Transvaginal mesh repair of anterior and posterior vaginal wall prolapse: a clinical and ultrasonographic study

Effect of anterior vaginal wall prolapse repair by modified transvaginal mesh surgery: a retrospective cohort study

OBJECTIVE

To explore clinical outcomes and complications of modified Transvaginal mesh (M-TVM) for advanced anterior vaginal wall prolapse in 1 year follow-up.

METHODS

574 patients underwent TVM surgeries from 2019 to 2020 were collected and divided into TVM group and M-TVM group, all preoperative and postoperative data was obtained and compared between the two groups.

RESULTS

285 women were involved eventually, including 181 in TVM group and 104 in M-TVM group. No significant difference of general conditions was found between these two groups. After long-term follow-up, patients in TVM group were more likely to suffer from pelvic pain than M-TVM group (P = 0.046). Meshes seemed much wider in M-TVM group (4.5 ± 0.69 cm) than in TVM group (3.0 ± 0.91 cm). No matter TVM or M-TVM, surgeries can significantly change point Aa and Ba when compared to preoperative data. Compared to TVM group, point C and D were significant changed in patients in M-TVM group after surgery (P < 0.001) CONCLUSION: M-TVM is a commendable procedure that can significant correct anterior prolapse with mesh extended wider, and also supply stable apical support at the same time.

Ultrasound evaluation of anterior transvaginal mesh for pelvic organ prolapse: correlation to 5-year clinical outcomes

Introduction and hypothesis

Vaginal prolapse mesh may effectively restore vaginal anatomy. The aim of this study was to investigate how the in vivo mesh position correlates to clinical outcomes.

Methods

Seventy-one women operated on using Uphold mesh for apical pelvic organ prolapse (POP-Q, C ≥ stage II) were examined 5 years after surgery by introital-perineal 2D ultrasound in a midsagittal plane at rest and Valsalva. The horizontal line and pubis symphysis were considered the reference for all measures. Ultrasound measures were statistically compared to clinical outcomes: POP-Q, Pelvic Floor Distress Inventory (PFDI-20) and subscales [Pelvic Organ Distress Inventory (PODI-6), and Urinary Distress Inventory (UDI-6)] and the VAS scale for pain.

Results

Original mesh length was preserved by 86% and correlated to improved pain as estimated by VAS scale (r 0.321). Valsalva was associated with a lowering of the superior and inferior mesh margins by 7.3 and 6.1 mm, respectively (p < 0.001) but a reduction of total mesh length by only 1 mm (30.2 ± 5.2 to 29.2 ± 4.7 mm, p < 0.001). Mobility of the anterior vaginal wall (bladder neck and midurethra) at Valsalva was parallel to downward movement of the mesh inferior margin (r 0.346 and 0.314) but inversely correlated to total UDI-6 (r − 0.254 and − 0.263). Mobility of the midurethra was inversely correlated to bladder emptying (PFDI-20 Question 19, r − 0.245).

Conclusions

Five years after surgery, preserved original length of the mesh with apical support was correlated to improved anatomical and patient-reported outcomes. Mesh support to the vaginal apex was associated with improved bladder emptying and total urinary distress outcomes but not stress urinary incontinence.

Ultrasound imaging of slings and meshes in urogynecology

Imaging is used increasingly in urogynecology. One of the main applications is in the assessment of synthetic implants. Ultrasound is particularly useful for this purpose as most such implants appear highly echogenic on ultrasound but are not visible using other imaging techniques. The worldwide success of synthetic mid-urethral slings, introduced in the late 90s, led to the subsequent introduction of transvaginal mesh in 2003-2004. Widespread use of synthetic implants for both urinary incontinence and prolapse has caused a rise in implant-related complications and increasing negative publicity and litigation, with many products removed from the market. It is not surprising that there is increasing demand for the assessment and evaluation of sling and mesh implants using imaging. This review article discusses the role of translabial/transperineal ultrasound in the evaluation of synthetic implants used in the treatment of urinary incontinence and pelvic organ prolapse. The discussion focuses on those applications of the technique that are useful for surgeons dealing with patients after mesh and/or sling placement. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Prospective ultrasonographic follow-up of transvaginal lightweight meshes: a 1-year multicenter study

INTRODUCTION AND HYPOTHESIS

The use of new lightweight meshes in pelvic organ prolapse (POP) surgery may reduce complications related to mesh retraction (chronic pain, dyspareunia, and mesh exposure). The aim of this study was to investigate changes in the area and position of Uphold Lite™ mesh 6 weeks and 12 months after anterior and/or apical prolapse repair.

