Serious complications and recurrences after retropubic vs transobturator midurethral sling procedures for 2682 patients in the VIGI-MESH register

BACKGROUND

Midurethral slings are the gold standard for treating stress urinary incontinence, but their complications may raise concerns. Complications may differ by the approach used to place them.

OBJECTIVE

This study aimed to compare serious complications and reoperations for recurrence after midurethral sling procedures when using the retropubic vs the transobturator route for female stress urinary incontinence.

STUDY DESIGN

This analysis was of patients included in the French, multicenter VIGI-MESH register since February 2017 who received a midurethral sling for female stress urinary incontinence either by the retropubic or the transobturator route and excluded patients with single-incision slings. Follow-up continued until October 2021. Serious complications (Clavien-Dindo classification ≥ grade III) attributable to the midurethral sling and reoperations for recurrence were compared using Cox proportional hazard models including any associated surgery (hysterectomy or prolapse) and a frailty term to consider the center effect. Baseline differences were balanced by propensity score weighting. Analyses using the propensity score and Cox models were adjusted for baseline differences, center effect, and associated surgery.

RESULTS

A total of 1830 participants received a retropubic sling and 852 received a transobturator sling in 27 French centers that were placed by 167 surgeons. The cumulative 2-year estimate of serious complications was 5.8% (95% confidence interval, 4.8-7.0) in the retropubic group and 2.9% (95% confidence interval, 1.9-4.3) in the transobturator group, that is, after adjustment, half of the retropubic group was affected (adjusted hazard ratio, 0.41; 95% confidence interval, 0.3-0.6). The cumulative 2-year estimate of reoperation for recurrence of stress urinary incontinence was 2.7% (95% confidence interval, 2.0-3.6) in the retropubic group and 2.8% (95% confidence interval, 1.7-4.2) in the transobturator group with risk for revision for recurrence being higher in the transobturator group after adjustment (adjusted hazard ratio, 1.9; 95% confidence interval, 1.2-2.9); this surplus risk disappeared after exclusion of the patients with a previous surgery for stress urinary incontinence.

CONCLUSION

The transobturator route for midurethral sling placement is associated with a lower risk for serious complications but a higher risk for surgical reoperation for recurrence than the retropubic route. Despite the large number of surgeons involved, these risks were low. The data are therefore reassuring.

Serious complications and recurrences after pelvic organ prolapse surgery for 2309 women in the VIGI-MESH registry

OBJECTIVE

To assess the incidence of serious complications and reoperations for recurrence after surgery for pelvic organ prolapse (POP) and compare the three most common types of repair.

DESIGN

Prospective cohort study using a registry.

SETTING

Nineteen French surgical centres.

POPULATION

A total of 2309 women participated between 2017 and 2019.

METHODS

A multivariate analysis including an inverse probability of treatment weighting approach was used to obtain three comparable groups.

MAIN OUTCOME MEASURES

Serious complications and subsequent reoperations for POP recurrence.

RESULTS

The median follow-up time was 17.6 months. Surgeries were native tissue vaginal repairs (n = 504), transvaginal mesh placements (n = 692) and laparoscopic sacropexies with mesh (n = 1113). Serious complications occurred among 52 women (2.3%), and reoperation for POP recurrence was required for 32 women (1.4%). At 1 year the cumulative weighted incidence of serious complications was 1.8% for native tissue vaginal repair, 3.9% for transvaginal mesh and 2.2% for sacropexy, and the rates for reoperation for recurrence of POP were 1.5, 0.7 and 1.1%, respectively. Compared with native tissue vaginal repair, the risk of serious complications was higher in the transvaginal mesh group (weighted hazard ratio, wHR 3.84, 95% CI 2.43-6.08) and the sacropexy group (wHR 2.48, 95% CI 1.45-4.23), whereas the risk of reoperation for prolapse recurrence was lower in both the transvaginal mesh (wHR 0.22, 95% CI 0.13-0.39) and sacropexy (wHR 0.29, 95% CI 0.18-0.47) groups.

CONCLUSIONS

Our results suggest that native tissue vaginal repairs have the lowest risk of serious complications but the highest risk of reoperation for recurrence. These results are useful for informing women and for shared decision making.

TWEETABLE ABSTRACT

Laparoscopic sacropexy had fewer serious complications than transvaginal mesh and fewer reoperations for recurrence than vaginal repair.

Long-term outcomes of primary cystocele repair by transvaginal mesh surgery versus laparoscopic mesh sacropexy: extended follow up of the PROSPERE multicentre randomised trial

OBJECTIVE

To compare the effectiveness and safety of laparoscopic sacropexy (LS) and transvaginal mesh (TVM) at 4 years.

DESIGN

Extended follow up of a randomised trial.

SETTING

Eleven centres.

