Antibacterial mesh sling: a prospective outcome analysis

Mesh-associated pain syndrome: predictors for continence and prolapse mesh removal surgery in a single centre

OBJECTIVE

Over the last two decades one of the main surgical treatment for stress urinary incontinence (SUI) and pelvic organ prolapse (POP) surgery was the insertion of non-absorbable mesh to restore continence and prolapse respectively. Over time complications arose including mesh-associated pain syndrome (MAPS), mesh exposure, mesh, erosion, chronic bladder/vaginal infections, and dyspareunia. Consequently, women chose surgical mesh removal to counter these problems. However, little is known about the demographics, medical co-morbidities, mesh types involved and the timing from mesh insertion to mesh removal. This retrospective study will look at which of these factors may be closely associated with mesh removal surgery.

DESIGN

Retrospective evaluation.

SETTING

Female Pelvic Medicine and Reconstructive Surgery (FPMRS) Clinic at University College London Hospitals NHS Foundation Trust.

POPULATION

All patients presenting to the FPMRS Clinic between June 2011 to December 2019, requesting mesh removal surgery with a history of MAPS and other mesh complications were included in this study.

METHODS

Patient demographics including age, ethnicity, obstetric history, and medical co-morbidities; type of mesh/anatomical route used; onset of symptoms; and time from insertion to removal were recorded.

MAIN OUTCOME MEASURES

Determination of correlation coefficients between patient demographics, patient reported symptoms and mesh removal surgery.

RESULTS

Three hundred and forty-five women with a history of MAPS were included in the study. Women in the 40-60 year old cohort accounted for 54.4% of mesh removal surgery; 54.8% had a BMI under 30 and almost 90% were Caucasian. 96.5% had had children, with over 77% having had a vaginal delivery. 91.9% of patients reported other health conditions including 18.8% with a concomitant history of mental health problems and 15.4% with a history of heart disease. Over 80% of women undergoing mesh removal surgery had a continence mesh (49% retropubic and 32% obturator continence mesh) removed, whereas 20% had an abdominal prolapse and/or vaginal prolapse mesh removed. The average time from mesh insertion to mesh removal was seven years, with the prevalence of mesh removal surgery averaging 85% (range 50-100%) depending on the comorbidity determined.

CONCLUSIONS

All women presented to the clinic with a history of MAPS and other comorbidities which may have influenced their decision to pursue mesh removal surgery. There were no specific predictors, other than chronic pain associated with mesh, determining which women underwent surgery, though those with continence mesh were more likely to do so.

Complications related to use of mesh implants in surgical treatment of stress urinary incontinence and pelvic organ prolapse: infection or inflammation?

The surgical mesh material used in the surgical treatment of stress urinary incontinence (SUI) and pelvic organ prolapse (POP) in women is associated with significant complications in some women. This has recently become a public health issue with involvement of national parliaments and regulatory bodies. The occurrence of mesh complications is thought to be a result of multifactorial processes involving problems related to the material design, the surgical techniques used and disease, and patient-related factors. However, the infectious complications and mesh–tissue interactions are least studied. The aim of this article is to review any previous clinical and basic scientific evidence about the contribution of infectious and inflammatory processes to the occurrence of mesh-related complications in SUI and POP. A literature search for the relevant publications without any time limits was performed on the Medline database. There is evidence to show that vaginal meshes are associated with an unfavourable host response at the site of implantation. The underlying mechanisms leading to this type of host response is not completely clear. Mesh contamination with vaginal flora during surgical implantation can be a factor modifying the host response if there is a subclinical infection that can trigger a sustained inflammation. More basic science research is required to identify the biological mechanisms causing a sustained inflammation at the mesh–tissue interface that can then lead to contraction, mesh erosion, and pain.

Complications from vaginally placed mesh in pelvic reconstructive surgery

INTRODUCTION AND HYPOTHESIS

We describe complications associated with the use of transvaginal mesh for treatment of pelvic organ prolapse.

METHODS

We retrospectively identified patients referred to our institution from January 2003 through September 2007 who had complications after vaginal placement of mesh.