METHODS

This observational prospective multicenter study included patients who had undergone transvaginal surgery for symptomatic POP-Q stage ≥ II anterior and/or apical compartment prolapse with placement of Uphold Lite mesh. The dimensions and position of the mesh were evaluated at 6 weeks and 12 months by ultrasonography. Correlations between ultrasonographic mesh characteristics and POP recurrence were analyzed.

RESULTS

Fifty evaluable women with an average age of 66.8 years were included. No statistically significant difference in mesh area was found between week 6 and month 12 postoperatively, either at rest (1746.92 vs. 1574.48 mm²; p = 0.15) or on Valsalva (1568.81 vs. 1542.98 mm²; p = 0.65). The ROC-AUC of the distance between the mesh and the bladder neck (M-BN) at 6 weeks for predicting cystocele recurrence at 12 months was 0.764 (95% CI 0.573-0.955) at rest and 0.724 (95% CI 0.533-0.916) on Valsalva. An M-BN distance > 12.5 mm could predict cystocele recurrence at month 12 with a sensitivity of 80% and a specificity of 69%.

CONCLUSIONS

Ultrasonographic measurements of the Uphold Lite™ mesh appear to remain stable between 6 weeks and 12 months postoperatively. M-BN distance correlates with cystocele recurrence. These results appear to confirm the value of ultrasound in mesh evaluation.

Laparoscopic approach to pelvic organ prolapse - the way to go or a blind alley?

Pelvic organ prolapse represents a relatively frequent diagnosis that requires attention due to its detrimental effect on quality of life. Not surprisingly, it is one of the commonest indications for surgery in premenopausal and postmenopausal women, often requiring a complex multidisciplinary approach. Traditional vaginal procedures are being gradually replaced by laparoscopic techniques, offering anticipated benefits in reduced recurrence and complication rates, while respecting the trend towards uterus sparing if desirable. Recently, questions about the safety of alloplastic materials used in pelvic organ prolapse surgery were raised, leading to official restrictions in their use, particularly for transvaginal application. As a result, laparoscopic procedures might appear slightly favored but caution must be taken to assure proper technique of mesh placement while maintaining high awareness of possible long-term mesh-related complications that require close surveillance. Therefore, adequate education and training becomes even more important to achieve optimal results and to avoid possible serious medico-legal charges.

A Proximal Straining Mesh Location Is Associated With De Novo Stress Urinary Incontinence After Transobturator Mesh Procedures

OBJECTIVES

The purpose of this study was to explore the association between mesh location and de novo stress urinary incontinence (SUI) after transvaginal mesh procedures.

METHODS

We retrospectively analyzed a database of women who had received transvaginal mesh procedures for stage III or greater cystocele according to the Pelvic Organ Prolapse Quantification system. Only data for women who neither reported SUI preoperatively nor had received concomitant anti-incontinence surgery were included for analyses. The mesh location was investigated by sonography via the percentage of the urethra covered by mesh, defined as the number calculated by dividing the portion of the urethral length covered by mesh (the distance from the bladder neck to the point of the urethra, which was indicated by an imaginary line at the level of the lower [caudal] mesh end and perpendicular to the urethra) by the total urethral length (the distance from the bladder neck to the external urethral meatus) in the sagittal plane. The resting, straining, coughing, and squeezing mesh locations of women who did (n = 29) and did not (n = 54) report SUI at the 12-month follow-up were compared.

RESULTS

At the 12-month follow-up, women who reported SUI had a significantly smaller straining percentage of the urethra covered by mesh (mean ± SD, 28.5% ± 9.6%) compared with continent women (35.2% ± 15.8%), indicating a more proximal straining mesh location.

CONCLUSIONS

Sonography is useful in investigating the location of the transvaginal mesh. De novo SUI after transvaginal mesh procedures is associated with a more proximal straining mesh location.

In Vivo Ultrasound Characteristics of Vaginal Mesh Kit Complications

OBJECTIVE

The objective of this study was to investigate the ultrasound characteristics of vaginal mesh in women with vaginal mesh complications.

METHODS

This was a cross-sectional study of women presenting with extrusion complications from vaginal mesh kit for prolapse at our tertiary care center between years 2009 and 2014. We included women who concurrently underwent a 3-dimensional endovaginal ultrasound (EVUS) as part of the clinical evaluation. We excluded women with incomplete charts and poor imaging quality. Subjects were categorized by the presence or absence of associated pelvic pain. Based on ultrasound findings, we compared the location of mesh, the appearance of mesh pattern (flat, folding, prominence, convoluted), and other EVUS characteristics of mesh.

