Clinical challenges in the management of vaginal prolapse

Nerve relationships to the sacrospinous ligament: application to suspension procedures and transgluteal approaches for nerve repair and tumor removal with three case illustrations

BACKGROUND

Transvaginal suspension procedures often use the sacrospinous ligament (SSL), which attaches onto the ischial spine (IS). However, nerve-related sequelae (e.g., sciatic nerve injury) following such procedures have been reported. Therefore, the current anatomical study was performed to better understand these relationships. Additionally, three case illustrations of patients with injury to the sciatic nerve following sacrospinous ligament suspension procedures are included to exemplify the significance of a thorough knowledge of this anatomy.

METHODS

In 20 human adult cadavers (40 sides), a gluteal dissection was performed to expose the IS and SSL and regional nerves near the greater sciatic foramen. Measurements between the IS and SSL were made between these structures and surrounding nerves.

RESULTS

The average distance between the IS and sciatic nerve was 1.4 cm. From this bony part, the average distance to the S1 and S2 ventral rami was 3.1 cm and 1.9 cm, respectively. From the IS to the lumbosacral trunk, pudendal nerve, nerve to obturator internus, and superior gluteal nerve, the mean distance was 4 cm, 0.5 cm, 0.7 cm, and 4.5 cm, respectively. From the SSL to the lumbosacral trunk, S1 ventral ramus, and S2 ventral ramus, there was an average distance of 4.2 cm, 1.6 cm, and 0.8 cm, respectively. Statistically, in females, the distances from the IS and SSL to the sciatic nerve, lumbosacral trunk, superior gluteal nerve, and S1 and S2 ventral rami were shorter when compared to males.

CONCLUSION

An improved understanding of the relationship between the SSL and IS and nerves near the greater sciatic foramen can lead to fewer intraoperative complications during approaches to various peripheral nerves in this region. Lastly, these relationships might help better understand the nerve injuries following pelvic suspension procedures that use the SSL.

Polypropylene Pelvic Mesh: What Went Wrong and What Will Be of the Future?

Background: Polypropylene (PP) pelvic mesh is a synthetic mesh made of PP polymer used to treat pelvic organ prolapse (POP). Its use has become highly controversial due to reports of serious complications. This research critically reviews the current management options for POP and PP mesh as a viable clinical application for the treatment of POP. The safety and suitability of PP material were rigorously studied and critically evaluated, with consideration to the mechanical and chemical properties of PP. We proposed the ideal properties of the ‘perfect’ synthetic pelvic mesh with emerging advanced materials. Methods: We performed a literature review using PubMed/Medline, Embase, Cochrane Library (Wiley) databases, and ClinicalTrials.gov databases, including the relevant keywords: pelvic organ prolapse (POP), polypropylene mesh, synthetic mesh, and mesh complications. Results: The results of this review found that although PP is nontoxic, its physical properties demonstrate a significant mismatch between its viscoelastic properties compared to the surrounding tissue, which is a likely cause of complications. In addition, a lack of integration of PP mesh into surrounding tissue over longer periods of follow up is another risk factor for irreversible complications. Conclusions: PP mesh has caused a rise in reports of complications involving chronic pain and mesh exposure. This is due to the mechanical and physicochemical properties of PP mesh. As a result, PP mesh for the treatment of POP has been banned in multiple countries, currently with no alternative available. We propose the development of a pelvic mesh using advanced materials including emerging graphene-based nanocomposite materials.

Endometrial SUSD2+ Mesenchymal Stem/Stromal Cells in Tissue Engineering: Advances in Novel Cellular Constructs for Pelvic Organ Prolapse

Cellular therapy is an emerging field in clinical and personalised medicine. Many adult mesenchymal stem/progenitor cells (MSC) or pluripotent derivatives are being assessed simultaneously in preclinical trials for their potential treatment applications in chronic and degenerative human diseases. Endometrial mesenchymal stem/progenitor cells (eMSC) have been identified as clonogenic cells that exist in unique perivascular niches within the uterine endometrium. Compared with MSC isolated from other tissue sources, such as bone marrow and adipose tissue, eMSC can be extracted through less invasive methods of tissue sampling, and they exhibit improvements in potency, proliferative capacity, and control of culture-induced differentiation. In this review, we summarize the potential cell therapy and tissue engineering applications of eMSC in pelvic organ prolapse (POP), emphasising their ability to exert angiogenic and strong immunomodulatory responses that improve tissue integration of novel surgical constructs for POP and promote vaginal tissue healing.

