Transvaginal PVDF-mesh for cystocele repair: A cohort study

Promoting cell proliferation and collagen production with ascorbic acid 2-phosphate-releasing poly(l-lactide-co-ε-caprolactone) membranes for treating pelvic organ prolapse

Pelvic organ prolapse (POP) afflicts millions of women globally. In POP, the weakened support of the pelvic floor results in the descent of pelvic organs into the vagina, causing a feeling of bulging, problems in urination, defaecation and/or sexual function. However, the existing surgical repair methods for relapsed POP remain insufficient, highlighting the urgent need for more effective alternatives. Collagen is an essential component in pelvic floor tissues, providing structural support, and its production is controlled by ascorbic acid. Therefore, we investigated novel ascorbic acid 2-phosphate (A2P)-releasing poly(l-lactide-co-ε-caprolactone) (PLCLA2P) membranes in vitro to promote cell proliferation and extracellular matrix protein production to strengthen the natural support of the pelvic fascia for POP applications. We analysed the mechanical properties and the impact of PLCLA2P on cellular responses through cell culture analysis using human vaginal fibroblasts (hVFs) and human adipose-derived stem/stromal cells (hASCs) compared to PLCL. In addition, the A2P release from PLCLA2P membranes was assessed in vitro. The PLCLA2P demonstrated slightly lower tensile strength (2.2 ± 0.4 MPa) compared to PLCL (3.7 ± 0.6 MPa) for the first 4 weeks in vitro. The A2P was most rapidly released during the first 48 h of in vitro incubation. Our findings demonstrated significantly increased proliferation and collagen production of both hVFs and hASCs on A2P-releasing PLCLA2P compared to PLCL. In addition, extracellular collagen Type I fibres were detected in hVFs, suggesting enhanced collagen maturation on PLCLA2P. Moreover, increased extracellular matrix protein expression was detected on PLCLA2P in both hVFs and hASCs compared to plain PLCL. In conclusion, these findings highlight the potential of PLCLA2P as a promising candidate for promoting tissue regeneration in applications aimed for POP tissue engineering applications.

Examining the application of the IDEAL framework in the reporting and evaluation of innovative invasive procedures: secondary qualitative analysis of a systematic review

OBJECTIVES

The development of new surgical procedures is fundamental to advancing patient care. The Idea, Developments, Exploration, Assessment and Long-term (IDEAL) framework describes study designs for stages of innovation. It can be difficult to apply due to challenges in defining and identifying innovative procedures. This study examined how the IDEAL framework is operationalised in real-world settings; specifically, the types of innovations evaluated using the framework and how authors justify their choice of IDEAL study design.

DESIGN

Secondary qualitative analysis of a systematic review.

DATA SOURCES

Citation searches (Web of Science and Scopus) identified studies following the IDEAL framework and citing any of the ten key IDEAL/IDEAL_D papers.

ELIGIBILITY CRITERIA

Studies of invasive procedures/devices of any design citing any of the ten key IDEAL/IDEAL_D papers.

DATA EXTRACTION AND SYNTHESIS

All relevant text was extracted. Three frameworks were developed, namely: (1) type of innovation under evaluation; (2) terminology used to describe stage of innovation and (3) reported rationale for IDEAL stage.

RESULTS

48 articles were included. 19/48 described entirely new procedures, including those used for the first time in a different clinical context (n=15/48), reported as IDEAL stage 2a (n=8, 53%). Terminology describing stage of innovation was varied, inconsistent and ambiguous and was not defined. Authors justified their choice of IDEAL study design based on limitations in published evidence (n=36) and unknown feasibility and safety (n=32) outcomes.

CONCLUSION

Identifying stage of innovation is crucial to inform appropriate study design and governance decisions. Authors' rationale for choice of IDEAL stage related to the existing evidence base or lack of sufficient outcome data for procedures. Stage of innovation was poorly defined with inconsistent descriptions. Further work is needed to develop methods to identify innovation to inform practical application of the IDEAL framework. Defining the concept of innovation in terms of uncertainty, risk and degree of evidence may help to inform decision-making.

