Prolapse repair by vaginal route using a new protected low-weight polypropylene mesh: 1-year functional and anatomical outcome in a prospective multicentre study

Films for Wound Healing Fabricated Using a Solvent Casting Technique

Wound healing is a complex process that involves restoring the structure of damaged tissues through four phases: hemostasis, inflammation, proliferation, and remodeling. Wound dressings are the most common treatment used to cover wounds, reduce infection risk and the loss of physiological fluids, and enhance wound healing. Despite there being several types of wound dressings based on different materials and fabricated through various techniques, polymeric films have been widely employed due to their biocompatibility and low immunogenicity. Furthermore, they are non-invasive, easy to apply, allow gas exchange, and can be transparent. Among different methods for designing polymeric films, solvent casting represents a reliable, preferable, and highly used technique due to its easygoing and relatively low-cost procedure compared to sophisticated methods such as spin coating, microfluidic spinning, or 3D printing. Therefore, this review focuses on the polymeric dressings obtained using this technique, emphasizing the critical manufacturing factors related to pharmaceuticals, specifically discussing the formulation variables necessary to create wound dressings that demonstrate effective performance.

Improvement in dyspareunia after vaginal mesh removal measured by a validated questionnaire

INTRODUCTION AND HYPOTHESIS

The objective was to examine the effect of the surgical removal of vaginally placed prolapse and incontinence mesh on sexual function. We hypothesize that patients with painful complications of mesh will experience improvement in dyspareunia and sexual function after mesh removal.

METHODS

The eligible cohort consisted of 133 women who presented with a new onset of pain attributed to mesh-augmented incontinence or prolapse surgery and who elected to undergo mesh removal between 1 August 2012 and 1 July 2013. Sexual function symptoms were assessed before and after mesh removal surgery using the Pelvic Organ Prolapse and Urinary Incontinence Sexual Function Questionnaire short form (PISQ-12). Multivariate analysis was performed to identify predictors of improvement in dyspareunia.

RESULTS

Ninety-four patients undergoing mesh removal completed a pre-operative questionnaire, 63 of whom also completed a post-operative questionnaire. After mesh removal, there was a nearly 50% reduction in the proportion of women reporting always experiencing post-operative pain with intercourse among those experiencing pre-operative pain. There was a statistically significant quantitative improvement in pain with intercourse after mesh removal based on mean change score of PISQ-12 question 5 "How often do you experience pain with intercourse?". In multivariate analysis, only history of vaginal delivery was associated with symptom improvement.

CONCLUSION

Removal of transvaginal prolapse mesh is associated with improvement in self-reported dyspareunia based on a standardized question on a validated instrument in a small cohort of women. Although larger studies are needed to confirm the relationship between mesh-augmented surgeries and post-procedural dyspareunia, these data suggest that consideration of mesh removal is a reasonable step for patients with painful intercourse attributed to mesh-augmented prolapse and incontinence surgeries.

Update in Transvaginal Grafts: The Role of Lightweight Meshes, Biologics, and Hybrid Grafts in Pelvic Organ Prolapse Surgery

Transvaginal mesh/grafts have been popularized over the past 20 years in an attempt to improve the longevity of traditional vaginal pelvic organ prolapse (POP) surgery. Several national bodies have concluded that the proposed benefits of mesh/graft implantation are outweighed by the significant increase in surgery complications related to these products. As a consequence mesh products for vaginal POP surgery have been withdrawn from use in many countries. This article is a narrative review of newer mesh and graft products including lightweight polypropylene mesh products, biological grafts, hybrid grafts, and tissue engineered grafts.

International Urogynecology Consultation Chapter 1 Committee 5: relationship of pelvic organ prolapse to associated pelvic floor dysfunction symptoms: lower urinary tract, bowel, sexual dysfunction and abdominopelvic pain

INTRODUCTION AND HYPOTHESIS

This article from Chapter 1 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) establishes the prevalence of lower urinary tract disorders, bowel symptoms, vulvo-vaginal/lower abdominal/back pain and sexual dysfunction in women with POP.

METHODS

An international group of nine urogynecologists/urologists and one medical student performed a search of the literature using pre-specified search terms in Ovid, MEDLINE, Embase and CINAHL from January 2000 to March 2019. Publications were eliminated if not relevant or they did not include clear definitions of POP or the symptoms associated with POP. Definitions of POP needed to include both a physical examination finding using a validated examination technique and the complaint of a bothersome vaginal bulge. Symptoms were categorized into symptom groups for ease of evaluation. The Specialist Unit for Review Evidence (SURE) was used to evaluate for quality of the included articles. The resulting list of articles was used to determine the prevalence of various symptoms in women with POP. Cohort studies were used to evaluate for possible causation of POP as either causing or worsening the symptom category.

RESULTS

The original search yielded over 12,000 references, of which 50 were used. More than 50% of women with POP report lower urinary tract symptoms. Cohort studies suggest that women with POP have more obstructive lower urinary tract symptoms than women without POP. Pain described in various ways is frequently reported in women with POP, with low back pain being the most common pain symptom reported in 45% of women with POP. In cohort studies those with POP had more pain complaints than those without POP. Sexual dysfunction is reported by over half of women with POP and obstructed intercourse in 37-100% of women with POP. Approximately 40% of women have complaints of bowel symptoms. There was no difference in the median prevalence of bowel symptoms in those with and without POP in cohort studies.

CONCLUSIONS

The prevalence of lower urinary tract disorders, bowel symptoms, vulvo-vaginal/lower abdominal/back pain and sexual dysfunction in women with POP are common but inconsistently reported. There are few data on incidence of associated symptoms with POP, and cohort studies evaluating causality are rare or inconsistent. Obstructive voiding, lower abdominal and pelvic pain, and sexual dysfunction are most frequently associated with POP.

Do we have adequate data to construct a valid algorithm for management of synthetic midurethral sling complications? ICI-RS 2019

BACKGROUND

Synthetic midurethral sling (MUS) procedures, purported for the last two decades as the gold standard surgical treatment for stress urinary incontinence, have been in creasingly scrutinized in recent years with regard to the rate and severity of complications.