Erosion of soft tissue by polypropylene mesh products

Surgical mesh products made from polypropylene (PP) have been extensively used in the treatment of stress urinary incontinence, pelvic organ prolapse and other conditions. Since the onset of the use of such implants, major complications have been reported. Mesh erosion, where neighbouring tissues are worn from the rubbing of mesh, occurs in a significant number of cases. However, there is still a lack in literature exploring the mechanics of this phenomenon. In this study, a purpose-built apparatus was used to generate erosion in soft tissue (porcine muscle) through the application of a force and a reciprocating action. Four different commercial products were tested, all made from knitted PP fibres: Monarc™ Gynecare™ and Obtryx™ slings and Sutulene™ mesh sheet material. A PP suture and three PP sheets with different edge roughness were also tested. Large differences were found in the erosion rates. Significantly, we found that meshes in which the edge had been formed using heat to cause partial melting gave much higher rates of erosion than mechanically cut edges. Heat-formed edges tended to retain their shape whilst mechanically cut edges degraded by unravelling. Several features of the mesh edge appear to be significant, including roughness, flexibility and the tendency to degrade. Constant load (non-reciprocating) tests were also carried out, revealing that creep can also cause erosion. These findings have significance for the design of surgical mesh products to minimise their adverse effects.

Oxidative Stress: A Possible Trigger for Pelvic Organ Prolapse

Pelvic organ prolapse is a frequent health problem in women, encountered worldwide, its physiopathology being still incompletely understood. The integrity of the pelvic-supportive structures is a key element that prevents the prolapse of the pelvic organs. Numerous researchers have underlined the role of connective tissue molecular changes in the pathogenesis of pelvic organ prolapse and have raised the attention upon oxidative stress as an important element involved in its appearance. The advancements made over the years in terms of molecular biology have allowed researchers to investigate how the constituent elements of the pelvic-supportive structures react in conditions of oxidative stress. The purpose of this paper is to underline the importance of oxidative stress in the pathogenesis of pelvic organ prolapse, as well as to highlight the main oxidative stress molecular changes that appear at the level of the pelvic-supportive structures. Sustained mechanical stress is proven to be a key factor in the appearance of pelvic organ prolapse, correlating with increased levels of free radicals production and mitochondrial-induced fibroblasts apoptosis, the rate of cellular apoptosis depending on the intensity of the mechanical stress, and the period of time the mechanical stress is applied. Oxidative stress hinders normal cellular signaling pathways, as well as different important cellular components like proteins, lipids, and cellular DNA, therefore significantly interfering with the process of collagen and elastin synthesis.

Emerging Nano/Micro-Structured Degradable Polymeric Meshes for Pelvic Floor Reconstruction

Pelvic organ prolapse (POP) is a hidden women's health disorder that impacts 1 in 4 women across all age groups. Surgical intervention has been the only treatment option, often involving non-degradable meshes, with variable results. However, recent reports have highlighted the adverse effects of meshes in the long term, which involve unacceptable rates of erosion, chronic infection and severe pain related to mesh shrinkage. Therefore, there is an urgent unmet need to fabricate of new class of biocompatible meshes for the treatment of POP. This review focuses on the causes for the downfall of commercial meshes, and discusses the use of emerging technologies such as electrospinning and 3D printing to design new meshes. Furthermore, we discuss the impact and advantage of nano-/microstructured alternative meshes over commercial meshes with respect to their tissue integration performance. Considering the key challenges of current meshes, we discuss the potential of cell-based tissue engineering strategies to augment the new class of meshes to improve biocompatibility and immunomodulation. Finally, this review highlights the future direction in designing the new class of mesh to overcome the hurdles of foreign body rejection faced by the traditional meshes, in order to have safe and effective treatment for women in the long term.

Mesh colposacropexy in the management of anterior vaginal compartment prolapse

Pelvic organ prolapse is a frequent female pathology, often causing a negative impact on the patient’s quality of life. The purpose of this paper is to present the results that we have achieved in 32 patients with anterior vaginal compartment prolapse, managed using the transvaginal mesh approach.

Over a period of twelve months, we have performed 32 transvaginal reconstructive procedures using a four arms polypropylene mesh. The superior arms of the mesh have been passed through the obturator foramen while the inferior arms have been passed through the sacrospinous ligament.

The surgery has lead to a significant improvement in the quality of life in this group of patients, this being assessed using self-administered questionnaires that evaluated the quality of life, the sexual function, and urinary continence. Anatomical success was achieved in 96.87% of the cases. In terms of postoperative complications, we mention one case of vaginal erosion, one case of de novo dyspareunia and three cases of pelvic discomfort. So far we have not encountered any mesh exposure cases nor prolapse recurrence.