Modified Vaginal Mesh Procedure with DynaMesh®-PR4 for the Treatment of Anterior/Apical Vaginal Prolapse

(1) Background: Treating female pelvic organ prolapse (POP) is challenging. Surgical meshes have been used in transvaginal surgeries since the 1990s, but complications such as mesh exposure and infection have been reported. Polyvinylidene fluoride (PVDF) mesh, known for its stability and non-reactive properties, has shown promise in urogynecological surgeries. (2) Methods: A retrospective analysis was conducted on 27 patients who underwent a modified PVDF vaginal mesh repair procedure using DynaMesh®-PR4 and combined trans-obturator and sacrospinous fixation techniques. Additional surgeries were performed as needed. (3) Results: The mean operation time was 56.7 min, and the mean blood loss was 66.7 mL. The average hospitalization period was 4.2 days with Foley catheter removal after 2 days. Patients experienced lower pain scores from the day of the operation to the following day. Postoperative follow-up revealed that 85.2% of patients achieved anatomic success, with 14.8% experiencing recurrent stage II cystocele. No recurrence of apical prolapse was observed. Complications were rare, with one case (3.7%) of asymptomatic mesh protrusion. (4) Conclusions: The modified vaginal mesh procedure using DynaMesh®-PR4 showed favorable outcomes with a short operation time, low recurrence rate, rare complications, and improved functional outcomes. This surgical option could be considered for anterior and apical pelvic organ prolapse in women.

Triple-compartment strategy for abdominal sacral colpopexy using PVDF mesh: one-year report of anatomical and subjective outcomes

INTRODUCTION AND HYPOTHESIS

Abdominal Sacral Colpopexy (ASC) is one of the best surgical methods to repair apical or uterine prolapse. We aimed to evaluate the short-term results of a triple-compartment open ASC strategy using polyvinylidene fluoride (PVDF) mesh in the treatment of patients with severe apical or uterine prolapse.

METHODS

Women with high-grade uterine or apical prolapse with or without cysto-rectocele were prospectively enrolled in the study from April 2015 to June 2021. We performed all-compartment repair using a tailored PVDF mesh for ASC. We assessed the severity of pelvic organ prolapse (POP) using the Pelvic Organ Prolapse Quantification (POP-Q) system at baseline and 12 months after the operation. The patients completed the International Continence Society Questionnaire Vaginal Symptom (ICIQ-VS) questionnaire at baseline, 3, 6, and 12 months postoperatively.

RESULTS

Thirty-five women with a mean age of 59.8±10.0 years were included in the final analysis. Stage III and stage IV prolapse was evident in 12 and 25 patients, respectively. After 12 months, the median POP-Q stage was significantly lower compared to the baseline (4 vs 0, p=<0.0001). Vaginal symptoms score was also reduced significantly at 3-month (7.5±3.5), 6-month (7.3±3.6), and 12-month (7.2±3.1) compared to the baseline (39.5±6.7) (p values < 0.0001). We did not observe any mesh extrusion or high-grade complications. Six (16.7%) patients had cystocele recurrence during the 12-month follow-up, and two of them needed reoperation.

CONCLUSIONS

Our short-term follow-up showed that using an open ASC technique with PVDF mesh in treating high-grade apical or uterine prolapse is associated with a high rate of procedural success and low rates of complication.

Surgical results in POP/UI surgery after using PVDF compared to other materials. A systematic review and meta-analysis

OBJECTIVES

Synthetic materials have been used for the surgical treatment of stress urinary incontinence (SUI) and pelvic organ prolapse (POP). During the last 25 years, these materials were composed mostly of polypropylene (PP), whereas recently the use of polyvinylidene difluoride (PVDF) is of increasing interest due to its characteristics. This study aimed to compare the results after SUI/POP surgery using PVDF versus PP materials by synthesizing the data of relevant existing literature.