POPULATION

Women with cystocele stage ≥2 (pelvic organ prolapse quantification [POP-Q], aged 45-75 years without previous prolapse surgery.

METHODS

Synthetic non-absorbable mesh placed in the vesicovaginal space and sutured to the promontory (LS) or maintained by arms through pelvic ligaments and/or muscles (TVM).

MAIN OUTCOME MEASURES

Functional outcomes (pelvic floor distress inventory [PFDI-20] as primary outcome); anatomical assessment (POP-Q), composite outcome of success; re-interventions for complications.

RESULTS

A total of 220 out of 262 randomised patients have been followed at 4 years. PFDI-20 significantly improved in both groups and was better (but below the minimal clinically important difference) after LS (mean difference -7.2 points; 95% CI -14.0 to -0.05; P = 0.029). The improvement in quality of life and the success rate (LS 70%, 61-81% versus TVM 71%, 62-81%; hazard ratio 0.92, 95% CI 0.55-1.54; P = 0.75) were similar. POP-Q measurements did not differ, except for point C (LS -57 mm versus TVM -48 mm, P = 0.0093). The grade III or higher complication rate was lower after LS (2%, 0-4.7%) than after TVM (8.7%, 3.4-13.7%; hazard ratio 4.6, 95% CI 1.007-21.0, P = 0.049)).

CONCLUSIONS

Both techniques provided improvement and similar success rates. LS had a better benefit-harm balance with fewer re-interventions due to complications. TVM remains an option when LS is not feasible.

TWEETABLE ABSTRACT

At 4 years, Laparoscopic Sacropexy (LS) had a better benefit-harm balance with fewer re-interventions due to complications than Trans-Vaginal Mesh (TVM).

Perioperative morbi-mortality after pelvic organ prolapse surgery in a large French national database from gynecologist surgeons

OBJECTIVE

To assess morbidity and mortality following pelvic organ prolapse surgery in France, irrespective of the surgical technique, using a broad national database.

MATERIALS AND METHODS

This descriptive multicenter retrospective study was conducted using a database populated via an application run by a professional association.

RESULTS

286 gynecologists contributed data to the database. Of the 4322 surgeries analyzed, an abdominal approach was used in 975 of cases (22.5%), a vaginal approach in 3277 (75.9%), and a combined approach in 68 (1.6%). After one year, abdominal surgery was associated with higher rates of de novo urinary incontinence, constipation, and intestinal obstruction, whereas vaginal surgery was associated with higher rates of urinary retention, hematoma, de novo chronic pain, and vaginal mesh extrusion. There was no significant difference between the groups in the incidence of severe complications. After one year, vaginal mesh-augmented cystocele repair was associated with higher rates of de novo urinary incontinence, de novo chronic pain, and reoperation than native tissue repair. Mesh repair was also associated with higher rates of severe complications at one year.

CONCLUSION

After pelvic organ prolapse surgery, the perioperative morbidity and mortality associated with transabdominal and transvaginal approaches are similar. However, transvaginal mesh repair is associated with greater perioperative morbidity than transvaginal native tissue repair.

Transvaginal treatment of anterior and apical genital prolapses using an Ultra lightweight mesh: Restorelle® Direct Fix™. A retrospective study on feasibility and morbidity

BACKGROUND

Vaginal mesh safety information is limited, especially concerning single incision techniques using ultra lightweight meshes for the treatment of anterior pelvic organ prolapse (POP).

OBJECTIVE

To determine the intraoperative and postoperative complication rates after anterior POP repair involving an ultralight mesh (19g/m²): Restorelle^® Direct Fix™.

METHODS

A case series of 218 consecutive patients, operated on between January 2013 and December 2016 in ten tertiary and secondary care centres, was retrospectively analyzed. Eligible patients had POP vaginal repair (recurrent or not) planned with anterior Restorelle^® Direct Fix™ mesh (with or without posterior mesh). Surgical complications were graded using the Clavien-Dindo classification.

RESULTS

Intraoperative complications were bladder wound (0.5%), rectal wound (0.5%), ureteral injuries (0.9%). 98.2% of the patient did not have per operative complications. We observed one fail of procedure. Early complications mainly included urinary retention (8.7%) urinary tract infections (5.5%) and haematoma (2.7%). One haematoma required surgical treatment and another, embolization. 80.7% of the patient did not have complications during hospitalization and 80.3% did not have complication at the follow up visit. None of the analyzed factors (age, body mass index, surgical history, grade of prolapse or concomitant procedure) was significantly associated with the risk of perioperative complications. A total of 2.8% patients had grade III complications according Clavien Dindo. None had grade IV or V.

CONCLUSIONS

This multicentre case-series on the early experience of the use of anterior Restorelle^® Direct Fix™ mesh showed a satisfactory technical feasibility and a low rate of grade III complications according Clavien Dindo. Long term studies are necessary to assess anterior Restorelle^® Direct Fix™ mesh performances and to appraise patient satisfaction feedback.

