Use of the Gynecare Prolift® system in surgery for pelvic organ prolapse: 1-year outcome

Are anterior mesh arms necessary in Japanese-style transvaginal mesh surgery for cystocele?

AIM

In this study, we retrospectively analyzed the medium-term efficacy and safety of surgery with transobturator two-arm transvaginal mesh for cystocele and to verify whether the anterior arms are necessary for Japanese-style transvaginal mesh surgery.

METHODS

The study included 203 patients with cystocele who underwent transobturator two-arm transvaginal mesh at our hospital between August 2015 and June 2017 and received appropriate follow-up care for at least 48 months after surgery.

RESULTS

The Pelvic Organ Prolapse Quantification stage was III in all the patients. Intraoperative complications included two cases of bladder injury and one case of more than 200 mL of blood loss. The mean observation period was 51.9 months, and prolapse recurred in the operated compartment in nine patients (4.4%). No cases of mesh exposure were observed. In comparing the preoperative characteristics of the 9 patients with prolapse recurrence at the surgical site with those of the other 194 patients, we found that the recurrence rate was significantly higher among patients in whom point Ba being 3.5 cm or more and among patients younger than 66 years.

CONCLUSIONS

Transobturator two-arm transvaginal mesh for cystocele was as good and safe as the procedure previously reported with four-arm mesh; thus, it was possible to omit the anterior mesh arms in Japanese-style transvaginal mesh surgery. Patients should be informed preoperatively that prolapse recurs at a significantly higher rate among younger patients and in those whose point Ba being 3.5 cm or more.

Transobturator four-arms mesh in the surgical management of cystocele: a long-term follow-up

We studied the long-term efficacy and safety of cystocele operation by polypropylene mesh. A total of 198 women with stage ≥2 cystocele who had anterior vaginal wall repair with transobturator four-arm polypropylene mesh during 2003 to 2015 were evaluated. Outcomes including clinical characteristics and complications were reviewed by extracting patient data from electronic medical records. In addition, telephone interviews were conducted using a validated questionnaire along with physical examination. The follow-up period was 9.3±0.3 years. The cystocele stage in patients was significantly decreased post-operation compared to that preoperation. The anatomical cure rate for cystocele was 93.4%, and that for stress urinary incontinence was 95%. Comparing the three questionnaires indicated overall average score was improved significantly, except for Female Sexual Function Index Assessment. Early complications were either resolved spontaneously or controlled medically in four cases of hematoma or abscess, three cases of vaginal infection and urinary tract infection, and four cases of difficult micturition. In late complications, four cases of pain were managed, five cases of recurrence were observed and two cases of mesh exposure were treated with ointment and local excision. Transobturator four-arms mesh is an effective and safe method for cystocele repair with low rate of recurrence and complications. We suggest that the use of transobturator four-arm mesh is a still good choice for the old patients with cystocele who are not suitable for general anesthesia and reside in areas where laparoscopy and robots are not available.

Concomitant transobturator tape and anterior colporrhaphy versus transobturator subvesical mesh for cystocele-associated stress urinary incontinence

INTRODUCTION AND HYPOTHESIS

Stress urinary incontinence (SUI) and cystocele often occur concomitantly and thus may potentially be treated via a single surgical procedure. This study evaluated the efficacy and safety of concomitant transobturator tape (TOT) with anterior colporrhaphy versus subvesical transobturator mesh (TOM) for cystocele-associated SUI.

METHODS

This prospective, clinical trial included women with cystocele-associated SUI. Patients were randomly allocated into either group I (anterior colporrhaphy with concomitant TOT "in-out" fixation) or group II (implantation of a subvesical four-armed TOM). All patients were followed up at 1, 3, 6, 9, and 12 months postoperatively. Statistical tests were performed to compare the group outcomes based on objective, subjective, and anatomical variables.

