) is the standard treatment for advanced stage primary vaginal cancer, there is a limited data about the treatment of primary vaginal cancer combined with POP due to its rarity. In addition, radiotherapy (RT) process may be difficult in these cases and often result in more toxicity.

Case presentation

In this case report, we present a 77-year-old woman with a diagnosis of primary vaginal cancer associated with POP, who was treated with definitive CRT using a pessary to restore vaginal anatomy for optimal radiation. Following CRT, complete response was observed and vaginal cuff BT was performed. The patient tolerated the treatment very well and is still alive without disease at 10-months follow-up.

Conclusions

Combined primary vaginal cancer and POP is an extremely rare clinical entity, with only a few cases reported in the literature. When applying CRT in these cases, critical organ doses may be higher than expected due to the downward descent of the pelvic organs. Especially in elderly patients, a pessary can be used as a non-surgical procedure to restore the anatomy for symptom relief during definitive CRT. Additionally, it allows tumors to be targeted more precisely.

Evaluation of the bioactivity about anti-sca-1/basic fibroblast growth factor-urinary bladder matrix scaffold for pelvic reconstruction

Introduction and hypothesis: Pelvic support structure injury is the major cause of pelvic organ prolapse. At present, polypropylene-based filler material has been suggested as a common method to treat pelvic organ prolapse. However, it cannot functionally rehabilitate the pelvic support structure. In addition to its poor long-term efficiency, the urinary bladder matrix was the most suitable biological scaffold material for pelvic floor repair. Here, we hypothesize that anti-sca-1 monoclonal antibody and basic fibroblast growth factor were cross-linked to urinary bladder matrix to construct a two-factor bioscaffold for pelvic reconstruction.

METHODS

Through a bispecific cross-linking reagent, sulfosuccinimidyl 4-[N-maleimidomethyl] cyclohexane-1-carboxylate (sulfo-smcc) immobilized anti-sca-1 and basic fibroblast growth factor to urinary bladder matrix. Then scanning electron microscope and plate reader were used to detect whether the anti-sca-1/basic fibroblast growth factor-urinary bladder matrix scaffold was built successfully. After that, the capacity of enriching sca-1 positive cells was measured both in vitro and in vivo. In addition, we evaluated the differentiation capacity and biocompatibility of the scaffold. Finally, western blotting was used to detect the level of fibulin-5 protein.

RESULTS

The scanning electron microscope and plate reader revealed that the double-factor biological scaffold was built successfully. The scaffold could significantly enrich a large number of sca-1 positive cells both in vitro and in vivo, and obviously accelerate cells and differentiate functional tissue with good biocompatibility. Moreover, the western blotting showed that the scaffold could improve the expression of fibulin-5 protein.

CONCLUSION

The anti-sca-1/basic fibroblast growth factor-urinary bladder matrix scaffold revealed good biological properties and might serve as an ideal scaffold for pelvic reconstruction.

Preparation of a small intestinal submucosa modified polypropylene hybrid mesh via a mussel-inspired polydopamine coating for pelvic reconstruction

Pelvic organ prolapse (POP) is a serious health issue that affects many adult women. Surgical treatments for POP patients comprise a common strategy in which scaffold materials are used to reconstruct the prolapsed pelvic. However, the existing materials for pelvic reconstruction cannot meet clinical requirements in terms of biocompatibility, mechanics and immunological rejection. To address these concerns, polypropylene (PP) mesh was selected because of its strong mechanical properties. Small intestinal submucosa (SIS) was used to modify the PP mesh via a mussel-inspired polydopamine coating to enhance its biocompatibility. The scanning electron microscopy (SEM) and atomic force microscopy (AFM) results demonstrated that SIS was successfully conjugated on the surface of the PP mesh. Moreover, the cytotoxicity results indicated that the PP mesh and SIS-modified PP mesh were safe to use. Furthermore, in vivo tests demonstrated that the fibroplasia around the implanted site in the SIS-modified PP mesh group was significantly less than the fibroplasia around the PP mesh group. In addition, the immunohistochemistry staining results indicated that the expression of pro-inflammatory macrophages (M1) was substantially lower and that the expression of pro-healing macrophages (M2) was higher in the SIS-modified PP mesh group. Furthermore, ELISA detection indicated that the expression of IL-1β and IL-6 in the SIS-modified PP mesh group was reduced compared with the PP mesh group. These findings suggest that a SIS-modified polypropylene hybrid mesh via a mussel-inspired polydopamine coating is a promising approach in pelvic reconstruction.