METHODS

During the International Consultation on Incontinence Research Society meeting held in Bristol, UK, in 2019, a multidisciplinary panel held a think tank and discussed the contemporary evidence pertaining to the classification, investigation, and treatment of MUS complications.

RESULTS

The current classification system of mesh-related complications was discussed, and shortcomings were identified. The lack of a standardized clinical pathway was noted, and the value of clinical investigations and surgical treatments was difficult to fully evaluate. The paucity of high-level evidence was a common factor in all discussions, and the difficulties with setting up relevant randomized-controlled trials were highlighted.

CONCLUSIONS

The outcome of the think-tank discussions is summarized with a set of recommendations designed to stimulate future research.

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.

Alterations of Vascular Endothelial Growth Factor A Expression and Microvessel Density Associated With Polypropylene Vaginal Mesh

OBJECTIVE

Vaginal mesh exposure is the most common complication from mesh use in prolapse and incontinence surgery. Angiogenesis is an essential component of tissue healing, and defective angiogenesis plays a role in chronic wounds. We hypothesized that patients with exposures will have impaired angiogenesis as evidenced by altered tissue vascular endothelial growth factor A (VEGFA) expression and microvessel density. The study objective was to compare angiogenesis in women with vaginal mesh exposures, those with vaginal mesh without exposures, and in women who were mesh-naive.

METHODS

Patients undergoing polypropylene mesh removal and patients without mesh undergoing urinary incontinence or prolapse surgery were recruited. Full-thickness vaginal epithelial biopsies were obtained. The relative abundance of VEGFA RNA was measured with reverse transcription-polymerase chain reaction. The VEGFA and CD31 immunohistochemistry were also performed.

RESULTS

Ninety-two subjects were enrolled and biopsied. Mean age (SD) was 57.2 (12.8) years, 16 (17.4%) were smokers, and 68 (73.9%) were postmenopausal.The VEGFA RNA expression did not differ between subjects with mesh exposure and with mesh but no exposure (P = 0.89). However, compared with subjects with no mesh, vaginal VEGFA expression was decreased in subjects with any implanted mesh (relative expression, 0.72; P = 0.02). Microvessel density was increased in subjects with mesh exposure compared with subjects with no mesh (P < 0.01). The VEGFA expression by immunohistochemistry was significantly lower in postmenopausal subjects without estrogen treatment compared with premenopausal and postmenopausal subjects being treated with estrogen (P = 0.02).

CONCLUSIONS

The presence of polypropylene mesh and hormonal status are associated with evidence of altered angiogenesis.

Graft and Mesh Use in Transvaginal Prolapse Repair: A Systematic Review

OBJECTIVE

To update clinical practice guidelines on graft and mesh use in transvaginal pelvic organ prolapse repair based on systematic review.

DATA SOURCES

Eligible studies, published through April 2015, were retrieved through ClinicalTrials.gov, MEDLINE, and Cochrane databases and bibliography searches.

METHODS OF STUDY SELECTION

We included studies of transvaginal prolapse repair that compared graft or mesh use with either native tissue repair or use of a different graft or mesh with anatomic and symptomatic outcomes with a minimum of 12 months of follow-up.

TABULATION, INTEGRATION, AND RESULTS

Study data were extracted by one reviewer and confirmed by a second reviewer. Studies were classified by vaginal compartment (anterior, posterior, apical, or multiple), graft type (biologic, synthetic absorbable, synthetic nonabsorbable), and outcome (anatomic, symptomatic, sexual function, mesh complications, and return to the operating room). We found 66 comparative studies reported in 70 articles, including 38 randomized trials; quality of the literature has improved over time, but some outcomes still show heterogeneity and limited power. In the anterior vaginal compartment, synthetic nonabsorbable mesh consistently showed improved anatomic and bulge symptom outcomes compared with native tissue repairs based on meta-analyses. Other subjective outcomes, including urinary incontinence or dyspareunia, generally did not differ. Biologic graft or synthetic absorbable mesh use did not provide an advantage in any compartment. Synthetic mesh use in the posterior or apical compartments did not improve success. Mesh erosion rates ranged from 1.4-19% at the anterior vaginal wall, but 3-36% when mesh was placed in multiple compartments. Operative mesh revision rates ranged from 3-8%.

CONCLUSION

Synthetic mesh augmentation of anterior wall prolapse repair improves anatomic outcomes and bulge symptoms compared with native tissue repair. Biologic grafts do not improve prolapse repair outcomes in any compartment. Mesh erosion occurred in up to 36% of patients, but reoperation rates were low.

Diagnosis and Therapy of Female Pelvic Organ Prolapse. Guideline of the DGGG, SGGG and OEGGG (S2e-Level, AWMF Registry Number 015/006, April 2016)

Aims: The aim was to establish an official interdisciplinary guideline, published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). The guideline was developed for use in German-speaking countries. In addition to the Germany Society of Gynecology and Obstetrics, the guideline has also been approved by the Swiss Society of Gynecology and Obstetrics (SGGG) and the Austrian Society of Gynecology and Obstetrics (OEGGG). This is a guideline published and coordinated by the DGGG. The aim is to provide evidence-based recommendations obtained by evaluating the relevant literature for the diagnostic, conservative and surgical treatment of women with female pelvic organ prolapse with or without stress incontinence. Methods: We conducted a systematic review together with a synthesis of data and meta-analyses, where feasible. MEDLINE, Embase, Cinahl, Pedro and the Cochrane Register were searched for relevant articles. Reference lists were hand-searched, as were the abstracts of the Annual Meetings of the International Continence Society and the International Urogynecological Association. We included only abstracts of randomized controlled trials that were presented and discussed in podium sessions. We assessed original data on surgical procedures published since 2008 with a minimum follow-up time of at least 12 months. If the studies included descriptions of perioperative complications, this minimum follow-up period did not apply. Recommendations: The guideline encompasses recommendations for the diagnosis and treatment of female pelvic organ prolapse. Recommendations for anterior, posterior and apical pelvic organ prolapse with or without concomitant stress urinary incontinence, uterine preservation options, and the pros and cons of mesh placements during surgery for pelvic organ prolapse are presented. The recommendations are based on an extensive and systematic review and evaluation of the current literature and include the experiences and specific conditions in Germany, Austria and Switzerland.