RESULTS

There were 81 patients in group I and 83 in group II. Median follow-up duration was 12 months. The demographic data and baseline clinical characteristics of both groups were comparable. There were no significant differences between groups regarding the success rates of SUI and cystocele repair. Groups I and II had similar cure rates of SUI (82.9 and 88.4%, respectively; p = 0.369) and incidences of successful cystocele repair (85.4 and 97.7%, respectively; p = 0.055). No urethral or bladder injuries or mesh erosions were reported. Both groups had comparable postoperative complications, except the greater incidence of micturition difficulty in group I than group II, during the early follow-up (12.2% vs. 0.0%; p = 0.024).

CONCLUSIONS

Transvaginal mesh was not superior to native tissue repair. Anterior colporrhaphy and TOT may be an appropriate alternative to four-armed TOM application for concomitant correction of SUI and cystocele.

Transobturator four arms mesh in the surgical management of stress urinary incontinence with cystocele

Objective

This study aims to evaluate safety and efficacy of four arms polypropylene mesh in the long- term follow-up in the management of stress urinary incontinence (SUI) associated with cystocele.

Material and methods

This prospective study was conducted on 50 female patients with SUI associated with cystocele. Patients underwent placement of transobturator four-arms mesh implants. Stress incontinence was evaluated using cough stress test with and without prolapse reduction, Stamey's grading of SUI, the validated Arabic version of the International Consultation on Incontinence Questionnaire-Short Form and King Health Questionnaire forms. Perioperative parameters evaluated included age, body mass index, grade of SUI, time of procedure, hospital stay after surgery, difference between pre-, and postoperative serum hemoglobin values, and need for blood transfusion. Follow- up visits were planned at 3, 9 and 18 months after surgery.

Results

The mean operative time was 37.4±10.2 (25-60) minutes. Blood transfusion was not required. The mean hospital stay was 30.5±10 (24-48) hrs. Five (10%) patients had fever and urinary tract infections were noticed in five (10%) patients. Two (4%) women had urine retention after catheter removal and vaginal mesh erosion was present in one (2%) patient. Forty (80%) patients were cured from SUI, 8 (16%) patients were improved and 2 (4%) patients failed to respond.

Conclusion

Cystocele associated with SUI can be repaired with transobturator four-arms mesh with promising results, improved quality of life, and tolerable side effects.

Efficacy and safety of Elevate® system on apical and anterior compartment prolapse repair with personal technique modification

AIM

To evaluate the effectiveness and safety of Anterior Elevate® mesh kit system (AES) in woman with symptomatic stage 3 or 4 anterior and/or apical pelvic organ prolapse (POP).

MATERIALS AND METHODS

This retrospective, monocentric, single surgeon study enrolled between May 2010 and January 2013 fifty-six woman experiencing symptomatic anterior vaginal prolapse with or without apical descent (POP-Q stage 3 or 4). All women received a AES and 7 (12.5%) received a concomitant transvaginal hysterectomy. Primary endpoint was anatomic correction of prolapse; success was defined as POP-Q stage ≤ 1 or asymptomatic stage 2. Secondary endpoints were quality-of-life (QOL) results and patients' safety outcomes, which were assessed by 3 validated self-reporting questionnaires at baseline and annually: ICIQ-UI short form, ICIQ-VS and P-QOL. All patients completed 2-years and 28 women 3-years of follow-up. Surgical approach was modified in women with uterus, moving the two-propylene strips anteriorly around the cervix itself crossing one another, so the left will take place in the right side and the right on the opposite. This modification was made in order to better support the uterus.

RESULTS

Vaginal mesh exposure was present in 3 (5,3%) patients. Very good anatomical outcomes were seen, with one (1,8%) failure at 6-months, 4 (7,1%) at 1-year, 6 at 2-years (10,7%). Statistically significant improvements were seen in the ICIQ-VS and P-QOL questionnaires throughout follow-up.

CONCLUSION

Our data suggest that AES is a minimally-invasive transvaginal procedure to repair anterior and apical POP, with good evidence related to mid-term safety and efficacy.

Pain Scores and Exposure Rates after Polypropylene Mesh for Pelvic Organ Prolapse

OBJECTIVES

To characterize pain and exposure after Prolift placement and identify risk factors.