Safety of Vaginal Mesh Surgery Versus Laparoscopic Mesh Sacropexy for Cystocele Repair: Results of the Prosthetic Pelvic Floor Repair Randomized Controlled Trial

BACKGROUND

Laparoscopic mesh sacropexy (LS) or transvaginal mesh repair (TVM) are surgical techniques used to treat cystoceles. Health authorities have highlighted the need for comparative studies to evaluate the safety of surgeries with meshes.

OBJECTIVE

To compare the rate of complications, and functional and anatomical outcomes between LS and TVM.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter randomized controlled trial from October 2012 to April 2014 in 11 French public hospitals. Women with cystocele stage ≥2 (pelvic organ prolapse quantification), aged 45-75 yr, without previous prolapse surgery.

INTERVENTION

Synthetic nonabsorbable mesh placed in the vesicovaginal space, sutured to the promontory (LS) or maintained by arms through pelvic ligaments (TVM).

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Rate of surgical complications ≥grade II according to the modified Clavien-Dindo classification at 1 yr. Secondary outcomes were reintervention rate, and functional and anatomical results.

RESULTS AND LIMITATIONS

A total of 130 women were randomized in LS and 132 in TVM; five women withdrew before intervention, leaving 129 in LS and 128 in TVM. The rate of complications ≥grade II was lower after LS than after TVM, but did not meet statistical significance (17% vs 26%, treatment difference 8.6% [95% confidence interval, CI -1.5 to 18]; p=0.088). The rate of complications of grade III or higher was nonetheless significantly lower after LS (LS=0.8%, TVM=9.4%, treatment difference 8.6% [95% CI 3.4%; 15%]; p=0.001). LS was converted to TVM in 6.3%. The total reoperation rate was lower after LS but did not meet statistical significance (LS=4.7%, TVM=10.9%, treatment difference 6.3% [95% CI -0.4 to 13.3]; p=0.060). There was no difference in symptoms, quality of life, improvement, composite definition of success, anatomical results rates between groups except for the vaginal apex and length, and dyspareunia (in favor of LS).

CONCLUSIONS

LS is a valuable option for primary repair of cystocele in sexually active patients. LS is safer than TVM, but may not be feasible in all cases. Both techniques offer same functional outcomes, success rates, and anatomical outcomes, but sexual function is better preserved by LS.

PATIENT SUMMARY

Our study demonstrates that laparoscopic sacropexy (LS) is a valuable option for primary repair of cystocele. LS offers equivalent success rates to vaginal mesh procedures, but is safer with a lower rate of complications and reoperations, and sexual function is better preserved.

[Place of the mini-sling in the treatment of female stress urinary incontinence]

OBJECTIVE

Evaluate the place of sub-urethral mini-slings in the treatment of female stress urinary incontinence.

MATERIAL AND METHODS

Review of the literature on 43 publications (comparative and prospective studies) more than 6443 patients who underwent for the treatment of urinary incontinence, a mini-strip type TVT®, TVT-S®, MiniArc®, Ajust®, Needleless®, Solyx®, or Ophira® in comparison to the conventional urethral sling. The comparison used objective (cough stress test and pad weight test) and subjective criteria (quality of life questionnaire). The papers have also studied the complication associated with these new techniques.

RESULTS

The overall effectiveness of this surgery varied between 40 to 84% for TVT-S®, 69 to 92% for MiniArc®, 80 to 91% for Ajust®, 87% for Needleless®, 95% for Solyx® and 85% for Ophira®. The efficacy on incontinence was higher with the TVT® TVT-S® and the MiniArc® (P=0.01 to 0.05). TVT-O® efficacy was higher than TVT-S® (P<0.01 and P=0.02). Conventional slings seems to be more efficient than TVT-S® and MiniArc® mini-slings. Ajust® mini-sling seems to be as efficient as MiniArc® and TVT-S® mini-sling and TVT-O®. It showed a decrease in the intensity of postoperative pain (P<0.001), faster return to normal activities (P=0.025) and use of a common local anesthetic to the adjustable mini-sling.

CONCLUSION

It seems that the adjustable mini-sling is currently the best compromise in terms of effectiveness and complications if the choice had to be among the mini-sling in the treatment of stress urinary incontinence.

Total transvaginal mesh (TVM) technique for treatment of pelvic organ prolapse: a 5-year prospective follow-up study

INTRODUCTION AND HYPOTHESIS

To evaluate clinical effectiveness and complication rates at 5 years following the total Trans Vaginal Mesh (TVM) technique to treat pelvic organ prolapse.

METHODS

Prospective, observational, multi-centre study in patients with prolapse of stage II or higher.