Analysis of changes in sexual function in women undergoing pelvic organ prolapse repair with abdominal or vaginal approaches

INTRODUCTION AND HYPOTHESIS

To examine changes in sexual function after abdominal and transvaginal pelvic organ prolapse repair.

METHODS

Women enrolled in our prospective, longitudinal prolapse database with abdominal sacrocolpopexy (ASC) or transvaginal (TVR) pelvic organ prolapse (POP) repair with or without mesh, between 19 December 2008 through 4 June 2014. The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) and the Pelvic Floor Distress Inventory (PFDI -20) were mailed preoperatively, and at 6 and 12 months postoperatively. Patients completed Global Response Assessments to rate their overall satisfaction.

RESULTS

Two hundred and four of the 300 women met the inclusion criteria: 74 out of 204 (36 %) had ASC and 130 out of 204 (64 %) had TVR. Seventy-two out of seventy-four ASCs were performed robotically and 2 were open. Baseline demographics were similar except that the ASC patients were significantly younger (60 vs 63, P = 0.019) and had a higher rate of apical repair (77 % vs 55 %). Thirty-six out of seventy-four ASC (48.7 %) and 63 out of 128 TVR patients (49.2 %) were sexually active at baseline (P = 0.94). Sixteen out of thirty-eight ASC (42.1 %) and 18 out 63 TVR patients (28.6 %; P = 0.16) reported dyspareunia at baseline. Seventy-two out of seventy-four ASC (97 %) and 86 out of 130 TVR patients (66 %) had mesh-augmented repairs. There was no difference in sexual activity or dyspareunia between the groups at the 6- or 12-month follow-up. PISQ and PFDI scores improved significantly in both the ASC and TVR groups over time compared with the baseline (p < 0.0001). Most women in the ASC (77.5 %) and TVR (64.8 %) groups were satisfied with the results of prolapse surgery at 12 months.

CONCLUSIONS

Sexual function and pelvic floor symptoms improved in a similar manner in patients after abdominal and transvaginal POP surgery.

Determination of a Central Avascular Triangle within the Obturator Foramen: A Radioanatomic Study

PURPOSE

To map the vascular anatomy of the obturator foramen using fixed anatomic landmarks.

METHOD

Twenty obturator regions were dissected in 10 fresh female cadavers after vascular blue dye injection in five cadavers (50%). Furthermore, 104 obturator regions were reconstructed by angiotomodensitometry from 52 women under investigation for suspected arterial disease. The anatomy of the obturator region was mapped by measuring the distance of vascular structures from the middle of the two branches of the ischiopubic bone, which were used as fixed landmarks.

RESULTS

The bifurcation of the obturator artery was at a mean (SD) distance of 30.0 mm (4.5) from the middle of the ischiopubic branch (MISP). The anterior branch of the obturator vessels was 15.2 mm (10.1) from the MISP. The posterior branch of the obturator vessels was 5.5 mm (4.0) and 23.6 mm (8.7) from the middle of the outer edge of the obturator foramen (MOE) and the MISP, respectively. Using 5° and 95° percentiles of these measurements we defined a central avascular triangle.

CONCLUSIONS

Our data show that, beyond inter-individual variations, a central triangular avascular area can be identified in the obturator foramen between the posterior and anterior obturator artery using fixed landmarks.

A nonlinear-elastic constitutive model for soft connective tissue based on a histologic description: Application to female pelvic soft tissue

To understand the mechanical behavior of soft tissues, two fields of science are essential: biomechanics and histology. Nonetheless, those two fields have not yet been studied together often enough to be unified by a comprehensive model. This study attempts to produce such model. Biomechanical uniaxial tension tests were performed on vaginal tissues from 7 patients undergoing surgery. In parallel, vaginal tissue from the same patients was histologically assessed to determine the elastic fiber ratio. These observations demonstrated a relationship between the stiffness of tissue and its elastin content. To extend this study, a mechanical model, based on an histologic description, was developed to quantitatively correlate the mechanical behavior of vaginal tissue to its elastic fiber content. A satisfactory single-parameter model was developed assuming that the mechanical behavior of collagen and elastin was the same for all patients and that tissues are only composed of collagen and elastin. This single-parameter model showed good correlation with experimental results. The single-parameter mechanical model described here, based on histological description, could be very useful in helping to understand and better describe soft tissues with a view to their characterization. The mechanical behavior of a tissue can thus be determined thanks to its elastin content without introducing too many unidentified parameters.

New strategies to improve results of mesh surgeries for vaginal prolapses repair--an update

The use of meshes has become the first option for the treatment of soft tissue disorders as hernias and stress urinary incontinence and widely used in vaginal prolapse's treatment. However, complications related to mesh issues cannot be neglected. Various strategies have been used to improve tissue integration of prosthetic meshes and reduce related complications. The aim of this review is to present the state of art of mesh innovations, presenting the whole arsenal which has been studied worldwide since composite meshes, coated meshes, collagen's derived meshes and tissue engineered prostheses, with focus on its biocompatibility and technical innovations, especially for vaginal prolapse surgery.

Transvaginal repair of stage III-IV cystocele using a lightweight mesh: safety and 36-month outcome

INTRODUCTION AND HYPOTHESIS

The aim of this study was to assess the 36-month safety and efficacy of a lightweight polypropylene mesh used for the transvaginal repair of stage III-IV cystocele.