RESULTS

Forty-six women with vaginal mesh complications and good image quality were included. When comparing mesh length between posterior and anterior compartments, the posterior meshes were significantly longer than the anterior meshes (42.1 [SD, 11.9] mm vs 25.8 [SD, 9] mm; P < 0.0001) and more often associated with pain. In the posterior compartment, the mean mesh length seen on EVUS was significantly longer in women with pain than in women without pain (46.5 [SD, 9] mm vs 31.8 [SD, 12.1] mm; P = 0.0001). There was also a higher proportion of a "flat" mesh pattern, 14 (58.3%) of 25, in the posterior compartment associated with the presence of pain (P = 0.013). In the posterior compartment, a smaller distance between the distal edge of the mesh and the anal sphincter was significantly associated with the presence of pain (8 mm [0-37] vs 21 mm [8-35], P = 0.024). In both compartments, the EVUS had 100% sensitivity for detection of mesh extrusions.

CONCLUSIONS

In this population of patients presenting with mesh complications, the posterior meshes were more often visualized as a "flat" pattern with a higher frequency of pain. Mesh complications of the anterior compartment had a higher frequency of folding and shrinkage.

Ultrasound imaging in urogynecology - state of the art 2016

The role of ultrasound imaging in urogynecology is not clearly defined. Despite significant developments in visualization techniques and interpretation of images, pelvic ultrasound is still more a tool for research than for clinical practice. Structures of the lower genitourinary tract and pelvic floor can be visualized from different approaches: transperineal, introital, transvaginal, abdominal or endoanal. According to contemporary guidelines and recommendations, the role of ultrasound in urogynecology is limited to the measurement of post-void residue. However, in many instances, including planning and audit of surgical procedures, management of recurrences or complications, ultrasound may be proposed as the initial examination of choice. Ultrasound may be used for assessment of bladder neck mobility before anti-incontinence procedures. On rare occasions it is helpful in recognition of pathologies mimicking vaginal prolapse such as vaginal cyst, urethral diverticula or rectal intussusception. In patients subjected to suburethral slings, causes of surgery failure or postsurgical voiding dysfunctions can be revealed by imaging. Many reports link the location of a tape close to the bladder neck to unfavorable outcomes of sling surgery. Some postoperative complications, such as urinary retention, mesh malposition, hematoma, or urinary tract injury, can be diagnosed by ultrasound. On the other hand, the clinical value of some applications of ultrasound in urogynecology, for example measurement of the bladder wall thickness as a marker of detrusor overactivity, has not been proved.

Host response to synthetic mesh in women with mesh complications

BACKGROUND

Despite good anatomic and functional outcomes, urogynecologic polypropylene meshes that are used to treat pelvic organ prolapse and stress urinary incontinence are associated with significant complications, most commonly mesh exposure and pain. Few studies have been performed that specifically focus on the host response to urogynecologic meshes. The macrophage has long been known to be the key cell type that mediates the foreign body response. Conceptually, macrophages that respond to a foreign body can be dichotomized broadly into M1 proinflammatory and M2 proremodeling subtypes. A prolonged M1 response is thought to result in chronic inflammation and the formation of foreign body giant cells with potential for ongoing tissue damage and destruction. Although a limited M2 predominant response is favorable for tissue integration and ingrowth, excessive M2 activity can lead to accelerated fibrillar matrix deposition and result in fibrosis and encapsulation of the mesh.

OBJECTIVE

The purpose of this study was to define and compare the macrophage response in patients who undergo mesh excision surgery for the indication of pain vs a mesh exposure.

STUDY DESIGN

Patients who were scheduled to undergo a surgical excision of mesh for pain or exposure at Magee-Womens Hospital were offered enrollment. Twenty-seven mesh-vagina complexes that were removed for the primary complaint of a mesh exposure (n = 15) vs pain in the absence of an exposure (n = 12) were compared with 30 full-thickness vaginal biopsy specimens from women who underwent benign gynecologic surgery without mesh. Macrophage M1 proinflammatory vs M2 proremodeling phenotypes were examined via immunofluorescent labeling for cell surface markers CD86 (M1) vs CD206 (M2) and M1 vs M2 cytokines via enzyme-linked immunosorbent assay. The amount of matrix metalloproteinase-2 (MMP-2) and matrix metalloproteinase-9 (MMP-9) proteolytic enzymes were quantified by zymography and substrate degradation assays, as an indication of tissue matrix degradation. Statistics were performed with the use of 1-way analysis of variance with appropriate post hoc tests, t-tests, and Fisher's Exact test.