RESULTS

Of the 90 women enrolled in the study, 82 (91%) were available for the 5-year follow-up period. At the 5-year endpoint, success, defined as no surgical prolapse reintervention and leading edge <-1 (International Continence Society [ICS] criteria) or above the level of the hymen, was 79% and 87% respectively. A composite criterion of success defined as: leading edge above the hymen (<0) and no bulge symptoms and no reintervention for prolapse was met by 90%, 88% and 84% at the 1-, 3-, and 5-year endpoints respectively. Quality of life improvement was sustained over the 5 years. Over the 5-year follow-up period, a total of only 4 patients (5%) required re-intervention for prolapse, while a total of 14 patients (16%) experienced mesh exposure for which 8 resections needed to be performed. Seven exposures were still ongoing at the 5-year endpoint, all asymptomatic. Only 33 out of 61 (54%) sexually active patients at baseline remained so at 5 years. De novo dyspareunia was reported by 10%, but no new cases at the 5-year endpoint. One patient reported de novo unprovoked mild pelvic pain at 5 years, 5 reported pains during pelvic examination only.

CONCLUSIONS

Five-year results indicated that TVM provided a stable anatomical repair. Improvements in QOL and associated improvements in prolapse-specific symptoms were sustained. Minimal new morbidity emerged between the 1- and 5-year follow-up.

Vaginal prolapse repair using the Prolift kit: a registry of 100 successive cases

OBJECTIVES

To evaluate anatomical, functional outcomes and complications inherent to the treatment of pelvic organ prolapse by implantation of polypropylene mesh, using the Prolift kit.

MATERIALS AND METHODS

Single-center observational study of 100 successive patients enrolled in a registry, who underwent Prolift prolapse repair. Data on prior treatments, associated procedures and per- and post-operative complications were collected and the patients were seen after 2, 6 and 12 months. Anatomical outcomes were assessed using the International Continence Society Pelvic Organ Prolapse Quantification (ICS POP-Q) system. Function was assessed in terms of urinary and digestive problems, and impact on sex life. Failure was defined as relapse of POP-Q Grade 2 or more.

RESULTS

Of the 100 patients, 32 had an anterior, 14 a posterior, 54 a total Prolift; 53 had concomitant urinary incontinence surgery. At 6 and 12 months respectively, 8% and 12% of the patients were lost to follow-up. Mean operating time was 39.8 min. With respect to peri-operative complications, there was no bladder or rectal damage but three patients experienced bleeding (≥ 300 ml) without needing transfusion. POP-Q Grades before surgery were: Grades III-IV cystocele in 65.7% of the anterior Prolift patients; Grades II-III rectocele in the posterior; and 77.8% of total were Grade III and 11.1% Grade IV. The incidence of recurrence was 3.6% at Month 6 and 10.2% at Month 12. Significant (p<0.05) improvements were seen in median scores for the various POP-Q items. With respect to functional problems, stress urinary incontinence was cured in 92% of the patients but 7.7% reported new-onset urinary incontinence after one year. One case of vaginal exposure after one year was observed and major or symptomatic mesh retraction was observed in 8%. New-onset dyspareunia was reported by 11.1% of the patients.

CONCLUSIONS

These results confirm the feasibility of using the Prolift kit in the repair of prolapse via a vaginal approach and the low per- and post-operative morbidity associated with that technique. Nevertheless, longer-term evaluation is required to confirm the results.

[MiniArc: preliminary prospective study on 72 cases]

OBJECTIVES

To present a new mini-invasive tape requiring only a single incision, to assess the complications and short-term results.

MATERIALS AND METHODS

Prospective study of 72 patients with stress urinary incontinence. Were selected for the study patients with stress urinary incontinence with or without intrinsic sphincter deficiency and mixed urinary incontinence with a predominance of leaks to the effort. Patients were evaluated at 2 months of the intervention.

RESULTS

Isolated stress urinary incontinence for 58 patients, mixed incontinence for 14 and intrinsic sphincter deficiency for five. The complications per procedure revealed one bleeding over 100ml, one malaise vagal and a failure of the procedure. At 2 months, the authors found: two urgenturies de novo, one de novo micturition disorder, one erosion, one urinary tract infection and four lateral vaginal bands. The early objective results are overall 75.7% of dry patients (79.6% for pure SUI, 66.6% for IUE with ISD and 61.5% for mixed incontinence). The overall failure rate was 2.9%.

CONCLUSION

The results of this simplified tape are worse than those of TVT and transobturator tapes.

Safety of Trans Vaginal Mesh procedure: retrospective study of 684 patients

AIM

To study peri-surgical complications after cure of genital prolapse by vaginal route using interposition of synthetic prostheses Gynemesh Prolene Soft (Gynecare) following the Trans Vaginal Mesh (TVM) technique.