METHODS

A multicenter prospective cohort study was performed. Preoperative assessment included an interview and evaluation with the Pelvic Organ Prolapse Quantification (POP-Q) system. Inclusion criteria were stage III-IV cystocele and no contraindications for mesh use. A lightweight (28 g/m(2)) four-arm transobturator polypropylene mesh was used for the study. Pre- and postoperative symptoms and quality of life were assessed using the Urinary Symptoms Measurement (MHU), Pelvic Floor Distress Inventory (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7), and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). The main endpoint was mesh safety. Secondary endpoints were anatomic (Ba point ≤ -1) and functional success.

RESULTS

In all, 111 patients with a mean age of 67 ± 9 years (range 47-89) were included in the study, and 94 (84.7%) were included in the analysis. Two intraoperative complications occurred (one bladder and one rectal injury, 2.2%). Medium-term analysis of 79 patients (84%) after 36 months showed a satisfaction rate of 98.7% (78/79), a mesh contraction rate of 5.1% (4/78), only one case of vaginal mesh exposure (1.3%), no cases of chronic pelvic pain, and a postoperative dyspareunia rate of 2.8% (1/36). The anatomic success rate of cystocele repair was 75/79 (94.9%) and a highly significant improvement was noted for symptoms and on quality of life questionnaires. Overall, 7/79 patients (8.9%) were reoperated, including 1 for hemorrhage, 1 for vaginal mesh exposure, 3 for stress urinary incontinence, and 2 for cystocele recurrence (2.5%).

CONCLUSION

Transvaginal cystocele repair using a lightweight transobturator polypropylene mesh was safe and efficient in the medium term. Long-term data and comparative studies are needed.

Management of pelvic organ prolapse

Quality of life is adversely affected by pelvic organ prolapse, the prevalence of which is increasing because of the persistently growing older population. Today, the tension-free vaginal mesh kit has grown in popularity owing to its comparable cure rate to traditional reconstructive surgery and the feasibility of an early return to normal life. However, significant debate remains over the long-term cure rate and the safety of tension-free vaginal mesh in the United States. The U.S. Food and Drug Administration recommends obtaining informed consent about the safety and cure rate when the patient chooses surgery using the tension-free vaginal mesh kit or meshes before surgery. The goal of surgery for pelvic organ prolapse is the restoration of anatomic defects. This review article provides an overview of basic surgical techniques and the results, advantages, and disadvantages of surgery for pelvic organ prolapse.

[Linguistic validation of Japanese version of Prolapse/Urinary Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR)]

PURPOSE

To translate the Prolapse/Urinary Incontinence Sexual Questionnaire, IUGA-Revised (PISQ-IR) into Japanese and evaluate the linguistic validation of the translated PISQ-IR.

METHODS

The translation and evaluation of PISQ-IR were performed through 3 steps: forward translation based on 2 urologists and discussed by another 4 urologists, 1 pharmacoeconomist and 1 nurse; the community review process consists of conducting one-on-one cognitive interviews with 20 patients by a professional interviewer; backward translation by a native English speaker, which was negotiated with the PISQ-IR Working Group comprised original authors in International Urogynecological Association (IUGA).

RESULTS

The PISQ-IR Working Group generally approved our translation and had 2 major concerns in the Japanese version; 1) "disagree" in every sentence of English version was not translated into Japanese, and 2) the Japanese expression in "sexual desire" should be more emotional. The former concern was approved by explaining that Japanese does not have the word which is the equivalent of "disagree", and "don't agree" is always used instead of "disagree". The latter concern was compromised by switching to a translation using emotional words.

CONCLUSION

The Japanese version of PISQ-IR was translated in a linguistically valid manner. It would be equivalent to the original English questionnaire. It may provide a tool to assess sexual function for Japanese women with prolapse, urinary incontinence and/or fecal incontinence in an internationally harmonized fashion.

Complications of pelvic organ prolapse surgery and methods of prevention

INTRODUCTION AND HYPOTHESIS

The aim was to review complications associated with pelvic organ prolapse surgery.

METHODS

Every 4 years and as part of the Fifth International Collaboration on Incontinence we reviewed the English-language scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials [RCT] or systematic reviews), level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 (case reports). The highest level of evidence was utilised by the committee to make evidence-based recommendations based upon the Oxford grading system. Grade A recommendation usually depends on consistent level 1 evidence. Grade B recommendation usually depends on consistent level 2 and/or 3 studies, or "majority evidence" from RCTs. Grade C recommendation usually depends on level 4 studies or "majority evidence from level 2/3 studies or Delphi processed expert opinion. Grade D "no recommendation possible" would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi.

RESULTS AND CONCLUSIONS

Transvaginal mesh has a higher re-operation rate than native tissue vaginal repairs (grade A). If a synthetic mesh is placed via the vaginal route, it is recommended that a macroporous polypropylene monofilament mesh should be used. At sacral colpopexy mesh should not be introduced or sutured via the vaginal route and silicone-coated polyester, porcine dermis, fascia lata and polytetrafluoroethylene meshes are not recommended as grafts. Hysterectomy should also be avoided (grade B). There is no evidence to recommend routine local or systemic oestrogen therapy before or after prolapse surgery using mesh. The first cases should be undertaken with the guidance of an experienced surgeon in the relevant technique (grade C). Expert opinion suggests that by whatever the surgical route pre-operative urinary tract infections are treated, smoking is ceased and antibiotic prophylaxis is undertaken. It is recommended that a non-absorbable synthetic mesh should not be inserted into the rectovaginal septum when a rectal injury occurs. The placement of a non-absorbable synthetic mesh into the vesicovaginal septum may be considered after a bladder injury has been repaired, if the repair is considered to be satisfactory. It is possible to perform a hysterectomy in association with the introduction of a non-absorbable synthetic mesh inserted vaginally, but this is not recommended routinely.

MRI findings before and after prolapse surgery

BACKGROUND

Therapeutical outcome after prolapse surgery is evaluated using a standardized grading system based on maximum prolapse extent, which might not provide the full picture of the patient's subjective outcome. We therefore applied an evaluation method, which is detached from a grading system.

