Perioperative complications and reoperations after incontinence and prolapse surgeries using prosthetic implants

Animal models of female pelvic organ prolapse: lessons learned

Pelvic organ prolapse is a vaginal protrusion of female pelvic organs. It has high prevalence worldwide and represents a great burden to the economy. The pathophysiology of pelvic organ prolapse is multifactorial and includes genetic predisposition, aberrant connective tissue, obesity, advancing age, vaginal delivery and other risk factors. Owing to the long course prior to patients becoming symptomatic and ethical questions surrounding human studies, animal models are necessary and useful. These models can mimic different human characteristics - histological, anatomical or hormonal, but none present all of the characteristics at the same time. Major animal models include knockout mice, rats, sheep, rabbits and nonhuman primates. In this article we discuss different animal models and their utility for investigating the natural progression of pelvic organ prolapse pathophysiology and novel treatment approaches.

Indications, contraindications, and complications of mesh in surgical treatment of pelvic organ prolapse

Women are seeking care for pelvic organ prolapse in increasing numbers and a significant proportion of them will undergo a second repair for recurrence. This has initiated interest by both surgeons and industry to utilize and design prosthetic mesh materials to help augment longevity of prolapse repairs. Unfortunately, the introduction of transvaginal synthetic mesh kits for use in women was done without the benefit of level 1 data to determine its utility compared with native tissue repair. This report summarizes the potential benefit/risks of transvaginal synthetic mesh use for pelvic organ prolapse and recommendations regarding its continued use.

The role of vaginal mesh procedures in pelvic organ prolapse surgery in view of complication risk

Synthetic transvaginal mesh has been employed in the treatment of pelvic organ prolapse for more than a decade. As the use of these devices increased during this period so did adverse event reporting. In 2008, the Food and Drug Administration (FDA) Public Health Notification informed physicians and patients of rising concerns with the use of synthetic transvaginal mesh. Shortly thereafter and in parallel to marked increases in adverse event reporting within the Manufacturer and User Device Experience (MAUDE), the FDA released a Safety Communication regarding urogynecologic surgical mesh use. Following this report and in the wake of increased medical industry product withdrawal, growing medicolegal concerns, patient safety, and clinical practice controversy, many gynecologists and pelvic reconstructive surgeons are left with limited long-term data, clinical guidance, and growing uncertainty regarding the role of synthetic transvaginal mesh use in pelvic organ prolapse. This paper reviews the reported complications of synthetic transvaginal mesh with an evidence-based approach as well as providing suggested guidance for the future role of its use amidst the controversy.

Long-term outcomes of vaginal mesh versus native tissue repair for anterior vaginal wall prolapse

INTRODUCTION AND HYPOTHESIS

To estimate the risk of repeat surgery for recurrent prolapse or mesh removal after vaginal mesh versus native tissue repair for anterior vaginal wall prolapse.

METHODS

We utilized longitudinal, adjudicated, healthcare claims from 2005 to 2010 to identify women ≥18 years who underwent an anterior colporrhaphy (CPT 57420) with or without concurrent vaginal mesh (CPT 57267). The primary outcome was repeat surgery for anterior or apical prolapse or for mesh removal/revision; these outcomes were also analyzed separately. We utilized Kaplan-Meier curves to estimate the cumulative risk of each outcome after vaginal mesh versus native tissue repair. Cox proportional hazards models were used to estimate the hazard ratio (HR) for vaginal mesh versus native tissue repair, adjusted for age, concurrent hysterectomy, and concurrent or recent sling.

RESULTS

We identified 27,809 anterior prolapse surgeries with 49,658 person-years of follow-up. Of those, 6,871 (24.7%) included vaginal mesh. The 5-year cumulative risk of any repeat surgery was significantly higher for vaginal mesh versus native tissue (15.2 % vs 9.8 %, p <0.0001) with a 5-year risk of mesh revision/removal of 5.9%. The 5-year risk of surgery for recurrent prolapse was similar between vaginal mesh and native tissue groups (10.4 % vs 9.3 %, p = 0.70. The results of the adjusted Cox model were similar (HR 0.93, 95%CI: 0.83, 1.05).