METHODS

The present retrospective multicentered study comprised 684 patients who underwent surgery at seven French centers between October 2002 and December 2004. All patients had a genital prolapse >or=3 (C3/H3/E3/R3) according to International continence society (ICS) classification. According to each case, prosthetic interposition was total, or anterior only or posterior only. Patients were systematically seen 6 weeks, 3 months and 6 months after surgery. Multivaried statistical analysis followed a model of logistic regression applied to each post-surgical complication.

RESULTS

The mean age of patients was 63.5 years (30-94). The mean follow-up period was 3.6 months. 84.3% of patients were post-menopause, 24.3% had hysterectomy, 16.7% previous cure of prolapse, and 11.1% cure of stress urinary incontinence (SUI). During the procedure, hysterectomy was combined in 50.3% of cases, cervix amputation in 1.5%, and cure of SUI in 40.9%. 15.8% were treated for a cystocele only. 14.8% had only a rectocele +/- elytrocele and 69.4% had a prolapse touching both compartments, anterior and posterior. In peri-surgical complications, (2%) were five bladder wounds (0.7%), one rectal wound (0.15%) and seven hemorrhages greater that 200 mL (1%). Among early post-surgical complications (during the first month after surgery) (2.8%) were two pelvic abscesses (0.29%), 13 pelvic hematomas (1.9%), one pelvic cellulitis (0.15%), two vesicovaginal fistulas and one rectovaginal fistula (0.15%). Among late post-surgical complications (33.6%) there were 77 granulomas or prosthetic expositions (11.3% [6.7% in the vaginal anterior wall, 2.1% in the vaginal posterior wall and 4.8% in the fornix]), 80 prosthetic retractions (11.7%), 36 relapse of prolapse (6.9%) and 37 SUI de novo (5.4%). Multivaried analysis shows that previous history of hysterectomy or placing of an isolated anterior prosthesis increase the risk of peri-surgical complication; preserved uterus and isolated posterior prosthesis lessen the risk of granulomas and prosthetic retractions; and association of a Richter's intervention increases the rate of prosthetic retractions.

CONCLUSION

Cure of genital prolapse with synthetic prostheses interposed by vaginal route is now reliable and can be reproduced with a low rate of peri- and early post-surgical complications. However, our study shows a certain number of late post-surgical complications after insertion of strengthening synthetic vaginal implants (prosthetic expositions and prosthetic retractions). These retrospective results will soon be compared to a prospective study.

Trans-obturator urethral sling for the surgical correction of female stress urinary incontinence: Outside-in (Monarc®) versus inside-out (TVT-O®)

INTRODUCTION

In 2001, the trans-obturator route was proposed for the surgical positioning of tape with a view to avoiding the retropubic space and its disadvantages. The route, originally described outside-in by Delorme was presented inside-out by de Leval. Since then, anatomical discussions have attempted to prove that one technique is safer than the other.

OBJECTIVE

Demonstrating the safety of the two techniques through personal and published experience.

MATERIAL AND METHODS

Non-randomized, prospective, observational, open-label, longitudinal study of 100 female patients (50 tension-free vaginal tape (TVT)-O and 50 Monarc). All the female patients presented with isolated stress urinary incontinence. Only four patients presented with mixed incontinence in the Monarc (MON) group. Sphincter incompetence was observed four times in the MON group and three times in the TVT-O group. Almost all the patients were undergoing their first procedure. All the patients underwent surgery under assisted local anesthesia in a day-hospital setting. All the patients underwent a full gynecological examination and a urodynamic assessment. Only those patients presenting with patent established urinary incontinence, corrected by the TVT test, underwent surgery. Post-operative control was conducted at 3 months and 1 year when a physical examination and urodynamic assessment were implemented.

RESULTS

All the patients underwent control up to time point 12 months. The duration of hospitalization was 10h for 48 patients in the MON group and 49 in the TVT-O group. The duration of hospitalization was 24h for one patient in each group and 4 days for one patient in the TVT-O group due to transient urine retention. The only per-operative complication was a vaginal perforation in the lateral angle of the vagina for a MON patient. Tape repositioning was necessary. Early post-operative complications were observed in the MON group: three cases of urinary tract infection, one of transient urine retention, three of pain in the thighs spontaneously resolving within 4 days and one of permanent pain in one leg at time 1 year, which remained bearable. For the TVT-O group the post-operative complications consisted in: one case of urinary tract infection, one of transient retention and four of pain in the thigh. No hematoma was reported in either group. Amongst the late complications, the de novo symptoms included one case of imperious urges to urinate in the TVT-O group and objective dysuria in two cases in the MON group versus seven in the TVT-O group. There was no statistically significant between-group difference in the complications. No tape exposure was observed. Overall, the recovery rate was 90% at 1 year for MON versus 94% for TVT-O (p=NS) with two cases of recurrence between 3 months and 1 year in that series. Mixed incontinence was corrected at time point 1 year in 75% of cases for MON, with one case of recurrence in the year. For the patients presenting with sphincter incompetence, competence was maintained at 3 months and 1 year in all cases in the MON group. The three TVT-O were cured at 3 months, but two recurrences were observed at 1 year. Almost all the patients were satisfied or very satisfied at time point 1 year and those who had sexual relations (54%) did not report any disorder at time point 1 year.