PURPOSE

To evaluate the impact of pelvic organ mobility in dynamic magnetic resonance imaging (MRI) before and after mesh-repair surgery in patients with symptomatic pelvic organ prolapse.

MATERIAL AND METHODS

To obtain measurements, we performed parasagittal T2-weighted turbo spin echo sequence at rest (TR, 3460 ms; TE, 85 ms; matrix, 512; slice thickness [ST], 5 mm), parasagittal T2-weighted true fast imaging with steady-state precession (TrueFISP) single-shot sequence during straining (TR, 397.4 ms; TE, 1.5 ms; matrix, 256; ST, 8 mm), and parasagittal T2-weighted TrueFISP sequence at maximum strain (TR, 4.3 ms; TE, 2.15 ms; matrix, 256; ST, 5 mm) at 1.5 T MRI. Pelvic organ prolapse (anatomical landmarks: bladder, cervix, pouch, rectum) was measured perpendicularly with reference to the pubococcygeal and the midpubic line. Pelvic organ mobility was defined as the difference between the measured distance at rest and at maximum strain for each anatomical landmark. All patients underwent mesh-repair procedure. Eighty patients could be included in this short-term follow-up study. Due to the physical diagnosis of pelvic organ prolapse, 51 underwent anterior mesh repair, 16 underwent posterior mesh repair, and 13 underwent total mesh repair. Surgery was performed by one surgeon, using mesh implants from several manufacturers.

RESULTS

Median values of maximum organ prolapse for bladder, cervix, pouch, and rectum preoperatively were 2.54 cm, 0.33 cm, 2.47 cm, and 0.32 cm, respectively, and 12 weeks postoperatively 0.87 cm, -1.79 cm, 1.49 cm, and 0.49 cm, respectively. Highly significant improvement (P < 0.001) of pelvic organ mobility was observed in the treated compartment at 4- and 12-week follow-up. Physical evaluation 12 weeks after mesh-repair showed an asymptomatic POP-Q stage I, if any.

CONCLUSION

Dynamic MRI is useful in visualizing the maximum extent of pelvic organ prolapse, as the evaluation of pelvic organ mobility documents the intraindividual therapeutic outcome detached from a grading system based on maximal prolapse values.

Anatomical Position of Four Different Transobturator Mesh Implants for Female Anterior Prolapse Repair

Purpose: Polypropylene mesh implants are frequently used for pelvic floor reconstruction in women. Yet they vary in size and fixation. The purpose of this study is to compare four mesh products with regard to their anatomical positioning and functionality within the pelvic floor, to determine whether each mesh fits equally well in a female cadaver. Methods: One female pelvis was dissected, opening the retropubic space exposing the endopelvic fascia and demonstrating the arcus tendineus fasciae pelvis (ATFP). Anatomical parameters were measured before and after implanting four meshes via the transobturator approach. Results: The anterior fixation of the ATFP was found to be 5 mm lateral to the symphysis in this cadaver. The endopelvic fascia covered 54.6 cm². The obturator nerve was located 35 mm from the white line. The distance of the proximal and lateral points of mesh fixation from the ischial spine or ATFP varied from 0 to 25 mm. The meshes varied in size and anatomical positioning. Conclusion: These observations demonstrate the necessity of developing optimally sized meshes and appropriate introducer techniques that can provide sufficient vaginal support. Surgeons, furthermore, need profound knowledge of anatomy, the patient's pelvic floor defect and the meshes available on the market.

Assessment of collagen-coated anterior mesh through morphology and clinical outcomes in pelvic reconstructive surgery for pelvic organ prolapse

STUDY OBJECTIVE

To assess the morphologic features of anterior armed transobturator collagen-coated polypropylene mesh and its clinical outcomes in pelvic reconstructive surgery to treat pelvic organ prolapse.

DESIGN

Evidence obtained from several timed series with intervention (Canadian Task Force classification II-3).

SETTING

Chang Gung Memorial Hospital, Taoyuan, Taiwan, China.

PATIENTS

Between April 2010 and October 2012, 70 patients underwent surgery to treat symptomatic pelvic organ prolapse, stage III/IV according to the POP-Q (Pelvic Organ Quantification System).

INTERVENTION

Anterior armed transobturator collagen-coated mesh.

MEASUREMENT AND MAIN RESULTS

Morphologic findings and clinical outcome were measured. Morphologic features were assessed via 2-dimensional introital ultrasonography and Doppler studies. Clinical outcome was measured via subjective and objective outcome. Objective outcome was assessed via the 9-point site-specific staging method of the International Continence Society Pelvic Organ Prolapse Quantification before the operation and at 1-year postoperative follow-up. Subjective outcome was based on 4 validated questionnaires: the 6-item UDI-6 (Urogenital Distress Inventory), the 7-item IIQ-7 (Incontinence Impact Questionnaire), the 6-item POPDI-6 (Pelvic Organ Prolapse Distress Inventory 6), and the 12-item PISQ-12 (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire), at baseline and at 12 months after the operation. Data were obtained for 65 patients who underwent the combined surgery and were able to comply with follow-up for >1 year. Ultrasound studies reveal that mesh length tends to shorten and decrease in thickness over the 1-year follow-up. Vagina thickness also was reduced. Neovascularization through the mesh was observed in <8.5% of patients in the first month and at 1 year, and was evident in approximately 83%. The mesh exposure rate was 6.4%. The recorded objective cure was 90.8% (59 of 65 patients), and subjective cure was 89.2% (58 of 65 patients) at mean (SD) follow-up of 19.40 (10.98) months. At 2 years, UDI-6, IIQ-7, and POPDI-6 scores were all significantly decreased (p < .001), whereas the PISQ-12 score was significantly increased (p = .01).

CONCLUSIONS

Ultrasound features suggest that the degeneration of collagen barrier may be longer than expected and that integration of collagen-coated mesh could occur up to 1 year. A substantially good clinical outcome was noted.