STUDY DESIGN

This systematic review and meta-analysis included clinical trials, case-control studies, or cohort studies written in the English language. The search strategy included the electronic databases MEDLINE, EMBASE, and Cochrane, and grey literature (congresses IUGA, EUGA, AUGS, FIGO). All studies have to provide numeric data or odds ratios (OR) of developing a specific outcome in surgeries with PVDF compared with outcomes of other used materials. No restrictions of race or ethnicity were applied, nor chronological restrictions. Exclusion criteria were studies that included patients with cognitive impairment, dementia, stroke, or central nervous system trauma. All studies were screened by two reviewers, initially by title and abstract, and afterward by full text. Disagreements were resolved through mutual consent. All studies were assessed for their quality and bias risk. Data were extracted using a data extraction form formulated in a Microsoft Excel spreadsheet. Our results were divided into studies dealing only with SUI patients, studies dealing only with POP patients, and cumulative analysis of variables expressed in both SUI and POP surgery. The primary outcomes were the rates of post-operative recurrence, mesh erosion, and postoperative pain after surgery with PVDF compared to PP. The secondary outcomes were post-operative sexual dissatisfaction, overall satisfaction rates, hematoma, urinary tract infection, de novo urge incontinence, and reoperation rate.

RESULTS

No differences in the post-operative rates of SUI/POP recurrence, mesh erosion, and pain were found after surgery with PVDF vs surgery with PP. Patients after SUI surgery with PVDF tapes had statistically significant lower rates of de-novo urgency compared to the PP group [OR = 0.38 (0.18, 0.88), p = 0.01]; patients after POP surgery with PVDF materials had statistically significant lower rates of de-novo sexual dysfunction compared to the PP group [OR = 0.12 (0.03, 0.46), p = 0.002].

CONCLUSIONS

This study provided evidence that the use of PVDF in SUI/POP surgeries could be a valid alternative to PP. However our results are limited by uncertainty due to the overall low quality of the existent data. Further research and validation would contribute to better surgical techniques.

The early outcomes of complex abdominal wall reconstruction with polyvinylidene (PVDF) mesh in the setting of active infection: a prospective series

PURPOSE

The use of synthetic mesh to repair infected abdominal wall defects remains controversial. Polyvinylidene fluoride (PVDF) mesh was introduced in 2002 as an alternative to polypropylene, with the advantages of improved biostability, lowered bending stiffness, and minimum tissue response. This study aimed to evaluate the short-term outcomes of using PVDF mesh to treat infected abdominal wall defects in the elective setting.

METHODS

This prospective clinical trial started in 2016 and was designed to evaluate the short- and mid-term outcomes of 38 patients submitted to abdominal wall reconstruction in the setting of active mesh infection and/or enteric fistulas (AI) when compared to a group of 38 patients submitted to clean ventral hernia repairs (CC). Patients were submitted to single-staged repairs, using onlay PVDF mesh (DynaMesh®-CICAT) reinforcement to treat their defects.

RESULTS

Groups had comparable demographic characteristics. The AI group had more previous abdominal operations and required a longer operative and anesthesia time. At 30 days, surgical site occurrences were observed in 16 (42.1%) AI vs. 17 (44.7%) CC, p = 0.817; surgical site infection occurred in 4 (10.5%) AI vs. 6 (15.8%) CC, p = 0.497; and a higher number of procedural interventions were required in the CC group, 15.8 AI vs. 28.9% CC, p = 0.169. Both groups did not have chronic infections at 1 year of follow-up, and one hernia recurrence was observed in the AI group.

CONCLUSIONS

The use of PVDF mesh in the infected setting presented favorable results with a low incidence of wound infection.

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.

Outcomes collected in female pelvic floor surgical procedure registries and databases: a scoping review

INTRODUCTION AND HYPOTHESIS

The objective was to overview the literature on the existing pelvic floor procedure registries and databases and to identify patient demographic, clinical and/or patient-reported data items for inclusion in the Australasian Pelvic Floor Procedure Registry (APFPR) Minimum Data Set (MDS).