RESULTS

Twenty-seven mesh-vaginal tissue complexes were excised from 27 different women with mesh complications: 15 incontinence mid urethral slings and 12 prolapse meshes. On histologic examination, macrophages surrounded each mesh fiber in both groups, with predominance of the M1 subtype. M1 and M2 cytokines/chemokines, MMP-9 (pro- and active), and MMP-2 (active) were increased significantly in mesh-vagina explants, as compared with vagina without mesh. Mesh explants that were removed for exposure had 88.4% higher pro-MMP-9 (P = .035) than those removed for pain. A positive correlation was observed between the profibrotic cytokine interleukin-10 and the percentage of M2 cells (r = 0.697; P = .037) in the pain group.

CONCLUSION

In women with complications, mesh induces a proinflammatory response that persists years after implantation. The increase in MMP-9 in mesh explants that were removed for exposure indicates degradation; the positive association between interleukin-10 and M2 macrophages in mesh explants that are removed for pain is consistent with fibrosis.

Role of ultrasound imaging in advancing treatment of female patients with pelvic floor mesh complications

Application of vaginal mesh for stress urinary incontinence has seen widespread use due to its relatively short operative time in combination with its efficacy in treatment. However, vaginal mesh is not without its drawbacks and can lead to mesh erosion or extrusion, infection, dyspareunia, and recurrence of incontinence. Vaginal mesh complications can lead to feelings of hopelessness, isolation, shame, and emotional distress. Furthermore, failure to identify and address these complications in a timely manner can be permanently damaging to patient health. It is vital to be able to identify mesh complications early. Various imaging methodologies exist to visualize vaginal mesh placement and complications, including ultrasound, magnetic resonance imaging (MRI), and computed tomography (CT). This invited review paper focuses on the role of ultrasound in mesh visualization, mesh complication identification, and operative planning in the event of subsequent surgical mesh revision. Polypropylene mesh is echogenic on ultrasound, making it a useful tool for visualizing post-operative mesh placement. Transperineal, translabial and endovaginal ultrasound technique use has been described in the pre- and peri-operative setting to identify mesh in complex cases. Efficacy and practicality of CT and MRI use in identifying mesh in these cases is limited.

Clinical and ultrasonographic study of patients presenting with transvaginal mesh complications

AIM

The objective of this study was to investigate the clinical and ultrasonographic findings of women who had three-dimensional endovaginal ultrasound (EVUS) for the management of vaginal mesh complications.

METHODS

This was a retrospective study of patients that had EVUS due to mesh complications at a tertiary care center. The clinical charts were reviewed. The stored 3D volumes were reviewed regarding mesh information by two examiners independently. The predictive value of physical examination for detection of vaginal mesh was calculated. Patient outcomes were reviewed.

RESULTS

Seventy-nine patients presented to our center because of their, or their physicians' concern regarding mesh complications. Forty-one (51.9%) had vaginal/pelvic pain, and 51/62 (82.2%) of sexually active women experienced dyspareunia. According to ultrasonographic findings, mesh or sling was not demonstrated in six patients who believed they have had mesh/sling implantation. The positive predictive value for vaginal examination was 94.5% (95% CI: 84.9%-98.8%), negative predictive value was 12.5% (95% CI: 2.8%-32.4%), sensitivity was 72.2% (95% CI: 59.4%-81.2%), and specificity was 50.0% (95% CI: 12.4%-87.6%). Fifty-four patients were indicated for surgical treatment. Median postoperative review was 12 (range, 3-18) months and 38/53 (71.7%) patients were satisfied.

CONCLUSIONS

The most common complaints of vaginal mesh complications were pain and dyspareunia. EVUS appeared to be helpful for assessing mesh presence, location, and extent including planning for surgical intervention.

Imaging of slings and meshes

The popularity of imaging in pelvic floor medicine continues to increase. Among the various modalities, ultrasound is superior as it is cheap, safe, easily accesible and simple, resulting in high patient compliance. It is the only technique that allows imaging of modern wide-weave polypropylene sling or mesh implants, and imaging of such implants is commonly required due to the popularity of surgical techniques that involve the placement of slings and meshes. This review article will discuss the role of translabial ultrasound in the evaluation of synthetic implants used in the treatment of urinary incontinence and pelvic organ prolapse.