METHODS

A case series of women who underwent Prolift vaginal mesh were surveyed. Pain was assessed using a visual analog scale. Exposure was evaluated clinically.

RESULTS

Of 183 eligible patients, 160 completed the survey, and 45 returned for examination. Mean preoperative pain score was 0.97 and postoperative was 1.35 (P = 0.12). Pre- and postoperative pain scores by compartment were: anterior (1.34 vs 1.25, mean change -0.09, P = 0.84), posterior (1.30 vs 1.56, mean change 0.26, P = 0.72), and total (0.63 vs 1.34, mean change 0.71, P = 0.05). Graft exposure was confirmed in 23 of 183 patients (12.6%); however, because asymptomatic patients were not examined, the true exposure rate may be underestimated. Hematoma formation is independently associated with mesh exposure, adjusted odds ratio 18.4 (95% confidence interval 3.4-147.4, P = 0.01).

CONCLUSIONS

Although pain scores did not increase overall, there was a trend toward increased pain score in the patients with total (anterior and posterior) Prolift. Hematoma formation was significantly associated with mesh exposure.

Pelvic reconstruction improves pelvic floor strength in pelvic organ prolapse patients

OBJECTIVE

To evaluate pelvic floor muscle strength after the modified pelvic reconstruction procedure for pelvic organ prolapse (POP).

MATERIALS AND METHODS

Patients were assigned to two groups consisting of 37 patients diagnosed with POP and undergoing modified pelvic reconstruction (reconstruction group), and 30 patients admitted to our hospital during the same period for other surgical indications (control group). Vaginal palpation of pelvic floor muscle strength was performed according to the modified Oxford grading system before operating on the two groups and again in the 3(rd) month following surgery for the reconstruction group. A comparative study was performed to evaluate the differences between the two groups and the improvement of pelvic floor muscle strength in the reconstruction group.

RESULTS

The pelvic floor muscle strength was significantly improved postoperatively when compared with preoperative results in the reconstruction group (t = -17.478, p < 0.001). However, pre- and postoperative muscle strength in the reconstruction group was significantly lower relative to the control group, respectively (χ(2) = 63.293, p < 0.001; χ(2) = 31.550, p < 0.001).

CONCLUSION

The modified pelvic reconstruction procedure could improve pelvic floor muscle strength in POP patients, which remains lower when compared with the normal population. Pelvic floor muscle strength should be included in the assessment of surgical outcomes in POP.

Perioperative outcomes and prospective patient reported outcome measures for transvaginal mesh surgery

PURPOSE

To determine perioperative morbidity associated with the transvaginal mesh and analyse patient reported outcome measures following transvaginal mesh surgery via a prospective cohort study.

METHODS

A retrospective review and a prospective cohort study of vaginal symptoms via a validated questionnaire (Ethically approved). 159 consecutive women who underwent transvaginal polypropylene mesh repair for pelvic organ prolapse from January 2009 to January 2012 by a single experienced urogynaecologist were identified using theatre records and formed the study population. The type and frequency of intraoperative and postoperative complications, mesh exposure rates and need for further surgery were recorded. 59/159 patients consented to complete both preoperative and postoperative assessment of vaginal symptoms using the validated International Consultation on Incontinence Modular Questionnaire-Vaginal symptoms (ICIQ-VS). 51/59 patients completed both questionnaires.

RESULTS

The average age of the study population was 63 years (range 39-87 years). The mean BMI was 28.5 (range 20-40). 86 % (n = 138/159) had a previous hysterectomy. 98 % (n = 156/159) of patients did not have any intraoperative complications. 0.62 % (n = 1/159) had a bladder injury. Mesh exposure was noted in 4 % of the entire group (n = 6/135) at follow-up with overall reoperation rate of 9 % (n = 13/135). Statistically significant improvement in most arms of the ICIQ-VS questionnaire was noted in the cohort of 51 patients at follow-up.

CONCLUSION

Our data revealed a very low intraoperative complication rate with a mesh exposure rate of 4 %. The prospective study showed a statistically significant improvement in vaginal symptoms.

