Treatment of total pelvic organ prolapse using a whole biological patch: A pilot study of 17 patients

Puerarin-Loaded Electrospun Patches with Anti-Inflammatory and Pro-Collagen Synthesis Properties for Pelvic Floor Reconstruction

Pelvic organ prolapse (POP) is one of the most common pelvic floor dysfunction disorders worldwide. The weakening of pelvic connective tissues initiated by excessive collagen degradation is a leading cause of POP. However, the patches currently used in the clinic trigger an unfavorable inflammatory response, which often leads to implantation failure and the inability to simultaneously reverse progressive collagen degradation. Therefore, to overcome the present challenges, a new strategy is applied by introducing puerarin (Pue) into poly(l-lactic acid) (PLLA) using electrospinning technology. PLLA improves the mechanical properties of the patch, while Pue offers intrinsic anti-inflammatory and pro-collagen synthesis effects. The results show that Pue is released from PLLA@Pue in a sustained manner for more than 20 days, with a total release rate exceeding 80%. The PLLA@Pue electrospun patches also show good biocompatibility and low cytotoxicity. The excellent anti-inflammatory and pro-collagen synthesis properties of the PLLA@Pue patch are demonstrated both in vitro in H2O2-stimulated mouse fibroblasts and in vivo in rat abdominal wall muscle defects. Therefore, it is believed that this multifunctional electrospun patch integrating anti-inflammatory and pro-collagen synthesis properties can overcome the limitations of traditional patches and has great prospects for efficient pelvic floor reconstruction.

Six-year follow-up outcomes of the P(LLA-CL)/Fg bio-patch for anterior vaginal wall prolapse treatment

INTRODUCTION AND HYPOTHESIS

There were few data about the long-term outcomes of bio-compatible patches for pelvic organ prolapse (POP). The efficacy of poly (L-lactide-co-caprolactone) blended with fibrinogen [P(LLA-CL)/Fg] bio-patches were investigated for anterior vaginal wall prolapse treatment in a 6-year follow-up.

METHODS

The P(LLA-CL)/Fg bio-patch was fabricated through electrospinning. Nineteen patients with symptomatic anterior prolapse (Pelvic Organ Prolapse Quantification [POP-Q] stage ≥ 2) were treated with anterior pelvic reconstruction surgery using a P(LLA-CL)/Fg bio-patch and were followed up at 1, 2, 3, 6 months, and 6 years. The primary outcome was objective anatomical cure (anterior POP-Q stage ≤ 1). Secondary outcomes included complications, MRI evaluation, and scores of the Pelvic Floor Impact Questionnaire-7 (PFIQ-7) and the Pelvic Floor Distress Inventory-20 (PFDI-20).

RESULTS

The micro-morphology of the bio-patch resembled the extracellular matrix, which was suitable for the growth of fibroblasts. Sixteen (84.2%) patients were finally assessed, with a mean follow-up of 6.08 ± 0.18 years. The cure rate without anterior prolapse recurrence was 93.8% at 6 years. Compared with baseline, the POP-Q measurements of Aa, Ba, and C points and scores of PFIQ-7 and PFDI-20 manifested significant differences at all times (all p < 0.05). One (5.26%) case of bio-patch-related infection, 1 (5.26%) case of urinary retention, and no exposures and erosion occurred. MRI evaluation showed that the bio-patch gradually degraded to fragments at 1 month and was completely absorbed at 3 months.

CONCLUSIONS

Among long-term follow-ups, anterior pelvic reconstruction surgery with a P(LLA-CL)/Fg bio-patch demonstrated significant improvements in anatomical correction of anterior pelvic prolapse and pelvic function without severe morbidity.

Exploratory safety study of an umbilical cord derived urethral sling in bilateral pudendal nerves injury-induced urinary incontinence in female rats

PURPOSE

Mid-urethral slings are the standard treatment for women with refractory stress urinary incontinence (SUI) but are at risk of infection or erosion due to host-prothesis interaction. In this proof-of-concept study, we aimed at evaluating umbilical vessel sling (UVS) in incontinent female rats.

MATERIAL AND METHODS

UVS was extracted from human umbilical cord lining and was placed on female rats who underwent bilateral pelvic nerve injury (PNI) to reproduce SUI (Group 3, N = 10). Two control groups were also studied: rats with no PNI (Group 1, N = 4) and rats with PNI but no UVS (Group 2, N = 10). Micturition calendar was frequently recorded using a metabolic cage, and leak point pressure (LPP) test was performed on Day 28. After the LPP test, rats were euthanized, and bladder/urethra were collected for histopathological analysis.