DISCUSSION

The outside-in technique necessitates more marked peri-urethral dissection and vesical complications are possible. The cadaveric studies by the outside-in partisans show a vascular and nervous risk, which has little reflection in terms of complications in the literature. Post-operative leg pains are encountered with both techniques and are usually only transient. All the studies of the two routes report a recovery rate of over 90% for pure stress incontinence.

CONCLUSION

The author's experience, like that reported in the literature, shows that the two trans-obturator access routes are equally safe and do not require per-operative cystoscopic control. The clinical results would appear to be equivalent, in terms of recovery, to the rates obtained with retropubic TVT. Attempting to find anatomical or etiological arguments in order to prove one technique superior to the other appears somewhat parochial.

[The prosthetic kits in the prolapse surgery: is it a gadget?]

OBJECTIVE

To search if the prosthetic kits bring an interest, other that financier.

MATERIALS AND METHOD

Authors have counted 5 firms presenting the varied kits. The Prolift kit with synthetic pre- cut mesh made of polypropylene, standardized needle, cannulas and protective devices of recovery of mesh arms in 3 versions, anterior, posterior and total. Perigee and Apogee systems in a synthetic version (IntePro) and a biological version (InteXen ++LP) matched of specific needles for the different obturator passages and infra coccygeus. The Avaulta kit declines in a biosynthetic version and a hybrid version with a specific needle for its anterior kit and an other for its posterior kit. The Biomesh Soft system presents a polypropylène mesh posed on a multi pattern sheet to carve following dots with a share of 3 needles according to the type of arm passage ended by a recuperator thread. The Nazca POP Repair System, in its anterior version claims to be able to correct in the same time a urinary incontinence by pre-pubic arms. The polypropylene mesh is perforated and is had with the help a needle for its anterior and posterior kit. Authors have been interested in the research of studies on prosthesis with and without kit.

RESULTS

The Prolift kit contains the alone prosthesis having been evaluated without (TVM) and with kit. Authors remind results of two studies, understanding 684 cases without kit and 110 cases with kit. The rate of early per and postoperative complications has been decreased half, the rate of mesh exposure decreased from 11,3 to 4,7%. Studies on Perigee and Apogee IntePro kits, whose meshe and the procedure are similar to the Prolift seem to obtain from results equal. The Biological version has not made the object of study. For the Avauta kit, alone the mesh in plate not pre-cut has been well studied as for its tolerance for the biosynthetic version. Nothing on the hybrid version. No study is found for the Biomesh Soft kit and Nazca POP repair system.

DISCUSSION

The cost of these kits, varying 1 to 4, is to take in consideration and to put in scale with the returned service. Alone TVM/Prolift allows to advance in a reply. The utilization of needles, presents in all the kits, but especially devices facilitating the passage and the recovery of prosthesis arms, presents solely in the Prolift kit, reduce the utilization of valves and the risk of tear tissues during their job. The improvement of techniques by elements of the kit make that the surgical procedure become mini invasive.

CONCLUSION

The full kits allow a best security of procedures, facilitate the surgical gesture and limit complications. It is necessary to remain vigilant in the evaluation of these new materials "ready to wear" and to require pre clinic and clinic studies before their distribution.

Prosthetic reinforcements: how to manage bladder injuries?

The aim of this study was to describe our experience in the management of bladder injuries occurring at intervesicovaginal dissection during the tension-free vaginal mesh (TVM) procedure. Seven hundred four patients were treated for prolapse by vaginal route using the TVM procedure. Bladder injury was diagnosed during the procedure in five patients. Polypropylene mesh was placed in the intervesicovaginal space after a careful repair of the bladder injury. Major postoperative complications were not diagnosed during the short-term follow up. We describe the occurrence and treatment of bladder injuries during the dissection phase in the TVM procedure. Such injuries can occur during the dissection. Placing an intervesicovaginal mesh is acceptable if cautious bladder repair is performed.