RESULTS

We identified 21 patients with a mean (SD) age of 61 (11) years. Types of mesh used included mesh kits (n = 9, 43%), nontrocar mesh augmentation (n = 5, 24%), IVS Tunneller (n = 4, 19%), and unspecified (n = 3, 14%). Eleven patients (52%) underwent more than one procedure before referral. Only three patients were referred by the original treating surgeon. Complications included mesh erosions in 12 women, dyspareunia in ten, and recurrent prolapse in nine. Sixteen patients (76%) were managed surgically. Follow-up survey among sexually active patients showed 50% with persistent dyspareunia.

CONCLUSIONS

Use of vaginal mesh for pelvic reconstruction can produce complications. Multiple interventions may be necessary, and bothersome symptoms may persist.

Infection Potentiation Study of Synthetic and Naturally Derived Surgical Mesh in Mice

PURPOSE

To evaluate the potential of synthetic surgical meshes (Marlex((R)) mesh [C.R. Bard, Inc., Murray Hill, NJ]; MYCROMESH PLUS [W.L. Gore and Associates, Inc., Flagstaff, AZ]; GYNECARE GYNEMESH Nonabsorbable PROLENE* Soft Mesh [Ethicon, Somerville, NJ]; and naturally derived surgical mesh materials (DermMatrix) [Carbon Medical Technologies, St. Paul, MN] and SURGISIS [Cook Surgical, Spencer, IN]) to serve as a nidus for microbial attachment and growth, thus exacerbating surgical site infection.

METHODS

Meshes were implanted subcutaneously in mice and inoculated with 10(4) colony-forming units (cfu) of Staphylococcus aureus. Mice were euthanized four days later, and the implants were removed, homogenized, and cultured using a standard agar pour plate method to determine the number of viable bacteria that could be recovered from each implant.

RESULTS

The Marlex mesh and Gynecare Gynemesh PS were comparable and "neutral" to infection, the average number of bacteria recovered being 1.61 x 10(5) and 5.41 x 10(4) cfu, respectively. Mycromesh Plus, with its antibacterial coating, resulted in a reduction in the number of bacteria recovered, the average being 1.61 x 10(1) cfu. Naturally derived meshes were considered to potentiate infection on the basis of macroscopic observation of infection and significantly increased numbers of bacteria recovered from the implant: 1.84 x 10(8) cfu from DermMatrix and 3.17 x 10(7) cfu from Surgisis.

CONCLUSION

The synthetic meshes did not potentiate infection in this model, whereas the naturally-derived materials did. As this preclinical model was able to detect differences between different implant materials, it may have utility in assessing the infection potentiation properties of newly developed materials.

Comparaison de différents biomatériaux destinés à la chirurgie vaginale dans un modèle in vivo d'infection de prothèse chez le rat

OBJECTIVES

The purpose of this study was to develop an animal model of prosthetic infection and compare in vivo bacterial infectiosity of different biomaterials used in vaginal surgery.

MATERIALS AND METHODS

We implanted 36 prostheses of poly(lactic acid) with 94% L forms (PLA94), in a model of incisional abdominal hernia in Wistar rats. Bacterial inoculation was done just after implantation with three strains of Escherichia coli of variable virulence, two different concentrations and two different times of inoculation (during surgery or 48 hours after). All meshes were explanted and animals sacrificed on day 30 after intervention. Bacteriology and histology were then performed. In the same way, three materials used in vaginal surgery (knitted light-weight polypropylene [PP], thermoformed PP [Uratape] and polyurethane coated poly[ethylene terephtalate] [PTFE]) were tested and compared to the PLA94 using the same protocol.

RESULTS

All inoculated prostheses were still infected at day 30 after implantation with the same E. coli strain. There was a significant difference in bacterial infectiosity linked to virulence of the inoculated strain (p=.005) and the amount injected (P<0.001). Infectiosity was significantly lower for PLA94 when compared to the three other prostheses (P=0.008). The most important infectiosity was seen with PTFE and thermoformed PP. For histologists, PLA94 also gave the weakest inflammatory reaction.

DISCUSSION AND CONCLUSION

An original animal model of prosthetic infection allowed us to compare in vivo bacterial infectiosity of different biomaterials used in vaginal surgery and to demonstrate that the PLA94 mesh induces a milder risk of infection than polypropylene.