A comparison of the incidence of early postoperative infections between patients using synthetic mesh and those undergoing traditional pelvic reconstructive surgical procedures

New mesh-related complications such as erosion, etc., can result from abnormal postoperative healing due to surgical site infection. The aim of our study was to compare systemic inflammatory responses and the incidence of early infectious complications after reconstructive surgery using synthetic mesh and after traditional vaginal wall repair. In this prospective observational study 99 women with symptomatic pelvic organ prolapse were included; 55 women underwent traditional repair and 44 repair using mesh. After the procedure infectious complications were monitored. The patients who underwent reconstructive surgery using mesh material were more likely to have febrile morbidity in the postoperative period than the patients who had been treated with traditional repair (p=0.031); there was a higher incidence of combination febrile morbidity with elevated C-reactive protein (CRP) > 50 mg/l; p=0.046, and a higher incidence of CRP increase over 30 mg/l; p=0.005. Reconstructive procedures using synthetic mesh are accompanied by a higher incidence of early post-operative infectious complications.

Can the PFDI (Pelvic Floor Distress Inventory) or PFIQ (Pelvic Floor Impact Questionnaires) be used to predict outcome in pelvic reconstructive surgery?

OBJECTIVE

To determine a syndrome score threshold on PFDI or PFIQ predictive of a significant improvement in post-operative functional results.

DESIGN

A retrospective case review (Canadian Task Force Classification II-2).

SETTING

University and research hospital.

POPULATION

Women diagnosed with pelvic organ prolapse and repaired with synthetic vaginal mesh.

METHODS

Quality of life was arbitrarily considered to have improved significantly if the score decreases by more than 50% between pre-operatively and 36 months post-operatively. We investigated the pre-operative cut-off score predictive of no quality of life improvement at M36 from a prospective trial for surgical pelvic organ prolapse treatment.

RESULTS

The most accurate pre-operative cut-off score predicting a failure to improve quality of life at 36 months post-operatively was 62/300 (PFDI Score). This cut-off value had a positive predictive value of 83.6% and specificity of 62.1%. No significant threshold was obtained from the PFIQ score.

CONCLUSION

The intensity of symptoms before surgery may interfere as a predictive factor for outcome.

[Safety and 12-month results on stage 3-4 cystocele repair by the vaginal route using a light-weight mesh]

OBJECTIVE

To assess safety and efficacy at short-term of a light-weight polypropylene mesh (28 g/m2) for stage 3-4 cystocele repair by the vaginal route.

MATERIAL AND METHODS

A multicentric prospective cohort study, performed between 2010 and 2011 in seven centers. Pre-operative assessment included prolapse quantification using the POP-Q. Pre- and postoperative validated symptoms and quality of life questionnaires were used. Main objective was mesh safety. Secondary objectives were anatomical and functional success.

RESULTS

One hundred and eleven patients, with a mean age of 67±9 years, were included in the study, and 94 were included in the analysis (84.7%). In 14 cases (12.8%), it was a secondary surgery. Two intra-operative complications occurred (2.2%). Safety analysis on 86 patients followed up at 12 months (91.5%) has shown satisfaction rate of 98.8% (85/86), mesh contraction rate of 9.3% (8/86), one case of vaginal mesh exposure (1.2%), no cases of pelvic pain and rate of postoperative dyspareunia of 5.5% (3/55). Anatomic success rate on cystocele (Ba point < -1) at short-term was 82/86 (95.3%) and improvement of symptoms and quality of life was highly significant. Five patients (5.3%) were reoperated.

CONCLUSION

Cystocele repair by the vaginal route using a light-weight transobturator polypropylene mesh was safe and efficient at short-term. Long-term data are needed.

[Utero-vaginal suspension using a bilateral vaginal anterior sacrospinous fixation with mesh. Preliminary results]

OBJECTIVE

To assess anatomical and functional preliminary results, and safety of a new surgical approach for a combined treatment of pelvic organ prolapse (POP) of anterior and medium compartments, using a mesh attached through the sacrospinous ligaments with the UpHold(®) system (Boston Scientific) and the Capio(®).

MATERIAL AND METHODS

A longitudinal case series of 59 consecutive patients operated between October 2009 and January 2012, by five senior surgeons in a single tertiary unit.

RESULTS

Mean age was 66.9 years. Ten patients (17%) had previous pelvic organ prolapse (POP) surgery. There was no intraoperative complication. Mean follow-up was 12 months. Anatomical success for both anterior and apical compartments, i.e. Ba and C/D point<1, was 93% (52/56). Anatomical results shown correction of cystocele with a mean Ba point from+0.79 cm (range -3 to +8) to -2.35 cm (range -3 to 0), correction of uterine/vaul prolapse with a mean C/D point from+0.14 cm (range -6 to+8) to -7.29 cm (range -9 to -1), and correction of rectocele with a mean Bp point from -0.68 cm (range -3 to 7) to -2.77 cm (range -3 to -1). Two patients required further surgery for mesh exposure (3.5%). One patient had a unilateral pudendal neuropathic pain postoperatively.

CONCLUSION

In the current series, utero-vaginal suspension using a bilateral vaginal anterior sacrospinous fixation with mesh was associated with good anatomical success rates. Prospective, comparative and long-term data are needed.

Transvaginal posterior colporrhaphy combined with laparoscopic ventral mesh rectopexy for isolated Grade III rectocele: a prospective study of 27 patients

AIM

The aim of this study was to evaluate prospectively transvaginal posterior colporrhaphy (TPC) combined with laparoscopic ventral mesh rectopexy (LVR) in patients with a symptomatic isolated rectocele.

METHOD

Patients with these complaints underwent dynamic and static MRI. All consecutive patients with a Grade III (4 cm or more) rectocele and without internal/external rectal prolapse, enterocele and external sphincter damage were operated on. The patients completed the Obstructed Defecation Syndrome (ODS) score and the Cleveland Clinic Incontinence Score (CCIS). All tests were repeated after treatment. Dynamic disorders of the pelvic floor detected by MRI were recorded.