METHODS

We conducted a literature search on the MEDLINE, Embase, CINAHL and PsycINFO databases in addition to Google Scholar and grey literature to identify studies in the period January 2008 to January 2020. All were English studies of registries and databases on female adults undergoing surgery for pelvic floor disorders including stress urinary incontinence (SUI) and pelvic organ prolapse (POP). Studies were assessed on demographic and clinical patient characteristics, procedure or treatment type, health-related quality of life, adverse events and safety outcomes, captured by pelvic floor procedure registries or databases that have been established to date.

RESULTS

From 1662 studies, 29 publications describing 22 different pelvic floor registries and databases were included for analysis, 12 (55%) of which were multicentre. Six (27%) registries and databases involved solely SUI, eight (36%) were regarding POP, and the remaining eight (36%) focussed on both conditions. The majority of registries and databases captured similar details on patient characteristics, comorbidities and other clinical features, procedure or treatment type, health-related quality of life, adverse events, safety and efficacy.

CONCLUSION

The findings of this scoping review will assist in determining the MDS for the APFPR, an initiative of the Australian government, to improve health and quality of life outcomes of women who undergo pelvic floor reconstructive procedures.

Transvaginal repair of anterior vaginal wall prolapse with polyvinylidene fluoride (PVDF) mesh: an alternative for previously restricted materials?

INTRODUCTION AND HYPOTHESIS

To study the mid-term safety and functional outcomes of transvaginal anterior vaginal wall prolapse repair using polyvinylidene fluoride (PVDF) mesh (DynaMesh®-PR4) by the double trans-obturator technique (TOT).

METHODS

Between 2015 and 2020, we prospectively included women with symptomatic high-stage anterior vaginal wall prolapse with or without uterine prolapse or stress urinary incontinence (SUI) in the study. The patients underwent transvaginal repair of the prolapse using PVDF mesh in two medical centers. We followed all patients for at least 12 months. We recorded the characteristics of vaginal and sexual symptoms, urinary incontinence, and prolapse stage pre- and postoperatively using International Consultation on Incontinence Questionnaire-Vaginal Symptoms (ICIQ-VS), International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form (ICIQ-UI-SF), and Pelvic Organ Prolapse Quantification (POP-Q) system, respectively.

RESULTS

One hundred eight women were included in the final analysis with a mean follow-up time of 34.5 ± 18.6 months. The anatomical success was achieved in 103 (95.4%) patients. There was a significant improvement in patients' vaginal symptoms, urinary incontinence, and quality of life scores postoperatively (p < 0.0001). Only six patients (5.5%) had mesh extrusion, five of whom were managed successfully. The total rates of complications and de novo urinary symptoms were 21.3% and 7.4%, respectively. Significant pain was reported in 17 cases (15.7%).

CONCLUSION

Our findings show that using PVDF mesh in the double TOT technique for anterior vaginal wall prolapse repair is a safe procedure with high anatomic and functional success rates and acceptable complication rates in mid-term follow-up.

Transvaginal polytetrafluoroethylene mesh surgery for pelvic organ prolapse: 1-year clinical outcomes

OBJECTIVES

To evaluate the safety and efficacy of transvaginal mesh surgery using a polytetrafluoroethylene mesh to treat pelvic organ prolapse.

METHODS

This prospective observational study included women undergoing transvaginal mesh surgery for pelvic organ prolapse that used new polytetrafluoroethylene mesh cut into a shape similar to that of Elevate. We evaluated the subjective and objective outcomes at 3 and 12 months, as well as postoperative complication rates.

RESULTS

This study included 55 patients. The pelvic organ prolapse quantification scores improved significantly at 3 and 12 months after surgery compared with scores before surgery. In four patients (7.3%), a pelvic examination showed stage 2 objective recurrence without subjective symptoms. Clavien-Dindo grades 2 and 3 perioperative complications were observed in 9.1% and 1.8% of the patients, respectively. Vaginal mesh exposure occurred in one patient (1.8%) at the time of the 3-month follow-up evaluation. The mesh was exposed at the proximal midline of the anterior vaginal wall.

CONCLUSIONS

These findings show the safe and effective use of the polytetrafluoroethylene mesh for transvaginal mesh surgery.

