The role of microbial colonisation and infection in pelvic floor mesh complications and implications for management: a commentary

Transvaginal Mesh-related Complications and the Potential Role of Bacterial Colonization: An Exploratory Observational Study

STUDY OBJECTIVE

This study aimed to investigate the potential role of transvaginal mesh bacterial colonization in the development of mesh-related complications (MRCs).

DESIGN

An observational and exploratory study.

SETTING

Tertiary referral center (Amsterdam UMC, location AMC, Amsterdam, The Netherlands). PATIëNTS: 49 patients indicated for mesh removal and 20 women of whom vaginal tissue was retrieved during prolapse surgery as a reference cohort.

INTERVENTIONS

collection of mesh-tissue complex (patient cohort) or vaginal tissue (reference cohort) MEASUREMENTS AND MAIN RESULTS: Homogenized samples were used for quantitative microbiological culture. Inflammation and fibrosis were semiquantitatively histologically scored; Gram staining and fluorescence in situ hybridization were used to detect bacteria and bacterial biofilms. Of the 49 patients, 44 samples (90%) were culture positive, with a higher diversity of species and more Gram-negative bacteria and polymicrobial cultures in the MRC cohort than the reference cohort, with mostly staphylococci, streptococci, Actinomyces spp., Cutibacterium acnes, and Escherichia coli. Patients with clinical signs of infection or exposure had the highest bacterial counts. Histology demonstrated moderate to severe inflammation in most samples. Gram staining showed bacteria in 57% of culture-positive samples, and in selected samples, fluorescence in situ hybridization illustrated a polymicrobial biofilm.

CONCLUSION

In this study, we observed distinct differences in bacterial numbers and species between patients with MRCs and a reference cohort. Bacteria were observed at the mesh-tissue interface in a biofilm. These results strongly support the potential role of bacterial mesh colonization in the development of MRCs.

Actinomyces in explanted transvaginal mesh: commensal or pathogen?

INTRODUCTION AND HYPOTHESIS

There is a paucity of information in the literature regarding the clinical impact and treatment of histologically positive actinomycosis explanted vaginal mesh. We aimed to report the prevalence and independent predicators of Actinomyces presence in explanted meshes on histology and to compare the clinical course in those with and without Actinomyces. Our hypothesis is that Actinomyces may act as a commensal rather than a pathogen when identified in extracted transvaginal meshes.

METHODS

A single-center retrospective review of explanted vaginal mesh removed between 2013 and 2018 was undertaken and compared Actinomyces-positive and -negative cohorts on histology. Uni- and multivariate logistic regression analysis evaluated possible risk factors for positive Actinomyces including patient demographics, smoking, diabetes, hormone replacement therapy (vaginal/systemic), hysterectomy in primary surgery, rate and indication for prior mesh removal. The rate of symptom resolution or need for subsequent mesh excisions is compared between the two cohorts.

RESULTS

Actinomycosis was identified in 11% (31/278) of explanted mesh. After multivariant analysis, only voiding dysfunction as an indication for mesh removal was statistically significantly associated with Actinomyces-negative histology (14 vs 0%, p < 0.001). At median review of 17 months, symptom resolution (87% vs 83% p = 0.68) and need for subsequent mesh removal (13% vs 19%, p = 0.37) following index mesh excision were similar between the groups.

CONCLUSION

Actinomyces in explanted transvaginal mesh frequently acts as a commensal in those who are infection free. In this cohort, individualized care including conservative surveillance without antibiotics or full explantation is reasonable.

Fully absorbable poly-4-hydroxybutyrate implants exhibit more favorable cell-matrix interactions than polypropylene