3-year results of transvaginal cystocele repair with transobturator four-arm mesh: A prospective study of 105 patients

OBJECTIVES

To evaluate the long-term efficacy and safety of transobturator four-arm mesh for treating cystoceles.

PATIENTS AND METHODS

In this prospective study, 105 patients had a cystocele corrected between January 2004 and December 2008. All patients had a symptomatic cystocele of stage ⩾2 according to the Baden-Walker halfway stratification. We used only the transobturator four-arm mesh kit (Surgimesh®, Aspide Medical, France). All surgical procedures were carried out by the same experienced surgeon. The patients' characteristics and surgical variables were recorded prospectively. The anatomical outcome, as measured by a physical examination and postoperative stratification of prolapse, and functional outcome, as assessed by a questionnaire derived from the French equivalents of the Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire and the Pelvic Organ Prolapse-Urinary Incontinence-Sexual Questionnaire, were considered as the primary outcome measures. Peri- and postoperative complications constituted the secondary outcome measures.

RESULTS

At 36 months after surgery the anatomical success rate (stage 0 or 1) was 93%. On a functional level, all the scores of quality of life and sexuality were improved. The overall satisfaction score (visual analogue scale) was 71.4%. There were no perioperative adverse events. Mesh erosion was reported in 7.6% and mesh retraction in 5.7% of the patients.

CONCLUSIONS

If the guidelines and precautions are followed, vaginal prosthetic surgery for genitourinary prolapse has shown long-term benefits. It provides excellent results both anatomically and functionally. However, complications are not negligible and some are specific to prosthetic surgery.

Exploring predictors of mesh exposure after vaginal prolapse repair

OBJECTIVES

To evaluate clinical, demographic, and surgical factors that may be associated with mesh exposure after vaginal repair of pelvic organ prolapse (POP).

METHODS

Records of women who underwent POP repair with Elevate or Prolift were retrospectively reviewed. Body mass index (BMI), prolapse grade, smoking history, diabetes, steroid and estrogen use, parity, compartment repaired, concurrent hysterectomy, operative time, postoperative pain, change in hemoglobin (ΔHgb) and other characteristics were evaluated for associations with mesh exposure.Categorical variables were examined using Pearson χ test where appropriate, or the Fisher exact test was used. The continuous variables were examined using Wilcoxon rank tests. A multivariable logistic regression analysis was completed to examine predictors of mesh exposure. All analyses used SAS for Windows version 9.2 (Cary, NC).

RESULTS

Three hundred thirty-five women underwent repair from 2006 to 2011. Vaginal mesh exposure was identified in 27 (8.1%) of the 335 women. Patients with exposure had longer median follow-up than the group with no exposure (357 vs 145 days; P = 0.0003). The median time to exposure was 96 days (15-1129 days). Mesh exposure was associated with lower BMI (25.2 ± 2.5 vs 27.4 ± 5.1; P = 0.020) and greater ΔHgb (-3.7 ± 1.7 mg/dL vs -2.5 ±1.3; P = 0.0011). Change in hemoglobin decreased over time (P = 0.0005). Exposure rates also decreased over time (17% in 2005 to 12% in 2006, then 5%-8% in 2006-2011) but were not statistically significant (P = 0.49).

CONCLUSIONS

In this study, vaginal mesh exposure was only associated with ΔHgb and lower BMI.

A multicenter, randomized, prospective, controlled study comparing sacrospinous fixation and transvaginal mesh in the treatment of posthysterectomy vaginal vault prolapse

OBJECTIVE

The objective of the study was to compare recurrence and complication rates for sacrospinous fixation (SSF) and prolene mesh techniques for the primary treatment of posthysterectomy vaginal vault prolapse.

STUDY DESIGN

Patients undergoing surgery for vault prolapse were included in a multicenter, randomized, controlled study comparing SSF or total mesh (Prolift; Gynecare/Ethicon, Somerville, NJ). The examination included pelvic organ prolapse quantification, urodynamics, ultrasound, and quality-of-life (QoL) questionnaires before and 3 and 12 months after surgery.