Outcome selection, measurement and reporting for new surgical procedures and devices: a systematic review of IDEAL/IDEAL-D studies to inform development of a core outcome set

BACKGROUND

Outcome selection, measurement and reporting for the evaluation of new surgical procedures and devices is inconsistent and lacks standardization. A core outcome set may promote the safe and transparent evaluation of surgical innovations. This systematic review examined outcome selection, measurement and reporting in studies conducted within the IDEAL (Idea, Development, Exploration, Assessment and Long-term monitoring) framework to examine current practice and inform the development of a core outcome set for early-phase studies of surgical procedures/devices.

METHODS

Web of Science and Scopus citation searches were performed to identify author-reported IDEAL/IDEAL-D studies for any surgical procedure/device. Outcomes were extracted verbatim, including contextual information regarding outcome selection and measurement. Outcomes were categorized to inform a conceptual framework of outcome domains relevant to evaluating innovation.

RESULTS

Some 48 studies were identified. Outcome selection, measurement and reporting varied widely across studies in different IDEAL stages. From 1737 outcomes extracted, 22 domains specific to evaluating innovation were conceptualized under seven broad categories: procedure completion success/failure; modifications; unanticipated events; surgeons' experiences; patients' experiences; resource use specific to the innovative procedure/device; and other innovation-specific outcomes. Most innovation-specific outcomes were measured and reported in only a small number of studies.

CONCLUSION

This review highlighted the need for guidance and standardization in outcome selection and reporting in the evaluation of new surgical procedures/devices. Novel outcome domains specific to innovation have been identified to establish a core outcome set for future evaluations of surgical innovations.

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

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

Efficacy and safety outcomes after genital prolapse repair by the vaginal route using the Avaulta Plus® mesh

OBJECTIVE(S)

With aging population, a rise in anterior wall prolapse surgery is expected. The aim of this study is to evaluate the efficacy and safety of genital prolapse repair by the vaginal route using a mixed polypropylene and porcine skin mesh (Avaulta Plus®).

STUDY DESIGN

Retrospective study conducted at Tenon University Hospital, Paris, France. We included seventy-nine women who underwent anterior wall prolapse repair using Avaulta Plus® mesh by the transobturator route for genital prolapse ≥ stage II from September 2008 to December 2017. Pre- and postoperative pelvic organ prolapse classification, functional symptoms, quality of life scores were evaluated, and complications were recorded.

RESULTS

The anatomical success rate for anterior wall prolapse was 97 %. The postoperative complication rate was 29.1 % among which the mesh exposure rate was 7.6 %. Pelvic symptoms such as vaginal discomfort and pelvic heaviness were significantly improved (p < 0.01). Voiding dysfunction were significantly improved (p < 0.01). A significant improvement in the PFDI-20 score (p < 0.01) and PFIQ-7 score (p < 0.01) was observed. After 3 years of follow-up, the recurrence rate was 12 %.

CONCLUSION(S)

Prolapse repair using the Avaulta Plus® mesh is effective and results in a significant improvement in quality of life. The complication rate, including mesh exposure, is acceptable.

Laparoscopic approach to pelvic organ prolapse - the way to go or a blind alley?

Pelvic organ prolapse represents a relatively frequent diagnosis that requires attention due to its detrimental effect on quality of life. Not surprisingly, it is one of the commonest indications for surgery in premenopausal and postmenopausal women, often requiring a complex multidisciplinary approach. Traditional vaginal procedures are being gradually replaced by laparoscopic techniques, offering anticipated benefits in reduced recurrence and complication rates, while respecting the trend towards uterus sparing if desirable. Recently, questions about the safety of alloplastic materials used in pelvic organ prolapse surgery were raised, leading to official restrictions in their use, particularly for transvaginal application. As a result, laparoscopic procedures might appear slightly favored but caution must be taken to assure proper technique of mesh placement while maintaining high awareness of possible long-term mesh-related complications that require close surveillance. Therefore, adequate education and training becomes even more important to achieve optimal results and to avoid possible serious medico-legal charges.