Mesh-related infections after pelvic organ prolapse repair surgery

The use of vaginal meshes has been an advance in the surgical management of women with pelvic organ prolapse. We reviewed the literature to synthesize the evidence regarding the infectious complications related to this new type of foreign body. We searched PubMed, current contents, and references of initially identified relevant articles and extracted data regarding the incidence, clinical manifestation, and management of vaginal mesh-related infections. The incidence of mesh-related infections and erosion ranged from 0 to 8%, and 0 to 33%, respectively, in the published studies. Various factors influence the development of vaginal mesh-related infectious complications such as the kind of biomedical material (e.g. filament structure, pore size) of the mesh, the type of procedure, the preventive measures taken, and the age and underlying comorbidity of the treated women. Non-specific pelvic pain, persistent vaginal discharge or bleeding, dyspareunia, and urinary or faecal incontinence are the most common manifestation of vaginal mesh-related infection. Clinical examination may reveal induration of the vaginal incision, vaginal granulation tissue, draining sinus tracts, and prosthesis erosion or rejection. Various pathogens have been implicated, including Gram-positive and Gram-negative aerobic and anaerobic bacteria. The management of mesh-related infections in women who underwent pelvic organ reconstruction is combined surgical and medical treatment. Although the use of vaginal meshes has become a new effective method of pelvic organ prolapse surgery clinicians should be aware of the various post-operative complications, including mesh-related infections.

Les prothèses synthétiques dans la cure de prolapsus génitaux par la voie vaginale : bilan en 2005

Since 1996, prosthetic meshes have become increasingly popular for transvaginal surgical cure of genital prolapse. In light of the growing number of proposed techniques and materials we reviewed the experience of the pioneers in order to provide surgeons with the most objective information available. We reviewed the literature indexed in Meline/PubMed and Current Contents retaining all work concerning resorbable and non-resorbable meshes. For the larger class of non-resorbable meshes we also reviewed articles by category of material, each type of mesh being carefully defined: different compositions of polypropylene, polyester, composite meshes and also insertion kits. Resorbable meshes were evaluated in two randomized studies which did not demonstrate better results than with simple folding known to have a high rate of recurrence. For polypropylene meshes, Marlex was studied in six trials which demonstrated a high rate of cure at one year but also a high rate of erosion which reached 25%. Use of Atrium was mentioned in three studies with a 6 to 12% recurrence rate and an erosion rate nearly reaching 20%. The majority of studies used Prolene and Gynemesh. Seventeen authors reported their experience, generally reviewing retrospective series, with recurrence rates of less than 10% for follow-up periods rarely greater than two years. A large variety of forms and sizes have been used, hindering comparisons. The rate of erosion was also quite variable, as high as 45%, demonstrating the need for a precise definition of erosion. Only recently have authors shown interest in the impact of prosthetic meshes on quality of life and sexual activity. An improvement is generally noted for defecation but the rate of dyspareunia has reached as high as 60%. Here again grades of prosthetic retraction should be better defined. Proposed to improve these phenomena, soft Prolene recently used by several authors does not appear to fulfil expectations. Since 2005, several precut polypropylene meshes have been proposed with an insertion kit. The Prolift kit has been followed prospectively in 100 patients undergoing regular surveillance. Surgipro has been used sporadically in small series but follow-up is still too short for proper assessment. Polyester meshes (Mersilene and Paritex) have been presented by three authors who have found them useful but reports have been vague concerning results and complications. Polytetrafluoroethylene has not been evaluated for transvaginal surgery, probably because of the poor tolerance of suburetral bands. For composite meshes, Vypro has been used by four authors who noted about 10% erosion but with a short follow-up insufficient to draw conclusions about the functional and anatomic outcome. Surfaced meshes, advocated for transvaginal treatments, have been studied in only two reports. Plevitex is a polypropylene mesh coated with collagen; another polyester composite with polyglactin 910. The rate of dyspareunia varied from 14 to 24%. Other composites with antiadherents or antiseptics are also proposed for transvaginal insertion but have not been studied. This work demonstrated the lack of sufficient evidence from prospective randomized trials and the lack of standardized techniques to draw any definite conclusions. While evidence is being accumulated on the lower rate of recurrence for anterior compartment prolapse, the lack of data on the rate of complications and patient quality of life is unacceptable for this functional surgery. We still have reservations about widespread use of synthetic meshes. A special chapter is detailed in appendix on post-operative complications. These new specific complications call to a new semiology, with a classification in 4 types and under-types, proposed by authors. Type 1: defects of healing. Type 2: the infection of the graft. Type 3: the shrinkage of the mesh. Type 4: erosions. Authors detail the symptoms of these 4 types as well as the prevention and the treatment of these complications.