RESULTS

In 27 patients [median age 67 (46-73) years], TPC combined with LVR was feasible. Complications were limited to port site infection in two patients. Sexual discomfort (n = 8) due to prolapse diminished in six (75%) patients and in one (4%) de novo dyspareunia developed after treatment. The median follow-up was 12 (10-18) months. The median CCIS was 12 (10-16) before treatment and 8 (7-10) after (P < 0.0001). The median ODS score was 19 (17-23) before and 6 (3-10) after treatment (P < 0.0001). There was no change in urinary symptoms.

CONCLUSION

TPC combined with LVR for obstructed defaecation and faecal incontinence in patients with Grade III rectocele significantly relieves the symptoms of these disorders.

Surgery for pelvic organ prolapse

OBJECTIVES

: Surgery for pelvic organ prolapse (POP) is common with increasing high-quality evidence to guide surgical practice. Yet many important basic questions remain, including the optimal timing for POP surgery, the optimal preoperative evaluation of urinary tract function, and the postoperative outcome assessment. This manuscript reviews traditional surgical approaches for POP.

METHODS

: Formal and hand-searching of prolapse literature was conducted by the committee on Pelvic Organ Prolapse Surgery for the most recent International Consultation on Incontinence. The committee (authors) was composed of prolapse specialists from around the world. Consensus recommendations were made following literature abstraction.

RESULTS

: Surgical correction of POP can be divided into 2 main categories as follows: reconstructive procedures to correct anterior and posterior wall defects and resuspend the vaginal apex or obliterative procedures to close off the vagina. Reconstructive surgery may use the vaginal route or the abdominal route.

CONCLUSIONS

: In addition to recommendations within the report, the committee reaffirms that in planning surgery, the individual patient's risk for surgery, risk of recurrence, previous treatments, and surgical goals are all considered in deciding on obliterative versus reconstructive procedures, and in deciding whether the vaginal or the abdominal approach will be used for reconstructive repairs.

Prevention of complications related to the use of prosthetic meshes in prolapse surgery: guidelines for clinical practice

The objective of the study was to provide guidelines for clinical practice from the French College of Obstetrics and Gynecology (CNGOF), based on the best evidence available, concerning adverse events related to surgical procedures involving the use of prosthetic meshes. French and English-language articles from Medline, PubMed, and the Cochrane Database were searched, using key words (mesh; pelvic organ prolapse; cystocele; rectocele; uterine prolapse; complications; adverse event; sacral colpopexy; extrusion; infection). As with any surgery, recommendations include perioperative smoking cessation (Expert opinion) and compliance with the prevention of nosocomial infections (regulatory recommendation). There is no evidence to recommend routine local or systemic estrogen therapy before or after prolapse surgery using mesh, regardless of the surgical approach (Grade C). Antibiotic prophylaxis is recommended, regardless of the approach (Expert opinion). It is recommended to check for pre-operative urinary tract infection and treat it (Expert opinion). The first procedure should be undertaken under the guidance of a surgeon experienced in the relevant technique (Grade C). It is recommended not to place a non-absorbable synthetic mesh into the rectovaginal septum when a rectal injury occurs (Expert opinion). Placement of a non-absorbable synthetic mesh into the vesicovaginal septum may be considered after suturing of a bladder injury if the suture is considered to be satisfactory (Expert opinion). If a synthetic mesh is placed by vaginal route, it is recommended to use a macroporous polypropylene monofilament mesh (Grade B). It is recommended not to use polyester mesh for vaginal surgery (Grade B). It is permissible to perform hysterectomy associated with the placement of a non-absorbable synthetic mesh placed by the vaginal route but this is not routinely recommended (Expert opinion). It is recommended to minimize the extent of the colpectomy (Expert opinion). The laparoscopic approach is recommended for sacral colpopexy (Expert opinion). It is recommended not to place and suture meshes by the vaginal route when a sacral colpopexy is performed (Grade B). It is recommended not to use silicone-coated polyester, porcine dermis, fascia lata, and polytetrafluoroethylene meshes (Grade B). It is recommended to use polyester (without silicone coating) or polypropylene meshes (Grade C). Suture of the meshes to the promontory can be performed using thread/needle or tacks (Grade C). Peritonization is recommended to cover the meshes (Grade C). If hysterectomy is required, it is recommended to perform a subtotal hysterectomy (Expert opinion). Implementation of this guideline should decrease the prevalence of complications related to surgical procedures involving the use of prosthetic meshes.

Vaginal sacrocolporectopexy for the surgical treatment of uterine and vaginal vault prolapses: confirmation of the surgical method and perioperative results of 101 cases

PURPOSE

In this study, we sought to confirm the surgical method of vaginal sacrocolporectopexy and previously reported positive perioperative results of this procedure in a large patient group. We describe the approach which offers a vaginal, safe alternative to sacrospinous repair, laparoscopic or open vaginosacropexy and the use of synthetic meshes to treat pelvic organ prolapse.

METHODS

We conducted a monocentric, prospective, nonrandomized study for treatment of patients with uterine and vaginal vault relapse (grade 2-4). All patients underwent a preoperative urogynecological urodynamic examination. We focus on method, operative time, complications, blood transfusions, hospital stay and clinical data.

RESULTS

Between March 2006 and March 2011, 101 consecutive patients of mean age 64 (40-89) years, with sub or total uterine prolapse (n=69, grade 2-4) and vaginal vault prolapse (n=32, grade 2-4) were treated with vaginal sacrocolporectopexy. Cystocele (grade 2-4) was found in 88 (87.1%) and rectocele (grade 2-4) in 43 (42.5%) patients. Mean duration of surgery with sacrocolporectopexy was 70 min (28-165) without hysterectomy, and 76 min (40-219) with hysterectomy. Regression analysis of all patients (n=101) showed a significant decrease of operative time in the group without hysterectomy after 40 cases. Three bladder lesions, two in patients with a history of hysterectomy, occurred during surgery and were corrected intraoperatively without further complications. No patient required a blood transfusion. Hemoglobin levels decreased slightly from a preoperative mean of 13.6 mg/dl (10.3-15.7) to a postoperative mean of 11.7 mg/dl (8.6-14.7).