CONCLUSIONS

The use of mesh for anterior prolapse was associated with an increased risk of any repeat surgery, which was driven by surgery for mesh removal. Native tissue and vaginal mesh surgery had similar 5-year risks for surgery for recurrent prolapse.

Sling revision/removal for mesh erosion and urinary retention: long-term risk and predictors

OBJECTIVE

The objective of the study was to estimate the long-term risk of sling revision/removal after an initial sling and to assess indications (mesh erosion and urinary retention) and predictors of sling revision/removal.

STUDY DESIGN

Using a population-based cohort of commercially insured individuals, we identified women 18 years old or older who underwent a sling (Current Procedural Terminology code 57288) between 2001 and 2010 and any subsequent sling revision/removal (Current Procedural Terminology code 57287). We estimated the cumulative risk of revision/removal annually and evaluated predictors of sling revision/removal using Kaplan-Meier survival curves and Cox proportional hazards models, respectively.

RESULTS

We identified 188,454 eligible women who underwent an index sling. The 9 year cumulative risk of sling revision/removal was 3.7% (95% confidence interval [CI], 3.5-3.9). At 1 year, this risk was already 2.2% and then increased to 3.2% at 4 years before plateauing. With regard to the indication for the sling revision/removal, a greater proportion was due to mesh erosion compared with urinary retention, with a 9 year risk of 2.5% (95% CI, 2.3-2.6) for mesh erosion vs 1.3% (95% CI, 1.2-1.4) for urinary retention. Age had an effect on the revision/removal rates for both mesh erosion and urinary retention, with the higher risks among those aged 18-29 years. The risk of revision/removal for mesh erosion and urinary retention was also elevated among women who had a concomitant anterior or apical prolapse procedure.

CONCLUSION

In this population-based analysis, the 9 year risk of sling revision/removal was relatively low at 3.7%, with 60% of revisions/removals caused by mesh erosion.

Complications of vaginal mesh surgery

PURPOSE OF REVIEW

Mesh used for slings and pelvic organ prolapse (POP) repair has resulted in increased efficacy. Yet, the benefits of a more durable repair must be weighed against such risks as vaginal mesh extrusion and erosion and increased dyspareunia, and pelvic pain. We review the current literature on complications seen with the use of vaginal mesh for both stress urinary incontinence and POP.

RECENT FINDINGS

The use of mesh in midurethral slings results in similar efficacy but less morbidity compared with nonmesh sling techniques. The use of mesh in abdominal sacrocolpopexy may result in lower rates of mesh complications compared with transvaginal mesh prolapse repairs. In 2011, the Food and Drug Administration issued an updated safety communication stating that serious complications associated with transvaginal mesh for POP repair are not rare. Yet, certain patients do benefit from the use of transvaginal mesh for POP repair.

SUMMARY

Better-controlled data are needed to answer questions regarding outcomes, complications, and quality of life after transvaginal mesh prolapse procedures. The surgeon and the patient must have a proper informed consent discussion about the risks, benefits, alternatives, and indications for the use of mesh.

Controversies in the management of mesh-based complications: a urology perspective

Since the introduction of the synthetic midurethral sling, several transvaginal mesh delivery systems have been developed for treating stress incontinence and pelvic organ prolapse. Widespread use of these "kits" has introduced a new dilemma of mesh-specific complications that female pelvic surgeons must manage. Differing treatment techniques have been described and controversy exists as to which method is preferred for vaginal mesh extrusion, mesh perforations, pelvic pain, and dyspareunia. This article addresses the differing management strategies for mesh complications after reconstructive surgery and highlights the available literature on the success of each option.

Central compartment and apical defect repair using synthetic mesh

Pelvic organ prolapse is an increasingly common condition for women that has been challenging to treat due to high recurrence rates after surgical repair. The introduction of mesh-augmented prolapse repairs as a means to achieve more robust repairs had great initial promise. As more data emerge on outcomes and novel mesh complications, the when and where of mesh augmentation has become much less clear. This article reviews the relevant literature on the use of mesh in central and apical repairs. This includes a detailed look at the available data for vaginal mesh kits and several recent trials comparing mesh kits to traditional repairs. The article ends with a discussion of the recent U.S. Food and Drug Administration (FDA) safety communication on the use of transvaginal mesh in pelvic organ prolapse and the authors' views of how practice may change in this new environment.