Pelvic organ prolapse (POP) is a multifactorial condition characterized by the descent of the pelvic organs due to the loss of supportive tissue strength. This is presumably caused by the decreased fibroblast function and the subsequent change in the quality of the extracellular matrix. The correction of POP using an implant intends to provide mechanical support to the pelvic organs and to stimulate a moderate host response. Synthetic polypropylene (PP) implants were commonly used for the correction of prolapse. Although they were successful in providing support, these implants have been associated with clinical complications in the long term due to substantial foreign body response and inappropriate tissue integration. The complications can be avoided or minimized by engineering a biocompatible and fully absorbable implant with optimized mechanical and structural characteristics that favor more appropriate cellular interactions with the implant. Therefore, in this study, we evaluated implants comprised of poly-4-hydroxybutyrate (P4HB), a fully absorbable material with high mechanical strength, as an alternative to PP. The P4HB implants were knitted in four unique designs with different pore shapes ranging from a more rectangular geometry- as it is in PP implant- to a rounded geometry, to determine the effect of the implant structure on the textural and mechanical properties and subsequent cell-matrix interaction. The cellular response was investigated by seeding primary vaginal fibroblasts isolated from patients with POP. P4HB favored cellular functions more than PP, as indicated by greater cell attachment and proliferation (P < 0.01), and significantly more collagen deposition (P4HB vs PP, 11.19 μg vs 6.67 μg) at 28 days culture (P < 0.05). All P4HB implants had higher strength and lower stiffness than the PP scaffold. The material and the design of the implant also influenced the behavior of vaginal fibroblasts. The aspect ratio of the vaginal POP fibroblasts cultured on the PP implant (1.61 ± 0.75) was significantly (P < 0.005) smaller than those cultured on P4HB implants (average 2.31 ± 0.09). The P4HB structure with rounded pores showed the lowest stiffness and highest fibroblast attachment and proliferation (P < 0.01). Overall, P4HB induces more matrix deposition compared to PP and knit design can further optimize cell behavior.

Transvaginal single-port laparoscopic pelvic reconstruction with Y-shaped mesh: experiences of 93 cases

INTRODUCTION AND HYPOTHESIS

To demonstrate the outcomes of pelvic reconstruction using Y-shaped mesh in patients with multiple-compartment pelvic organ prolapse via transvaginal single-port laparoscopy.

METHODS

We conducted a retrospective case series study. Patients diagnosed with severe multiple-compartment prolapse were enrolled between July 1, 2017, and March 31, 2020. Patients underwent transvaginal single-port laparoscopic pelvic reconstruction with Y-shaped mesh. Baseline data and perioperative results were collected. Patients were followed up with the POP-Q score, Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form (PISQ-12). T-test was used for statistical analysis.

RESULTS

Operations were successful in all 93 patients without conversion or serious complications. Mean operative time was 132.70 ± 28.02 min and estimated blood loss was 110.65 ± 56.31 ml. VAS pain score was 2.91 ± 1.16 and cosmetic score was 9.20 ± 0.60. During 1-33 months of follow-up, no recurrence or mesh exposure was observed. Five patients suffered from de novo SUI, six had constipation, two had dyspareunia, and one had persistent pelvic pain. The pre- and postoperative Aa point was +2.13 ± 1.23 vs. -2.91 ± 0.28 (P < 0.05), C point was 2.63 ± 2.41 vs. -6.86 ± 0.69 (P < 0.05), and Ap point was -0.26 ± 1.79 vs. -2.97 ± 0.16 (P < 0.05). The PFDI-20 score was 76.81 ± 32.06 vs. 18.18 ± 20.25 (P < 0.05), while the PISQ-12 score was 34.30 ± 4.17 vs. 37.20 ± 2.60 (P < 0.05), which suggested significant improvements in both physical prolapse and quality of life after surgery.

CONCLUSION

Transvaginal single-port laparoscopic pelvic reconstruction with Y-shaped mesh is a feasible, effective and safe treatment option for severe multiple-compartment prolapse. Patients may benefit from its mild pain level and good cosmetic effect as well as only minor mesh-related complications.

Tendon Descensus Repair (TENDER) - A prospective clinical feasibility study of tendon transplantation for pelvic organ prolapse repair

OBJECTIVE

To show the feasibility of tendon transplantation for minimally invasive pectopexy in pelvic organ prolapse repair.

STUDY DESIGN

Patients with uterine or vaginal vault prolapse (POP-Q point C Stage 2-4) were offered laparoscopic pectopexy by means of autologous semitendinosus tendon transplantation. This paper presents a case series and describes the technique regarding the first 10 patients who underwent surgery. After preparing the vagina or cervix for laparoscopic pectopexy a tendon of the patient's semitendinosus muscle was stripped and brought intraabdominally through the 10 mm trocar. The tendon was fixed between the cervix or vagina and to the pectineal ligaments on both sides of the pelvis.

RESULTS

All operations were performed successfully without complications. Vaginal examination demonstrated the intended elevation of the middle compartment. Mobility and power of the affected leg did not change. Recovery was fast, and discharge was possible between the second and third postoperative day.

CONCLUSION

Our approach demonstrates the feasibility and safety of a laparoscopic pectopexy with a semitendinosus autograft instead of a synthetic mesh. The experience from orthopedic surgery shows that a semitendinosus tendon autograft is long-lasting and stable. In addition, the morbidity on the operated leg is low.