Three-dimensional endovaginal sonography of synthetic implanted materials in the female pelvic floor

The objective of this pictorial essay is to emphasize the ability of 3-dimensional endovaginal sonography to image synthetic implanted materials in the female pelvic floor. Implanted materials discussed in this pictorial essay include polypropylene vaginal mesh, polypropylene suburethral slings, and urethral bulking agents. Three-dimensional endovaginal sonography allows for more detailed imaging compared to computed tomography and magnetic resonance imaging of the female pelvic floor, in that each plane can be manipulated to show unique images of synthetic implanted materials.

Mesh contraction: in vivo documentation of changes in apparent surface area utilizing meshes visible on magnetic resonance imaging in the rabbit abdominal wall model

INTRODUCTION AND HYPOTHESIS

Our aim was to analyze the apparent contraction of meshes in vivo after abdominal wall reconstruction and evaluate histological and biomechanical properties after explantation.

METHODS

Nine New Zealand female rabbits underwent repair of two full-thickness 25 × 30-mm midline defects in the upper and lower parts of the abdomen. These were primarily overlaid by 35 × 40-mm implants of a polyvinylidene fluoride (PVDF) DynaMesh (n = 6) or polypropylene meshes Ultrapro (n = 6) and Marlex (n = 6). Edges of the meshes were secured with iron(II,III) oxide (Fe(3)O(4))-loaded PVDF sutures. Magnetic resonance images (MRIs) were taken at days 2, 30 and 90 after implantation. The perimeter of the mesh was traced using a 3D spline curve. The apparent surface area or the area within the PVDF sutures was compared with the initial size using the one-sample t test. A two-way repeat analysis of variance (ANOVA) was used to compare the apparent surface area over time and between groups.

RESULTS

PVDF meshes and sutures with Fe(3)O(4) could be well visualized on MRI. DynaMesh and Marlex each had a 17 % decrease in apparent surface area by day 2 (p < 0.001 and p = 0.001), respectively, which persisted after day 90. Whereas there was a decrease in apparent surface area in Ultrapro, it did not reach significance until day 90 (p = 0.01). Overall, the apparent surface area decreased 21 % in all meshes by day 90. No differences in histological or biomechanical properties were observed at day 90.

CONCLUSIONS

There was a reduction in the apparent surface area between implantation and day 2, indicating that most mesh deformation occurs prior to tissue in-growth.

Mesh retraction correlates with vaginal pain and overactive bladder symptoms after anterior vaginal mesh repair

INTRODUCTION AND HYPOTHESIS

The aim of the present study was to determine possible correlations between mesh retraction after anterior vaginal mesh repair and de novo stress urinary incontinence (SUI), overactive bladder (OAB), and vaginal pain symptoms.

METHODS

One hundred and three women with symptomatic prolapse of the anterior vaginal wall, stages 3 and 4 based on the Pelvic Organ Prolapse Quantification (POP-Q) system, underwent Prolift anterior™ implantation. At a 6-month follow-up, the patients were interviewed for de novo SUI, OAB, and vaginal pain, and underwent an introital/transvaginal ultrasound examination to measure the mesh length in the midsagittal plane.

RESULTS

Mesh retraction was significantly larger in a subgroup of patients (n = 20; 19.4 %) presenting de novo OAB symptoms on the follow-up assessment compared with those without this complication (5.0 cm vs. 4.3 cm; p < 0.05). Mesh retraction was also significantly larger in a subgroup of patients (n = 23; 22.3 %) reporting postoperative vaginal pain compared with the women who did not report any postoperative vaginal pain (5.3 cm vs. 4.2 cm; p < 0.01). A significant correlation was found between mesh retraction and the severity of vaginal pain (R = 0.4, p < 0.01). Mesh retraction did not differ between patients with de novo SUI symptoms and those without this complication.

CONCLUSIONS

Mesh retraction assessed on ultrasound examination after anterior vaginal mesh repair may correlate with de novo OAB symptoms and vaginal pain.

Transvaginal mesh surgery for pelvic organ prolapse: one-year outcome analysis

OBJECTIVE

The aim of the study was to assess the role of Prolift + M (PP-PG) vaginal mesh surgery to correct uterovaginal prolapse not only from an anatomic but also a subjective (patient's) standpoint.