Integration of nondegradable polystyrene and degradable gelatin in a core-sheath nanofibrous patch for pelvic reconstruction

Pelvic organ prolapse (POP) is a serious health issue affecting many adult women. Complications of POP include pelvic pressure, pelvic pain, and problems in emptying their bowels or bladder. Sometimes, POP may even cause urinary outflow obstruction and lead to bladder or kidney infections. Currently, synthetic and naturally derived materials have been chosen for treatment of POP to reduce the high recurrence rates after surgical interventions. However, existing materials for POP treatment cannot meet the clinical requirements in terms of biocompatibility, mechanics, and minimal risk of rejection. Especially, erosion in synthetic polymers and rapid degradation in natural polymers limit their further applications in clinics. To address these concerns, we report a novel POP replacement using core-sheath polystyrene/gelatin electrospun nanofiber mesh. The outside gelatin sheath provides a hydrophilic surface and implantable integrity between host and guest, while the inner PS core offers the necessary mechanical support. The composite mesh shows graft accommodation in pelvic submucosa after implantation in vivo, as shown in hematoxylin-eosin staining and T helper cell phenotype and macrophage phenotype stainings. Qualitative analysis of inducible nitric oxide synthase, arginase, interferon-γ, and interleukin-10 gene expressions also indicates that the implanted composite mesh switches to accommodation mode 2 weeks postimplantation. Thus, these novel core-sheath polystyrene/gelatin nanofibrous membranes are promising in pelvic reconstruction.

The use of synthetic mesh and the management of mesh extrusion in vaginal surgery

The authors present a review of the literature regarding the management of mesh extrusion in vaginal surgery. As used in traditional surgical techniques, the use of mesh theoretically allows for a broader base of support and eliminates the need to rely on pre-existing weakened fascia. In this article, the different physical properties and types of synthetic mesh used, and their respective advantages and disadvantages in terms of mesh extrusion, are reviewed.

Porcine urinary bladder matrix-polypropylene mesh: a novel scaffold material reduces immunorejection in rat pelvic surgery

INTRODUCTION AND HYPOTHESIS

The present study set out to modify polypropylene vaginal surgical material using porcine urinary bladder matrix (UBM) in order to improve biocompatibility. The aim was to develop a compound scaffold that induced less vaginal erosion and to evaluate host immunoreactivity to this material in vivo.

METHODS

Forty-eight Sprague-Dawley rats were randomly divided into four equal groups. One group underwent a sham operation, and the other groups underwent vaginal implantation with different materials: UBM (U); UBM + polypropylene (UP); or polypropylene (P). The host tissue response was determined by macro-observation, and by histological and immunohistochemical methods at 7, 14, 21, or 28 days after surgery.

RESULTS

The inflammation reaction was strongest throughout the entire observation time in Group P, but was weaker and had a tendency to decrease with time in Groups U and UP. The presence of the UBM material in the compound scaffold allowed the polypropylene to fuse with newly proliferating surrounding tissue and resulted in less rejection of the material by the host, as indicated by the reduced appearance of CD4-, and CD8-positive cells.

CONCLUSIONS

Porcine UBM allowed mechanical isolation of polypropylene, and also reduced the immune reaction to polypropylene. This study suggests that the UBM + polypropylene compound scaffold may be a promising material for clinical use in pelvic reconstruction surgery.