RESULTS

Overall, 24 rats were included, of whom 10 had both PNI and UVS placement. Compared with Group 2, Group 3 had increased maximal LPP but the difference did not reach significance (respectively 21.8 ± 2.1 mmHg vs. 28.4 ± 4.1 mmHg, p = 0.2). Micturition frequencies were similar between the groups. Total voided volume was higher in Group 3 at the end of the study compared with Group 2 (12.5 ± 1.1 ml vs. 9.4 ± 0.6 ml, respectively, p < 0.05). Histopathological findings evidenced a good local tolerance and a moderate to high tissue integration of the UVS.

CONCLUSIONS

Biological sling derived from human umbilical vessel could be safely placed with a slight improvement of LPP in a population of rats who had bilateral PNI without major modification of micturition calendar. UVS could be a promising biomaterial in the management of SUI in women. Clinical studies are needed.

Stress Urinary Incontinence and Pelvic Organ Prolapse: Biologic Graft Materials Revisited

Symptomatic stress urinary incontinence (SUI) and pelvic organ prolapse (POP) refractory to conservative management with pelvic floor muscle training or vaginal pessaries may warrant surgical intervention with different forms of biologic or synthetic material. However, in recent years, several global regulatory agencies have issued health warnings and recalled several mesh products due to an increase in complications such as mesh erosion, infection, chronic pain, and perioperative bleeding. At present, current surgical treatment strategies for SUI and POP are aimed at developing biological graft materials with similar mechanical properties to established synthetic meshes, but with improved tissue integration and minimal host response. This narrative review aims to highlight recent studies related to the development of biomimetic and biologic graft materials as alternatives to traditional synthetic materials for SUI/POP repair in female patients. We also investigate complications and technical limitations associated with synthetic mesh and biological biomaterials in conventional SUI and POP surgery. Our findings demonstrate that newly developed biologic grafts have a lower incidence of adverse events compared to synthetic biomaterials. However there remains a significant disparity between success in preclinical trials and long-term clinical translation. Further characterization on the optimal structural, integrative, and mechanical properties of biological grafts is required before they can be reliably introduced into clinical practice for SUI and POP surgery. Impact statement Our review article aims to outline the clinical history of developments and controversies associated with the use of synthetic mesh materials in the surgical treatment of stress urinary incontinence and pelvic organ prolapse, as well as highlighting recent advancements in the area of biological graft materials and their potential importance in an area that remains an enduring issue for patients and clinicians alike. This article aims to provide a concise summary of previous controversies in the field of urinary incontinence, while evaluating the future of potential biomaterials in this field.

Laparoscopic Sacrocolpopexy Plus Colporrhaphy With a Small Intestine Submucosa Graft Versus Total Pelvic Floor Reconstruction for Advanced Prolapse: A Retrospective Cohort Study

Purpose

Transvaginal mesh (TVM) results in a greater anatomic cure but more complications. We aimed to compare laparoscopic sacrocolpopexy (LSC) plus colporrhaphy with the small intestine submucosa (SIS) graft versus TVM for advanced pelvic organ prolapse (POP).

Methods

Patients with advanced POP who underwent LSC plus colporrhaphy with the SIS graft or TVM at a center between September 2015 and November 2016 were studied. Anatomical outcomes were evaluated using POP quantification. Functional outcomes related to POP and sexual life were evaluated using the Pelvic Floor Distress Inventory (PFDI-20) and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12). Data regarding surgical procedures and patient demographic variables were recorded. Chi-square and Student t -tests were used for 2 independent samples.

Results

A total of 76 patients were enrolled in this study with 26 patients in the LSC plus colporrhaphy with the SIS graft group (group A) and 50 patients with TVM group (group B). All patients in both groups demonstrated significant improvement in anatomical outcomes (P<0.05) after surgery. PFDI-20 scores were significantly improved 12 months after operation in both groups (P<0.001). PISQ-12 scores were significantly improved in patients after surgery, especially patients in group A (P<0.001). Mesh exposure occurred in both groups as follows: 8 patients (30.7%) in group A and 5 patients (10%) in group B.

Conclusions

Even though both surgeries showed excellent results for subjective and objective outcomes, the use of an SIS graft might increase the exposure of polypropylene mesh. We do not recommend LSC plus colporrhaphy with the SIS graft for advanced multiple-compartments prolapse.

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.