METHODS

A prospective cohort of subjects treated with transvaginal mesh for prolapse between April 2009 and November 2010 was analyzed. A composite score that included subjective criteria of absence of a bothersome bulge and objective criteria based on Pelvic Organ Prolapse Quantification lower than stage II was used to assess treatment success.

RESULTS

Transvaginal mesh was performed in 157 subjects (age, 64.7 ± 11.6 years; body mass index, 28.5 ± 4.8 kg/m) for pelvic organ prolapse. Five anterior mesh surgeries (3.2%), 48 posterior mesh surgeries (30.6%), and 104 total mesh surgeries (66.2%) were performed in subjects with stage II or greater degrees of prolapse. Stage II prolapse was noted in 44 subjects (28.0%), 91 subjects (58.0%) had stage III prolapse, and 22 subjects (14.0%) had stage IV prolapse. The mean follow-up was 13 months. Our composite success score was 88.1%. Pure anatomic success based on Pelvic Organ Prolapse Quantification lower than stage II was 94%. The mean operative time was 117.8 ± 42.4 minutes. The mean intraoperative blood loss was 106.1 ± 116.4 mL. There were 3 cases (2.2%) of mesh exposure in the vagina. There were no visceral injuries. The incidence of de novo dyspareunia was 6%.

CONCLUSION

Transvaginal PP-PG mesh surgery is safe and effective with few postoperative morbidities.

Vaginal placement of synthetic mesh for pelvic organ prolapse

Since 2004, use of synthetic mesh has increased in vaginal surgery for the treatment of pelvic organ prolapse. However, concerns exist about the safety and efficacy of transvaginally placed mesh. Based on the currently available limited data, although many patients undergoing mesh-augmented vaginal repairs heal well without problems, there seems to be a small but significant group of patients who experience permanent and life-altering sequelae, including pain and dyspareunia, from the use of vaginal mesh. The American College of Obstetricians and Gynecologists and the American Urogynecologic Society provide background information on the use of vaginally placed mesh for the treatment of pelvic organ prolapse and offer recommendations for practice.

Mesh contraction: myth or reality?

OBJECTIVE

Mesh implants are widely used in surgery for female pelvic organ prolapse. Mesh shrinkage is thought to be common and caused by immunological processes. In this longitudinal study, we examined mesh dimensions at 2 time points after implantation.

STUDY DESIGN

We analyzed translabial 4-dimensional ultrasound (US) volume datasets of women seen 3-52 months after anterior compartment mesh. Datasets of first and last postoperative appointments were analyzed, with the operator blinded against all other data.

RESULTS

Forty women were assessed at least twice, comprising 59.6 woman-years. Thirty-seven of 40 (93%) were satisfied at their last appointment. Eighteen of 40 considered themselves cured, and 18 of 40 felt improved. Objective recurrence (cystocele stage 2 or greater) was seen in 16 of 40. Midsagittal mesh length increased significantly (35.8 vs 32.7; P = .006), and coronal mesh diameters increased nonsignificantly (37.4 vs 36.6 mm; P = .44).

CONCLUSION

Over an observation period of almost 60 woman-years, we found no evidence of mesh contraction.

Ultrasound appearances after mesh implantation--evidence of mesh contraction or folding?

INTRODUCTION AND HYPOTHESIS

Polypropylene meshes are frequently used in abdominal and vaginal reconstructive surgery. Recently, several authors have claimed that mesh-associated complications may be linked to mesh shrinkage. We have performed a prospective study with postoperative follow-up by ultrasound examination at two time points after Prolift anterior implantation to assess changes in the ultrasound appearance of mesh implants over time.

METHODS

We assessed 36 patients who had undergone mesh implantation with Prolift anterior mesh for the correction of symptomatic anterior vaginal wall prolapse. During the surgery, we measured the actual midline length of the mesh (initial length). On the fourth postoperative day, we performed a vaginal ultrasound examination (US) to measure mesh length in the midsagittal plane. A second US was performed 3-5 months after surgery to repeat this measurement.

RESULTS

There was a significant difference in mesh length determined before and 4 days after surgery (90.3 vs. 57.1 mm, P = <0.0001) indicating intraoperative folding. On comparing early and late postoperative ultrasound measurements, there was a reduction in length from 57.1 to 48.3 mm (P < 0.0001), indicating possible shrinkage or retraction.

CONCLUSIONS

Intraoperative folding seems to be responsible for a large part of the difference between preoperative (in vitro) and postoperative (US) measurements of mesh dimensions, suggesting that surgical techniques may require adjustment.