Considering the results that we have achieved in our study, we can conclude that the transvaginal polypropylene mesh approach can prove itself to be a viable solution for the management of genital prolapse, especially if we consider the high postoperative rates of anatomical success and low rates of postoperative complications, as well as improving the patient’s quality of life. In spite of these encouraging results, the fact that in recent years FDA has emitted several warnings in terms of postoperative complications following such procedures, as well as the fact that our study was conducted on a small group of patients, limits the strength of our research, its only purpose being to present our experience for this surgical approach over a limited period of time.

Application of a Mixed Material Graft to Posterior Intravaginal Slingoplasty Procedure: Preliminary Pilot Series

Good anatomic outcomes have been achieved with transvaginal synthetic materials in pelvic organ prolapse, but mesh-related complications are a major health concern. Therefore, developing new synthetic or biological materials with increased tissue strength and decreased complications are major challenges. This paper presents preliminary pilot series of Posterior Intravaginal Slingoplasty (PIVS) procedure performed with mixed material graft containing both autologous tissue and a synthetic material. Six women with symptomatic Utero-Vaginal Prolapse (UVP) ≥ stage 2 underwent the PIVS procedure. Pelvic floor symptoms were assessed with the Pelvic Organ Prolapse Quantification (POP-Q) system, Pelvic Floor Distress Inventory (PFDI), and the Pelvic Floor Impact Questionnaire (PFIQ) both before the procedure and 36 months after the surgery. There were no mesh-related complications or recurrence and all the patients had good functional and anatomic outcomes. These preliminary results are promising, but further long-term studies with a larger series are needed.

Prolapse repair with and without apical resuspension-Practice patterns among certifying American urologists

AIMS

To examine surgeon characteristics in certifying urologists performing prolapse surgeries. Anterior compartment prolapse is often associated with apical prolapse, with high rates of recurrence when anterior repair is performed without apical resuspension.

METHODS

Six-month case log data of certifying urologists between 2003 and 2013 was obtained from the American Board of Urology (ABU). Cases with a CPT code for common prolapse repairs in females ≥18 years were analyzed.

RESULTS

Among 2,588 urologists logging at least one prolapse surgery and a total of 30,983 surgeries, 320 (1.0% of all cases) uterosacral ligament suspension, 3,673 (11.9%) sacrospinous ligament suspension, and 2,618 (8.4%) abdominal sacrocolpopexy were identified. The remaining 14,585 cases were logged as anterior repair. 54.7% of anterior repairs did not include apical suspension. The proportion of anterior repairs without apical suspension has decreased from 77.7% in 2004 to 41.4% in 2012 (P < 0.001). Female subspecialists before 2011 performed anterior repair without apical suspension in 58.5%, versus 70.3% by all others. Since 2011 there has been a decrease in number of anterior repairs without apical suspension, notably in those applying for Female Pelvic Medicine and Reconstructive Surgery (FPMRS) certification (17.1% vs. 30.7% by all other urologists, P < 0.001); nonacademically affiliated urologists are 2.1 times more likely to report anterior repair without apical suspension than academically affiliated colleagues (P < 0.001).

CONCLUSIONS

The proportion of prolapse repairs reported as anterior repairs without apical suspension is decreasing, although it remains a substantial portion. Recent log year, FPMRS, and academic affiliation were associated with prolapse repairs addressing apical support. Neurourol. Urodynam. 36:344-348, 2017. © 2015 Wiley Periodicals, Inc.

Sacrocolpopexy with polypropylene tape as valuable surgical modification during cystectomy with orthotopic ileal bladder: functional results

Introduction. Urinary diversion is very often associated with urinary retention and urinary incontinence. In this study, a surgical modification during cystectomy with orthotopic ileal neobladder is presented. Material and Methods. Female patients enrolled in the study (n-24) were subjected to sacrocolpopexy during the operation. Apart from oncological control, the follow-up consisted of 1-hour inlay test and questionnaires (UDI-6 and IIQ-7) in the 3rd, 6th, and 12th month after the operation. In the 12th month after the surgery, the urodynamic pressure-flow test was performed. Outcomes were compared with the control group (n-18) in which sacrocolpopexy was not implemented. Results. The study group was characterised by reduced urinary retention and improved continence. Conclusion. Sacrocolpopexy during cystectomy with orthotopic ileal bladder is a valuable surgical method which provides patients with a better quality of life.