CONCLUSION

Vaginal sacrocolporectopexy is a safe vaginal method for the treatment of sub-/total uterine/vaginal vault prolapse.

Medium-term effects of a monofilament polypropylene mesh for pelvic organ prolapse and sexual function symptoms

This report is aimed at describing the effects and complications of a polypropylene mesh in standard gynaecological practice. This is single centre prospective cohort observational study performed at a University affiliated hospital in the UK. It involved the prospective symptom assessment of 41 consecutive patients in 2007 who underwent anterior and/or posterior Avaulta Plus™ or Avaulta™ Biosynthetic Support System (BARD). The validated International Consultation on Incontinence Modular Questionnaire - Vaginal Symptoms (ICIQ-VS) was completed in the clinic preoperatively. Postal questionnaires were sent to the patients up to 3 years postoperatively. Preoperatively the mean overall Quality of life (QoL) was 19.78 (SD 9.052) and at follow-up was 1.67 (SD 1.0) with p< 0.008. Mean VAS preoperatively was 15.00 (SD 7.566) and at follow-up was 0.44 (SD 0.882) with p< 0.008. A decrease in this score over time, indicates improved symptoms. In select patients, repair with mesh augmentation using Avaulta™ or Avaulta Plus™ is a safe and effective procedure up to 3 years with a median follow-up of 27 months (range 20-36 months).

Reattachment of the endopelvic fascia to the apex during anterior colporrhaphy: does the type of suture matter?

INTRODUCTION AND HYPOTHESIS

We aimed to determine if the use of permanent suture for the apical fixation during traditional anterior colporrhaphy results in improved outcomes compared to delayed absorbable suture.

METHODS

A retrospective case-control study was performed in patients who underwent traditional non-grafted anterior colporrhaphy with reattachment of the anterior endopelvic fascia to the apex/cervix comparing permanent (group 1) or absorbable suture (group 2). Patients were matched based on age, body mass index, and presenting stage of prolapse. The primary outcome assessed was anterior wall vaginal prolapse recurrence defined as Pelvic Organ Prolapse Quantification (POP-Q) points Aa or Ba ≥ -1 cm. Secondary outcome measures included overall prolapse stage, subjective reporting of satisfaction, and any healing abnormalities or complications resulting from suture type.

RESULTS

A total of 230 patients were reviewed (80 in group 1 and 150 in group 2) and median follow-up was 52 (24-174) weeks. A statistically significant improvement in anterior wall anatomy was seen in group 1 compared to group 2 [(Aa -2.70 ± 0.6 cm vs -2.5 ± 0.75 cm, p = 0.02) and Ba (-2.68 ± 0.65 cm vs -2.51 ± 0.73 cm, p = 0.03), respectively]. Comparing prolapse stage, there were no observed differences between the groups. Exposure of the permanent suture occurred in 12 patients (15 %) and 5 (6.5 %) required suture trimming to treat the exposure.

CONCLUSIONS

Reattachment of endopelvic fascia to the apex at the time of anterior colporrhaphy results in low recurrence rates. Use of permanent suture for apical fixation is associated with improved anatomic correction at the expense of increased suture exposures.

[Prolapse surgery. With abdominal or vaginal meshes?]

In prolapse surgery several surgical techniques are available. The different open, laparoscopic and vaginal approaches are distinguished by distinct success and relapse rates and operation-specific complications. A safe and optimal therapeutic pelvic floor surgery should be based on the three support levels according to DeLancy and be individually adjusted for every patient. The vaginal approach may be used for all kinds of female genital prolapse and is a comparatively less invasive technique with a short time of convalescence. Apart from stress incontinence there is no need for synthetic meshes in primary approaches and excellent results with low complication and relapse rates can be achieved. An uncritical application of synthetic material is to be avoided in vaginal repair at all times. Abdominal surgical techniques, both open and laparoscopic, present their strengths in the therapeutic approach to level 1 defects or stress incontinence. They provide excellent functional and anatomical corrections and low relapse rates. Abdominally inserted meshes have lower complication rates than vaginal ones.

Potential relevance of pre-operative quality of life questionnaires to identify candidates for surgical treatment of genital prolapse: a pilot study

BACKGROUND

To evaluate prolapse-related symptoms, quality of life and sexuality of patients with validated questionnaires before and after surgery for genital prolapse and assess relevance of such an evaluation to select women for surgery.

METHODS

From November 2009 to April 2010, 16 patients operated on for genital prolapse of grade greater than or equal to 2 (POP-Q classification) were evaluated prospectively by three questionnaires of quality of life Pelvic Floor Distress Inventory (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7) and Pelvic Organ Prolaps/Urinary Incontinence Sexual Questionnaire (PISQ-12). Data were collected the day before surgery and 6 weeks postoperatively.

RESULTS

Eleven patients had laparoscopic surgery and five vaginal surgery. There was a significant decrease in pelvic heaviness, vaginal discomfort and urinary symptoms after surgery. The score of symptoms of prolapse, the PFDI-20 score was 98.5 preoperatively and 31.8 postoperatively (p < 0.0001). The score for quality of life, the PFIQ-7 score was 54.5 preoperatively and 7.4 postoperatively (p = 0.001). The score of sexuality, the PISQ-12 score was 35.3 preoperatively and 37.5 postoperatively (p = 0.1). Two of the 3 patients with a PFIQ 7 under or equal to 20 were not improved while all the women with a preoperative PFIQ-7 over 20 were improved after surgery.

CONCLUSIONS

This study suggests that surgery improves quality of life of patients with genital prolapse. Quality of life questionnaires could help select good candidates for surgery. Further studies are required to determine threshold to standardize indications of surgery.