Result of the tension-free vaginal tape in patients with concomitant prolapse surgery: a 2-year follow-up study. An analysis from the Netherlands TVT database

This study assessed the long-term outcome of tension-free vaginal tape (TVT) in women with concomitant pelvic surgery. A prospective cohort study of 746 patients in 41 hospitals was undertaken. The Incontinence Impact Questionnaire (IIQ-7) and Urogenital Distress Inventory (UDI-6) were used to measure the results of the TVT. Fifty-nine patients with concomitant prolapse surgery were compared with 687 women with TVT only. The decrease in IIQ/UDI mean scores were statistically significant in both groups after the TVT. The success rates of "no leakage at all" is comparable for both groups. This study, with 54 gynecologists and urologists participating, showed the long-term (2 years) success rates of TVT with concomitant prolapse surgery. It shows that the procedure in conjunction with prolapse surgery can be safely performed with good results.

Efficacy of botulinum-A toxin bladder injections for the treatment of neurogenic detrusor overactivity in multiple sclerosis patients: an objective and subjective analysis

AIMS

We studied the use of botulinum-a toxin (BTX-A) injections into the bladder as an alternative approach in patients with neurogenic detrusor overactivity due to multiple sclerosis (MS) with drug-refractory overactive bladder (OAB) symptoms.

METHODS

Sixteen MS patients--11 women, 5 men; mean age 48.6 years--with refractory OAB symptoms were included in a one-center prospective study. For outcome analysis, we used a bladder diary, a complete urodynamic study, and validated questionnaires for subjective assessment. We injected 300 U of BTX-A (Botox) into the bladder and into the external sphincter muscle to reduce the probability of posttreatment urine retention.

RESULTS

There was an increase in residual volume from 81.3 +/- 23.8 to 126.3 +/- 32.9 ml after 4 weeks. In one woman, transient self-catheterization was unavoidable. Four weeks and 3 and 6 months after BTX-A injection, the significant results were as follows: daytime frequency was reduced by 29%, 44%, and 30%, respectively. Nocturia diminished by 33%, 72%, and 40%. Use of pads was be reduced by 38% after 4 weeks and by 64% after 3 months. Urodynamically, reflex volume and maximal cystometric bladder capacity increased by 73%, 77%, and 58% (at 6 months, the increase was not significant) and by 36%, 27%, and 36% (not significant). Maximal detrusor pressure decreased by 35%, 22%, and 57%. Subjective outcome indicated significant improvement of symptoms at 4 weeks and 3 months, but not at 6 months. Patient satisfaction with the therapy was very high.

CONCLUSIONS

BTX-A detrusor injections are very effective in the treatment of drug-resistant OAB symptoms in MS patients as reflected in urodynamic measurements and in patient satisfaction. Build up of residual urine remains a problem of which patients must be informed.

Bladder neck pubovaginal slings

Over the past 30 years, the pubovaginal sling has surpassed retropubic and transvaginal suspensions as the most common surgical operation for correcting stress urinary incontinence. This resurgence has been due in part to innovative technological advances that have shortened operative times and expedited postoperative recovery. The introduction of novel allografts, xenografts and synthetic materials has also been accompanied by unique complications, previously not encountered with autologous materials. The aim of this review is to compare the available sling materials in the context of biocompatibility and efficacy.

Botulinum-A toxin detrusor and sphincter injection in treatment of overactive bladder syndrome: objective outcome and patient satisfaction

OBJECTIVE

We investigated the effect of botulinum-a toxin injections into the detrusor and external sphincter muscle in patients with overactive bladder (OAB) symptoms.