Current surgical management of pelvic organ prolapse: Strategies for the improvement of surgical outcomes

There are a variety of surgical management strategies to help surgeons repair pelvic organ prolapse (POP). Surgical treatment for POP includes native tissue repair, augmentation with mesh, and minimally invasive surgeries. Currently, laparoscopic or robotic techniques for POP repair are increasing in popularity and continuing to evolve. The aim of this review is to present an up-to-date review of surgical techniques used for POP repair and to discuss ways to optimize surgical outcomes.

Medium-term outcome of laparoscopic sacrocolpopexy using polivinylidene fluoride as compared to a hybrid polyglecaprone and polypropylene mesh: A matched control study

AIM

To compare 2-year outcomes of laparoscopic sacrocolpopexy (LSCP) either with polyvinylidene fluoride (PVDF) or hybrid polypropylene containing a resorbable polyglecaprone (PP+ PG) mesh.

MATERIALS AND METHODS

Retrospective audit on 105 consecutive patients undergoing LSCP a with PVDF-mesh (DynaMesh, FEG Textiltechniken), matched by prolapse stage and cervicopexy or vault suspension to 105 controls undergoing LSCP with a hybrid PP + PG-mesh (Ultrapro, Ethicon). Patients are part of an ongoing prospective study. The primary outcome measure was the Patient Global Impression of Change score (PGIC), the coprimary variable was failure rate at the vault (≤1 cm). Other outcomes were intraoperative and postoperative complications within 3 months categorized by the Clavien-Dindo classification, reinterventions, graft-related complications (GRCs) and functional outcomes. All assessments were performed by an independent assessor. Data are reported as median (interquartile range) number and percent as appropriate, the Mann-Whitney U, χ² , or Fisher exact were used for comparison.

RESULTS

Patient satisfaction in the PVDF group, as measured with the PGIC, was high (90.9% PGIC, ≥4) as well as was the anatomical success (97.3%) at a follow-up of 26 months. These outcomes were comparable to those of PP + PG-patients (84.8% PGIC, ≥4; 94.9% anatomical success). There were five patients (2.4%) with Dindo-III or higher complications and three patients had GRCs (1.5%), without differences between mesh type. Level-II posterior defects (Bp ≥ -1) were less likely in PVDF patients (34.1% vs 50% for PP + PG-patients; P = .003). Women in the PVDF group also were less bothered by prolapse (7.5% vs 26.4%; P = .001), yet they complained more of constipation (15.0% vs 9.0%; P = .01).

CONCLUSION

There were no differences in patient satisfaction and anatomical outcomes after LSCP either with PVDF or PP + PG mesh.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Vaginal hysterectomy with bilateral sacrospinous fixation plus an anterior mesh versus abdominal sacrocervicopexy for the treatment of primary apical prolapse in postmenopausal women: a randomized controlled study

INTRODUCTION AND HYPOTHESIS

We compared vaginal hysterectomy with bilateral sacrospinous fixation plus an anterior polyvinylidene fluoride mesh versus abdominal sacrocolpopexy for the treatment of primary apical prolapse in postmenopausal women.

METHODS

A prospective, randomized, single-blind, parallel study [Registro Brasileiro de Ensaios Clinicos (REBEC) trial register code RBR-7t6rg2] was performed from October 2015 to May 2016. A total of 71 postmenopausal women with advanced pelvic organ prolapse (POP) and undergoing surgery were randomized to the abdominal sacrocolpopexy (ASC) (n = 36) or the vaginal sacrospinous fixation with anterior mesh (VSF-AM) (n = 35) groups. Pelvic Organ Prolapse Quantification (POP-Q) system classification was performed for objective assessment, and the International Consultation on Incontinence Questionnaire-Vaginal Symptoms (ICIQ-VS), International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF), and International Consultation on Incontinence Questionnaire Overactive Bladder (ICIQ-OAB) questionnaires were filled out for subjective evaluation by women before and 1 year after surgery. All procedures were performed by a single surgeon.