Transvaginal repair of genital prolapse: preliminary results of a new tension-free vaginal mesh (Prolift technique)--a case series multicentric study

Our goal was to report the preliminary results of a transvaginal mesh repair of genital prolapse using the Prolift system. This retrospective multicentric study includes 110 patients. All patients had a stage 3 (at the hymen) or stage 4 (beyond the hymen) prolapse. Total mesh was used in 59 patients (53.6%), an isolated anterior mesh in 22 patients (20%) and an isolated posterior mesh in 29 patients (26.4%). We report one bladder injury sutured at surgery and two haematomas requiring secondary surgical management. At 3 months, 106 patients were available for follow-up. Mesh exposure occurred in five patients (4.7%), two of them requiring a surgical management. Granuloma without exposure occurred in three patients (2.8%). Failure rate (recurrent prolapse even asymptomatic or low grade symptomatic prolapse) was 4.7%. According to the perioperative and immediate post-operative results, Prolift repair seems to be a safe technique to correct pelvic organ prolapse. Anatomical and functional results must be assessed with a long-term follow-up to confirm the effectiveness and safety of the procedure.

Soutènement sous-urétral par la voie obturatrice pour la cure chirurgicale de l’incontinence urinaire d’effort féminine: dehors en dedans (Monarc®) versus dedans en dehors (TVT-O®)

INTRODUCTION

The originally described outside-in procedure for the trans-obturator route was later turned inside-out. We wanted to demonstrate the safety of the two techniques through personal and published experience.

MATERIAL AND METHODS

Non-randomized, prospective, observational, open-label, longitudinal study of 100 female patients (50 TVT-O and 50 Monarc). All the female patients presented with isolated stress urinary incontinence. Only 4 patients presented with mixed incontinence in the Monarc (MON) group. Sphincter incompetence was observed 4 times in the MON group and 3 times in the TVT-O group. All the patients underwent surgery under assisted local anesthesia in a day-hospital setting. Only those patients presenting with patent established urinary incontinence, corrected by the TVT test, underwent surgery. Post-operative control was conducted at 3 months and 1 year.

RESULTS

The duration of hospitalization was 10 h for 48 patients in the MON group and 49 in the TVTO group. The only per-operative complication was a vaginal perforation in the lateral angle of the vagina for a MON patient. Early post-operative complications were observed in the MON group: 3 cases of urinary tract infection, 1 of transient urine retention, 3 of pain in the thighs spontaneously resolving within 4 days and 1 of permanent pain in one leg at time 1 year, which remained bearable. For the TVTO group the post-operative complications consisted in: 1 case of urinary tract infection, 1 of transient retention and 4 of pain in the thigh. No hematoma was reported in either group. Among the late complications, the de novo symptoms included 1 case of imperious urges to urinate in the TVTO group and objective dysuria in 2 cases in the MON group vs. 7 in the TVTO group. There was no statistically significant between-group difference in the complications. No tape exposure was observed. Overall, the recovery rate was 90% at 1 year for MON vs. 94% for TVTO (p = NS) with 2 cases of recurrence between 3 months and 1 year in that series. Mixed incontinence was corrected at time point 1 year in 75% of cases for MON, with 1 case of recurrence in the year. For the patients presenting with sphincter incompetence, competence was maintained at 3 months and 1 year in all cases in the MON group. The 3 TVT-O were cured at 3 months, but 2 recurrences were observed at 1 year. All patients, except one, were satisfied at time point 1 year and those who had sexual relations (54%) did not report any disorder at time point 1 year.

DISCUSSION

The cadaveric studies by advocates of the outside-in technique show a vascular and nervous risk which has received little attention in terms of complications in the literature. Post-operative leg pain is encountered with both techniques and usually is transient.

CONCLUSION

Our experience, like that reported in the literature, shows that the two trans-obturator access routes are equally safe. The clinical results would appear to be equivalent, in terms of recovery, to the rates obtained with retropubic TVT.

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.

Grossesse après soutènement sous-urétral par voie trans-obturatrice (Monarc®)

Rare cases of pregnancy occur after surgical treatment of an urinary incontinence. We report the case of a 37-year-old patient became pregnant 5 months after trans-obturator insertion of a suburethral sling (Monarc). The pregnancy was monitored regularly and no sign of urinary incontinence was observed. Caesarean delivery was decided at 40 weeks gestation. The patient has remained quite continent, one year after delivery. The appropriate mode of delivery is discussed.

[Dermoid cyst of the urachus: a case report and review of the literature]

The urachus, a normal embryonic remnant of the primitive bladder dome, exists as a fibrous cord in adult. Urachal disorders are not exceptional, and are expression of incomplete regression. Diagnosis is generally ultrasonographic, rarely clinical. We report a case of urachal dermoid cyst revealed by abdominal pain and underline the diagnostic difficulties related to this unusual localization.

Grossesse angulaire diagnostiquée à 11 SA sur un utérus fibromyomateux

Reported cases of angular pregnancy, which by definition corresponds to pregnancy developing in a uterine horn, are rare. Etiologies as well as the diagnostic and therapeutic strategies are discussed. The anatomic modifications resulting from uterine fibromyoma and affecting embryo nidation in the uterine cavity of the uterus are the leading cause of angular pregnancy. The course of pregnancy depends on the evolution of the fibromyoma. Treatment therefore depends on the clinical course. Early diagnosis is essential for conservative treatment. In the case presented here, angular pregnancy was diagnosis following development of aseptic necrobiosis, the most common complication of fibromyosma.