METHODS

We included 44 patients - 41 women and three men with a mean age of 66.1 years - who were suffering from OAB symptoms that were refractory to anticholinergic treatment. We injected 200-300 U of BTX-A (Botox) into the detrusor muscle; 22 patients also received external sphincter injections. For outcome analysis, we used a bladder diary, a urodynamic examination, and a questionnaire that consisted of 27 validated questions.

RESULTS

Changes in the bladder diary 4 weeks and 3, 6, and 9 months after BTX-A injection were as follows: Micturition frequency was reduced by 12%, 16%, 13% and 9%, respectively. Average pad use decreased from 4.2 pads per day to at most 2.4 pads per day after 6 months. Urodynamic changes were most distinct after 4 weeks: the volume when the first uninhibited detrusor contraction occurred increased from 149+/-18.2 mL to 263 +/- 24.2 mL, and maximum cystometric bladder capacity increased from 228 +/- 19.2 mL to 305 +/- 19.0 mL. Subjectively, 86% of the patients would choose this procedure for their bladder condition again. Residua 4 weeks after additional injection into the sphincter muscle were distinctly smaller than in the "only detrusor" group.

CONCLUSIONS

BTX-A detrusor and sphincter injection is very effective in treating OAB symptoms. For patients who might be expected to have residual urine after injection only into the detrusor, additional injection of low doses of BTX-A into the external sphincter muscle could be one option to reduce that risk.

Botulinum-A toxin for treatment of overactive bladder without detrusor overactivity: Urodynamic outcome and patient satisfaction

OBJECTIVES

To investigate the effect of botulinum toxin type A bladder injections in the treatment of overactive bladder syndrome in the absence of detrusor overactivity.

METHODS

The subjects were 7 women (average age 61.1 years, range 51 to 79) who presented with overactive bladder symptoms. Their disorder had been refractory to several classic treatment options. Urodynamic examination excluded detrusor overactivity. A total of 300 U BTX-A (Botox) was injected, of which 50 to 75 U was injected as quadrant injections into the external sphincter muscle to avoid the postoperative need for catheterization in the case of high postvoid residual urine volume. For follow-up, complete urodynamic studies were performed, and a bladder diary and validated incontinence questionnaires were given to patients at all visits at 1, 3, and 6 months.

RESULTS

The bladder diaries indicated a clear reduction in daytime frequency and nocturia and a reduction in pad use. The maximal voiding volume increased significantly. The urodynamic examinations showed a significant increase in volume when the first and the strong desire to void were expressed. The maximal bladder capacity increased by 20% in 3 months. In the questionnaires, 5 of the 7 patients reported better urine control after therapy, and 6 would have chosen this therapy again for their condition. The overall satisfaction score (on a scale of 0 to 10) averaged 6.8. No side effects, such as urine retention, occurred.

CONCLUSIONS

Botulinum-A toxin injection has positive effects in treating overactive bladder symptoms without detrusor overactivity. The effects were seen not only in urodynamic measures but also in patient satisfaction.

Suprapubic sling adjustment: minimally invasive method of curing recurrent stress incontinence after sling surgery

PURPOSE

Recurrent stress urinary incontinence after sling surgery is a complex problem. A minimally invasive method of correcting recurrent stress urinary incontinence after pubovaginal sling surgery is described.

MATERIALS AND METHODS

We performed suprapubic sling adjustment in 10 women with recurrent stress urinary incontinence after sling surgery. Of these 10 women 4 had received antibacterial polytetrafluoroethylene patch sling, 3 an autologous dermis patch sling and 3 an autologous rectus fascia patch sling but stress incontinence recurred. To correct recurrent incontinence, a pubovaginal sling was revised by adjusting the sling tension suprapubically with the aid of a cotton swab test and bladder leak test.

