Short-term efficacy and complications of posterior intravaginal slingplasty

Historic transvaginal meshes and procedures: what did my patient have done?

PURPOSE OF REVIEW

Transvaginal mesh kits were widely used to treat pelvic organ prolapse for over a 10-year period in the early 2000s. Due to safety concerns and FDA regulations, these mesh kits are no longer available for use. Thus, current Obstetricians and Gynecologists are likely to encounter these meshes, but may have no previous experience or exposure to the devices making it difficult to adequately monitor, counsel, and care for patients that underwent these types of procedures. This review highlights the most commonly used transvaginal mesh kit types, provides insight into signs and symptoms related to transvaginal mesh complications, and provides guidance for management of mesh complications.

RECENT FINDINGS

Not all transvaginal mesh will give rise to a complication. If complications do occur, treatment options range from conservative observation to total mesh excision. Management must be customized to an individual patient's needs and goals.

SUMMARY

Transvaginal mesh kits promised increased durability of surgical repair for pelvic organ prolapse. Safety concerns over time caused these kits to no longer be available for use. Practicing Obstetricians and Gynecologists should be aware of the history of transvaginal mesh and the signs and symptoms of mesh complications.

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

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

Posterior Intravaginal Slingplasty versus Unilateral Sacrospinous Ligament Fixation in Treatment of Vaginal Vault Prolapse

Objective. To investigate the differences in efficacy, postoperative complications, and patient satisfaction between posterior intravaginal slingplasty (PIVS) and unilateral sacrospinous ligament fixation (SSLF) procedures. Study Design. A retrospective study of thirty-three women who underwent PIVS or SSLF treatment for vaginal vault prolapse in Oulu University Hospital. The patients were invited to a follow-up visit to evaluate the objective and subjective outcomes. Median follow-up time was 16 months (range 6–52). The anatomical outcome was detected by the Pelvic Organ Prolapse Quantification (POP-Q) system. Information on urinary, bowel, and sexual dysfunctions and overall satisfaction was gathered with specific questionnaire. The data were analyzed using Mann-Whitney U test and Fisher's exact test. Results. Mesh erosion was found in 4 (25%) patients in the PIVS group. Anatomical stage II prolapse or worse (any POP-Q point ≥−1) was detected in 8 (50%) patients in the PIVS group and 9 (53%) patients in the SSLF group. Overall satisfaction rates were 62% and 76%, respectively. Conclusion. The efficacy of PIVS and SSLF is equally poor, and the rate of vaginal erosion is intolerably high with the PIVS method. Based on our study, we cannot recommend the usage of either technique in operative treatment of vaginal vault prolapse.

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

OBJECTIVE

To estimate the perioperative complication and reoperation rates associated with slings and prolapse repairs using mesh and biologic grafts.

METHODS

Analysis of all female members of Kaiser Permanente Southern and Northern California and Hawaii who underwent sling procedures or pelvic organ prolapse surgeries using implanted grafts or mesh between September 1, 2008, and May 31, 2010. Physicians' Current Procedural Terminology Coding System, 4th edition, International Classification of Diseases, 9th Revision, and surgical implant logs were used to identify the procedures performed, implants used, perioperative complications, and readmissions and reoperations within 12 months of the index surgery.

RESULTS

During the 21-month period, 4,142 women (mean age 57 years [standard deviation 12.2], median parity 3 [interquartile range 1-4], median body mass index 28 [interquartile range 25-32]) underwent 3,747 (71%) slings and 1,508 (29%) prolapse repair procedures using implanted prostheses. Trocar-related bladder perforations (51 of 3,747 [1.4%]) occurred more commonly than urethral perforations (2 of 3,747 [0.05%]) in sling procedures (P<.001). There were no trocar-related injuries for prolapse repair kit procedures. Mesh-related reoperations after sling procedures were performed for voiding dysfunction or urinary retention (49 of 3,747 [1.3%]), vaginal mesh erosion (30 of 3,747 [0.8%]), and urethral erosion (3 of 3,747 [0.08%]). Reoperations after prolapse procedures were performed more often for vaginal mesh erosion (29 of 858 [3%]) than for biologic graft infection (2 of 650 [0.3%]; P=.01) and were performed more commonly after anterior (19 of 307 [6%]) compared with apical (9 of 487 [2%]) or posterior vaginal mesh repairs (1 of 64 [2%]; P=.018).

CONCLUSION

Reoperations for mesh-related complications occurred most often after transvaginal mesh placement in the anterior vagina.

Anatomical and functional outcomes of posterior intravaginal slingplasty for the treatment of vaginal vault or uterine prolapse: a prospective, multicenter study

Purpose

We aimed to evaluate the anatomical and functional outcomes of posterior intravaginal slingplasty (P-IVS) for the treatment of a vaginal vault or uterine prolapse (VP/UP).