RESULTS

Both groups had improvement in almost POP-Q points (except for vaginal length in the VSF-AM group) and all ICIQ scores. The ASC group had a longer operative time (129 versus 117 min, p = 0.0038) and duration for return to activities (103 versus 57 days, p < .05). Four women (11%) in the VSF-AM group were reoperated versus none from the ASC group (p = .05).

CONCLUSIONS

Although the study did not achieve the planned recruitment, after 12 months of follow-up, ASC did not differ from VSF-AM in objective and subjective scores (ICIQ questionnaires; POP-Q measurements). Recovery time was longer after open abdominal surgery.

Use of the IDEAL framework in the urological literature: where are we in 2018?

OBJECTIVES

To assess uptake and application of the IDEAL principles in original surgical procedure- or device-related clinical research studies, as well as its reported relevance as characterized by secondary publications, editorials and reviews.

MATERIALS AND METHODS

IDEAL (Idea, Development, Exploration, Assessment, Long-term study) is a framework that provides stage-specific guidance for surgical innovation and represented a major advance towards raising evidential standards. We performed a comprehensive literature search of all urology-related publications citing one or more of seven key publications on IDEAL in The Lancet and BMJ using multiple databases up to 31 December 2017.

RESULTS

We identified a total of 150 urology-related manuscripts citing IDEAL, of which 83 (55.3%) were original research and 67 (44.7%) were secondary publications. Among the original research articles, 40 (48.2%) did not explicitly apply IDEAL principles or were not surgical innovation studies. The IDEAL phases of the 43 (51.8%) remaining original research studies were IDEAL, in nine (20.9%), 27 (62.8%), four (9.3%), 0 (0%), and three publications (7.0%), respectively. Across IDEAL stages, 30 (75.0%) studies were prospective, 29 (85.3%) reported ethical oversight, and 39 (90.7%) captured treatment-related harms. None of the studies collected information on physician experience.

CONCLUSIONS

The IDEAL framework has found widespread adoption in the urology literature as witnessed by a large number of original manuscripts and secondary publications citing IDEAL; however, its application is largely limited to the early stages of surgical innovation, frequently with inappropriate and incomplete implementation. Further efforts are needed to guide investigators in the optimal use of the IDEAL framework as it relates to surgical innovation in urology.

Trials of transvaginal mesh devices for pelvic organ prolapse: a systematic database review of the US FDA approval process

INTRODUCTION

Transvaginal mesh devices are approved in the USA by the Food and Drug Administration (FDA), through the 510(k) system. However, there is uncertainty about the benefit to harm balance of mesh approved for pelvic organ prolapse. We, therefore, assessed the evidence at the time of approval for transvaginal mesh products and the impact of safety studies the FDA mandated in 2012 because of emerging harms.

METHODS

We used FDA databases to determine the evidence for approval of transvaginal mesh. To create a 'family tree' of device equivalence, we used the 510(k) regulatory approval of the 1985 Mersilene Mesh (Ethicon) and the 1996 ProteGen Sling (Boston Scientific), searched for all subsequently related device approvals, and for the first published randomised trial evidence. We assessed compliance with all FDA 522 orders issued in 2012 requiring postmarketing surveillance studies.

RESULTS

We found 61 devices whose approval ultimately relied on claimed equivalence to the Mersilene Mesh and the ProteGen Sling. We found no clinical trials evidence for these 61 devices at the time of approval. Publication of randomised clinical trials occurred at a median of 5 years after device approval (range 1-14 years). Analysis of 119 FDA 522 orders revealed that in 79 (66%) the manufacturer ceased market distribution of the device, and in 26 (22%) the manufacturer had changed the indication. Only seven studies (six cohorts and new randomised controlled trial) covering 11 orders were recruiting participants (none had reported outcomes).

CONCLUSIONS

Transvaginal mesh products for pelvic organ prolapse have been approved on the basis of weak evidence over the last 20 years. Devices have inherited approval status from a few products. A publicly accessible registry of licensed invasive devices, with details of marketing status and linked evidence, should be created and maintained at the time of approval.