RESULTS

Mean followup was 13 months (range 8 to 28). Of the 10 women 9 became completely dry and 1 was greatly improved. One patient who had persistent stress incontinence generated an abdominal leak point pressure of 189 cm. H(2)O compared to a preoperative pressure of 120 cm. H(2)O. The incidence of de novo urge incontinence was 2% (2 of 10 cases). Mean resting cotton swab angle was (+) 20 and (+) 5 degrees, and mean Valsalva cotton swab angle was (+) 40 and (+) 5 preoperatively and postoperatively. Mean pad use decreased from 3 pads to less than 1 pad a day. Mean self-reported satisfaction score was 9 (range 8 to 10) on a visual analog scale.

CONCLUSIONS

Pubovaginal slings may be revised safely with excellent results. Adjusting the sling tension suprapubically is a minimally invasive technique. Suprapubic sling adjustment may be performed as an intermediary step before resorting to a complete sling takedown/revision.

Nonautologous sling materials

This article provides a comprehensive and updated review of the current nonautologous sling materials available for treatment of stress urinary incontinence. The various materials are described, relevant clinical studies are discussed, and newer materials are outlined. Complications arising from use of different materials also are described.

Autologous, cadaveric, and synthetic materials used in sling surgery: comparative biomechanical analysis

OBJECTIVES

To compare the biomechanical properties of allografts, autografts, and synthetic materials used in sling surgery using the Instron tensinometer.

METHODS

The sling grafts we studied consisted of autologous tissues (dermis, rectus fascia, and vaginal mucosa), cadaver tissues (decellularized dermis and freeze-dried, gamma-irradiated fascia lata), and synthetics (Gore-Tex and polypropylene mesh). The sling grafts were constructed into two types of slings: full strip sling (FSS) versus patch suture sling (PSS). The slings were loaded onto the Instron tensinometer and uniaxially loaded in tension until failure. From the load deformation curve, the mechanical properties of the sling grafts were compared.

RESULTS

A total of 140 sling grafts were analyzed. In rank order for the FSSs, cadaver allografts had the strongest tensile strength followed by the synthetics and autologous tissues (P <0.05). The tensile strength of the FSSs was greater than for the PSSs for all groups (P </=0.001). In rank order for the PSSs, the synthetics and dermal tissues (autograft and allograft) had the highest tensile strength followed by cadaver fascia lata, rectus fascia, and vaginal mucosa (P <0.05).

CONCLUSIONS

The tensile strength of the FSS was greater than that of the PSS for the autograft, allograft, and synthetic tissues. The autograft and allograft tissues were significantly weaker as a PSS. The synthetics were more durable as a PSS compared with the organic tissues. When a PSS is constructed from autograft and allograft tissues, the risk of suture pull-through and recurrent stress incontinence must be considered.

Pubovaginal slings: a review of the technical variables

The pubovaginal sling, reintroduced in the late 1970s by Maguire and Blaivas, has become the gold standard for managing anatomic incontinence. Newer technology, materials, surgical techniques and even new theories on the mechanism of action are evolving to further reduce the morbidity of these procedures and improve patient satisfaction. In the following review, we will highlight some of the exciting advances we have witnessed over the last year and try to put them into perspective for the reader.

Antimicrobial efficacy of external fixator pins coated with a lipid stabilized hydroxyapatite/chlorhexidine complex to prevent pin tract infection in a goat model

BACKGROUND

Pin tract infection is a common complication of external fixation. An antiinfective external fixator pin might help to reduce the incidence of pin tract infection and improve pin fixation.

METHODS

Stainless steel and titanium external fixator pins, with and without a lipid stabilized hydroxyapatite/chlorhexidine coating, were evaluated in a goat model. Two pins contaminated with an identifiable Staphylococcus aureus strain were inserted into each tibia of 12 goats. The pin sites were examined daily. On day 14, the animals were killed, and the pin tips cultured. Insertion and extraction torques were measured.

RESULTS

Infection developed in 100% of uncoated pins, whereas coated pins demonstrated 4.2% infected, 12.5% colonized, and the remainder, 83.3%, had no growth (p < 0.01). Pin coating decreased the percent loss of fixation torque over uncoated pins (p = 0.04).

CONCLUSION

These results demonstrate that the lipid stabilized hydroxyapatite/chlorhexidine coating was successful in decreasing infection and improving fixation of external fixator pins.