Materials and Methods

This was a 12-month prospective, multicenter, observational study. Women aged over 30 years who presented with stage II or greater VP/UP underwent P-IVS by four urologists at four university hospitals. Preoperatively, pelvic examination by use of the Pelvic Organ Prolapse Quantification (POP-Q) system, the Pelvic Floor Distress Inventory (PFDI) questionnaire, the 3-day frequency volume chart, and uroflowmetry were completed. At the 12-month follow-up, changes in the POP-Q, PFDI, frequency volume chart, and uroflowmetry parameters were assessed. Cure was defined as VP/UP stage 0 and improvement as stage I.

Results

The cure and improvement rates among the 32 women were 65.6% and 34.4%, respectively. All subscale scores of the Urinary Distress Inventory, the general subscale score of the Pelvic Organ Prolapse Distress Inventory, and the rectal prolapse subscale score of the Colo-Rectal-Anal Distress Inventory were significantly improved. There were no significant changes in the frequency volume chart or uroflowmetry parameters. There was one case of surgery-related transfusion.

Conclusions

Trans-vaginal repair by P-IVS is an effective and safe procedure for restoring the anatomical defect and improving the associated pelvic floor symptoms in women with VP/UP.

[Vaginal pelvic repair. Always with mesh or not?]

Several surgical methods are possible when aiming at reconstruction of pelvic organ prolapse in women, and the experienced surgeon implements the knowledge gained from open, laparoscopic, and vaginal techniques. These feature different rates of success and relapse as well as different complication risks. Because of the accumulating morbidity of aging patients, there is a search for a safe minimally invasive technique. With the advent of synthetic meshes, surgeons have used them frequently and often uncritically for reconstruction of the female pelvic floor. In these cases the vaginal approach is preferred as opposed to alternative techniques, as it is less invasive and allows for better convalescence. Furthermore, this approach leads to low complication and relapse rates even when synthetic meshes are omitted.

Complex pelvic floor failure and associated problems

The pelvic floor is a highly complex structure made up of skeletal and striated muscles, support and suspensory ligaments, fascial coverings and an intricate neural network. Its dual role is to provide support for the pelvic viscera (bladder, bowel and uterus) and maintain functional integrity of these organs. In order to maintain good pelvic floor function, this elaborate system must work in a highly integrated manner. When this system if damaged, pelvic floor failure ensues. The aetiology is inevitably multi-factorial, and seldom as a consequence of a single aetiological factor. It can affect one or all the three compartments of the pelvic floor, often resulting in prolapse and functional disturbance of the bladder (urinary incontinence and voiding dysfunction), rectum (faecal incontinence), vagina and/or uterus (sexual dysfunction). This compartmentalisation of the pelvic floor has resulted in the partitioning of patients into urology, colo-rectal surgery or gynaecology, respectively, depending on the patients presenting symptoms. In complete pelvic floor failure, all three compartments are inevitably damaged resulting in apical prolapse, with associated organ dysfunction. It is clear that in this state, the patient needs the clinical input of at least two of the three pelvic floor clinical specialities. Whilst the primary clinical aim is to correct the anatomy, it must also be to preserve or restore pelvic floor function. As a consequence, these patients need careful clinical assessment, appropriate investigations, and counselling before embarking on a well-defined management pathway. The latter includes behavioural and lifestyle changes, conservative treatments (pelvic support pessaries, physiotherapy and biofeedback), pharmacotherapy, minimally invasive surgery (intravaginal slingoplasty, sacrospinous fixation and mid-urethral tapes) and radical specialised surgery (open or laparoscopic sacrocolpopexy). It is not surprising that in this complex group of patients, a multi-disciplinary approach is not only essential, but also critical, if good clinical care and governance is to be ensured.

[What about transvaginal mesh repair of pelvic organ prolapse? Review of the literature since the HAS (French Health Authorities) report]

The French Health Authorities' (HAS) report of November 2006 concluded that the use of mesh at the time of transvaginal repair of pelvic organ prolapse (POP) should be limited to clinical research. This review intends to analyse and comment the recent data on this topic. A review on PubMed, on a personal database and actualisation until May 2008 has been performed choosing French or English language series concerning prolapse surgery with mesh disposed by the vaginal route. It includes six randomised controlled trials comparing transvaginal repair of POP with or without mesh: four about cystocele, one about rectocele and one about apical prolapse. Both surgical techniques and recurrence criteria are poorly standardised. The four randomised trials focusing on cystocele repair support the anatomical superiority of techniques using mesh, with similar functional results with or without mesh reinforcement. In the other indications, the results remain unclear or controversial. According to the randomised trials, the complications rate, except mesh exposure, is similar with and without mesh. However there are some specific complications when using mesh, such as mesh infection, mesh exposure or shrinkage and visceral extrusion. We recommend using vaginal reinforcement mesh with specific care in selected patients and we suggest some guidelines to be proposed for consensus at concerned French scientific societies.