Facteurs de risque des expositions prothétiques après cure de prolapsus génital par voie vaginale

OBJECTIVES

Prosthetic reinforcement in the surgical repair of pelvic prolapse by the vaginal approach is currently on the increase. However, this technique is not without tolerance-related problems. The most frequently described complication is prosthesis exposure, including erosion and delayed healing. It is independent of a granuloma and a major infection as pelvic cellulitis. Its mechanism is associated with defective vaginal healing. The purpose of our study is to define the risk factors for exposure of the prosthetic material.

PATIENTS AND METHODS

Two hundred and seventy-seven medical records relating to patients undergoing surgery due to pelvic prolapse were included in our study. The treatment of genital prolapse was managed via the vaginal approach with polypropylene mesh. This is a continuous, retrospective study conducted over a period of 24 months.

RESULTS

Thirty-four cases of prosthesis exposure were observed in the 2 months following surgery, which represents an incidence of 12.27%. The risk factors are concomitant hysterectomy [odds ratio 5.17 (P = 0.001)] and inverted T colpotomy [odds ratio 6.06 (P = 0.01)]. The protective factors are preservation of the uterus and the performance of a minor colpotomy in patients who had already undergone a hysterectomy or in those whose uterus had been preserved [odds ratio 5.16 (P = 0.0001)].

DISCUSSION AND CONCLUSION

In our study, we have only found risk factors of operative protocol. In fact, other information as age, menopause status or medical history of the patient is not significant. The uterus must be preserved and the number and extent of colpotomies needed to insert the prosthesis must be limited.

Prise en charge des expositions de prothèse après cure de prolapsus génitaux par voie vaginale

INTRODUCTION

Prosthetic reinforcement by the vaginal approach for surgical repair of pelvic prolapse is experiencing increasing popularity despite problems with tolerance. The most frequently described complication is prosthesis exposure, also known as erosion or granuloma. The mechanism is associated with defective vaginal healing and is independent of major infection such as pelvic cellulitis.

OBJECTIVES

The purpose of our study was to define the course of this complication and the best therapeutic strategy for patients with prosthesis exposure.

MATERIALS AND METHOD

Our continuous and retrospective study conducted over a period of 24 months between January 2002 and December 2003 recorded 34 files. These patients underwent prosthetic treatment via the vaginal approach of genital prolapse associated with prosthesis exposure. The procedure, known as TVM (Tension free Vaginal Mesh), involves the insertion without fixing of a synthetic prosthesis in areas of bladder-vagina and rectum-vagina detachment.

RESULTS

In 33 cases out of 34, the exposure site was located on the anterior colpotomy scar (97%). These prosthesis exposures were managed in two stages, using antiseptic treatment first. This treatment cured 9 patients (26.47%). In the event of failure, a procedure was carried out under brief general anesthesia on an outpatient basis or during a 24-hour hospital stay. This single resection was sufficient for 20 patients (88%). Two patients nevertheless required a second removal procedure (8%) and one patient a third procedure (4%). To notice, one patient presented with a bladder-vagina fistula after resection. This observation of a bladder-vagina fistula following partial removal led us to recommend a blue test and/or cystoscopy as routine practice for each procedure.

CONCLUSION

With this new vaginal approach for prolapse repair, it is important to monitor prosthesis exposure. To manage exposures, it is necessary to begin with antiseptic or estrogenic treatment. In the event of failure, a partial resection is warranted. We recommend careful prosthesis resection and systematic verification of the bladder.

Transvaginal mesh technique for pelvic organ prolapse repair: mesh exposure management and risk factors

Prosthetic reinforcement in the surgical repair of pelvic prolapse by the vaginal approach is not devoid of tolerability-related problems such as vaginal erosion. The purposes of our study are to define the risk factors for exposure of the mesh material, to describe advances and to recommend a therapeutic strategy. Two hundred and seventy-seven patients undergoing surgery due to pelvic prolapse with transvaginal mesh technique were included in a continuous, retrospective study between January 2002 and December 2003. Thirty-four cases of mesh exposure were observed within the 2 months following surgery, which represents an incidence of 12.27%. All the patients were medically treated, nine of whom were found to have completely healed during the check-up performed at 2 months. In contrast, 25 patients required partial mesh exeresis. Risk factors of erosion were concomitant hysterectomy [OR = 5.17 (p = 10(-3))] and inverted T colpotomy [OR = 6.06 (p = 10(-2))]. Two technical guidelines can be defined from this study as regards the surgical procedure required in order to limit mesh exposure via the vaginal route. The uterus must be preserved, and the number and extent of colpotomies needed to insert the mesh must be limited.