RESULTS

Of 168 randomized patients, 83 underwent SSF and 85 mesh repair. Prolapse recurrence after 12 months occurred in 39.4% of the SSF group and in 16.9% of the mesh group (P = .003). The mesh exposure rate was 20.8%. No difference in QoL improvement as well as of de novo stress urinary incontinence and overactive bladder onset was found.

CONCLUSION

Mesh exposure occurrence was balanced against a lower prolapse recurrence rate in the patients undergoing mesh surgery compared with those undergoing SSF.

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.

Pelvic organ prolapse transvaginal repair by the Prolift system: evaluation of efficacy and complications after a 4.5 years follow up

OBJECTIVES

The Prolift system is a polypropylene device designed for pelvic organ prolapse repair by a transvaginal approach. Numerous studies have reported on short-term outcomes of this procedure, but long-term studies are lacking.

METHODS

A retrospective study of patients who underwent pelvic organ prolapse repair by Prolift between September 2005 and September 2008 was carried out in two tertiary reference centers by two experienced surgeons. Preoperative and postoperative follow up was based on medical records of baseline and follow-up visits with complete clinical examination, including Pelvic Organ Prolapse Quantification stage. At last follow up, the Pelvic Floor Distress Inventory-20 questionnaire was assessed by telephone interview. Cure was defined as an anatomical success at last follow up, being a Pelvic Organ Prolapse Quantification stage ≤ 1 without further surgical intervention in any compartment.

RESULTS

A total of 75 patients were included in this analysis with a mean follow up of 53.7 ± 8.8 months (range 36-72 months). Patients were treated with two-arm Prolift posterior, four-arm Prolift anterior and six-arm Prolift total in three (4%), 51 (69%) and 21 (27%) cases, respectively. At last follow up, 64 (85.3%) patients were cured, with no prolapse recurrence. Mesh exposure occurred in four (5.3%) patients. The Pelvic Floor Distress Inventory-20 symptom score was low at last follow up (median 8, range 3-18), in accordance with objective cure data.

CONCLUSIONS

The Prolift system is safe and efficacious for pelvic organ prolapse repair by transvaginal approach after a 4.5-year follow up.

Central compartment and apical defect repair using synthetic mesh

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

Mesh complications in female pelvic floor reconstructive surgery and their management: A systematic review

We reviewed the incidence, predisposing factors, presentation and management of complications related to the use of synthetic mesh in the management of stress urinary incontinence and pelvic organ prolapse repair. Immediate complications, such as bleeding, hematoma, injury to adjacent organs during placement of mesh and complication of voiding dysfunction are not discussed in this review, since they are primarily related to technique. A PubMed search of related articles published in English was done from April 2008 to March 2011. Key words used were urinary incontinence, mesh, complications, midurethral sling, anterior prolapse, anterior vaginal repair, pelvic organ prolapse, transvaginal mesh, vault prolapse, midurethral slings, female stress urinary incontinence, mesh erosion, vaginal mesh complications, and posterior vaginal wall prolapse. Since there were very few articles dealing with the management of mesh-related complications in the period covered in the search we extended the search from January 2005 onwards. Articles were selected to fit the scope of the topic. In addition, landmark publications and Manufacturer and User Facility Device Experience (MAUDE) data (FDA website) were included on the present topic. A total of 170 articles were identified. The use of synthetic mesh in sub-urethral sling procedures is now considered the standard for the surgical management of stress urinary incontinence. Synthetic mesh is being increasingly used in the management of pelvic organ prolapse. While the incidence of extrusion and erosion with mid-urethral sling is low, the extrusion rate in prolapse repair is somewhat higher and the use in posterior compartment remains controversial. When used through the abdominal approach the extrusion and erosion rates are lower. The management of mesh complication is an individualized approach. The choice of the technique should be based on the type of mesh complication, location of the extrusion and/or erosion, its magnitude, severity and potential recurrence of pelvic floor defect.