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Baekelandt J, Vertongen AS, Matak L, Stuart A. No mess with mesh; vaginal natural orifice transluminal endoscopic surgery (vNOTES) autologous posterior rectus fascia mesh for vaginal urinary incontinence procedures. J Gynecol Obstet Hum Reprod 2024:102816. [PMID: 38909957 DOI: 10.1016/j.jogoh.2024.102816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 06/20/2024] [Indexed: 06/25/2024]
Abstract
Urinary incontinence affects 25-45% of women with the gold standard surgical approach being placement of mid-urethral synthetic slings; tension-free vaginal tape (TVT) and trans-obturator tape (TOT). Due to the controversies regarding vaginal mesh the last decade, an increasing demand has evolved for incontinence treatment without vaginal synthetic mesh. The short term results of autologous rectus fascia sling for TOT surgery have shown similar success rates compared to those after the use of synthetic mesh, but the harvesting of the mesh is less minimally invasive and is associated with longer surgical time. vNOTES is a combination of a vaginal entrance to the abdomen and endoscopy via the vagina. The aim with the video is to show a new surgical technique with a fully vaginal, scarless vNOTES approach for harvesting the posterior rectus fascia for TVT and TOT procedures.
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Affiliation(s)
- Jan Baekelandt
- Department of Obstetrics and Gynecology, Imelda Hospital, Bonheiden, Belgium; Department of Development and Regeneration, Faculty of Medicine, Group Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Ann Sofie Vertongen
- Department of Obstetrics and Gynecology, Imelda Hospital, Bonheiden, Belgium
| | - Luka Matak
- Department of Obstetrics and Gynecology, General Hospital Zadar, Croatia
| | - Andrea Stuart
- Department of Obstetrics and Gynecology, Helsingborg, Sweden; Institution of Clinical Sciences, Dept. of Obstetrics and Gynecology, Lund University, Lund.
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Rotem R, Galvin D, Daykan Y, Al-Shukaili S, O'Reilly BA, O'Sullivan OE. Precision in Practice: The Critical Role of Mesh and Procedure Type Specification in Urogynecological Surgeries and Research. Int Urogynecol J 2024:10.1007/s00192-024-05820-5. [PMID: 38811409 DOI: 10.1007/s00192-024-05820-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 04/24/2024] [Indexed: 05/31/2024]
Abstract
Recently, the debate surrounding the use of mesh in urogynecological procedures has intensified, leading to FDA warnings and heightened safety concerns. This clinical opinion emphasizes the vital need to specify mesh types in these procedures, drawing attention to the risk profiles and clinical outcomes associated with various meshes and the procedures that utilize them. A significant issue identified in contemporary literature is the tendency to group diverse mesh types under the same umbrella, disregarding their unique characteristics and applications. We describe the range of mesh types, their application routes, and associated complications, highlighting the risks of this nonspecific approach to patient safety and informed decision making. We critically examine the generalization of mesh terminology in clinical and research dialogues. Concluding with specific recommendations for health care providers and researchers, the paper advocates for a more nuanced understanding and communication in the field, ultimately aiming to improve patient care and safety in urogynecological practice.
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Affiliation(s)
- Reut Rotem
- Department of Urogynaecology, Cork University Maternity Hospital, Wilton Road, Wilton, Cork, Ireland
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, affiliated with the Hebrew University School of Medicine, Jerusalem, Israel
| | - Daniel Galvin
- Department of Urogynaecology, Cork University Maternity Hospital, Wilton Road, Wilton, Cork, Ireland.
| | - Yair Daykan
- Department of Obstetrics and Gynaecology, Meir Medical Center, Kfar Saba, Israel
- School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sumaiya Al-Shukaili
- Department of Urogynaecology, Cork University Maternity Hospital, Wilton Road, Wilton, Cork, Ireland
- Obstetrics and Gynaecology Department, Urogynaecology, Royal Hospital, Muscat, Oman
| | - Barry A O'Reilly
- Department of Urogynaecology, Cork University Maternity Hospital, Wilton Road, Wilton, Cork, Ireland
| | - Orfhlaith E O'Sullivan
- Department of Urogynaecology, Cork University Maternity Hospital, Wilton Road, Wilton, Cork, Ireland
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Zhang Z, Guo J, Tian W, Zhang Y, Zhang Y, Sun T, Duan J, Bao X, Wang Y, Ye Y, Gao Q, Shi H, Morse AN, Chen J, Zhu L. Efficacy and safety of transvaginal mesh repair in a cohort with a minimum of 10-year follow-up. SCIENCE CHINA. LIFE SCIENCES 2024; 67:1061-1068. [PMID: 38418758 DOI: 10.1007/s11427-023-2508-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 12/11/2023] [Indexed: 03/02/2024]
Abstract
Although transvaginal mesh (TVM) repair is no longer used in some countries, long-term outcomes after TVM surgery are of great importance globally. However, reports with follow-up >10 years are limited. Thus, this study aimed to report outcomes in a prospective cohort with at least 10 years of follow-up. Women with stage III-IV symptomatic prolapse were approached consecutively from 2008 to 2013 at one tertiary hospital. The main outcome measure was symptomatic failure. Secondary outcomes included anatomic failure, recurrence, patient satisfaction, complications, and reoperation. The Kaplan-Meier curve was used to estimate the cumulative failure rate. Of the 121 patients enrolled in the study, 103 (85.1%) completed a median follow-up of 11 years. The estimated probability rates of symptomatic and anatomic failure were 17.6% and 8.8% in 11 years, respectively. The estimated incidence of symptomatic failure increased by 8.2% between 5 and 11 years; however, the corresponding rate for anatomic failure was 3.7%. The most common complication was vaginal mesh exposure, and its estimated probability increased from 19.3% to 28.4% from 5 to 11 years, respectively. Office trimming resolved 80.0% of vaginal exposures. These patients did not report decreased overall satisfaction. Patients with vaginal mesh exposure requiring>3 office procedures or mesh removal in the operating room (5.8% by 11 years) had lower satisfaction rates (P<0.01) and were defined as having severe mesh exposure. The rates of postoperative pain, reoperation, and Patient Global Impression of Improvement ⩾2 were 2.5%, 3.3%, and 94.2%, respectively. The results of this study implied that TVM treatment gradually increased the symptomatic failure rate but provided durable anatomical support of the vaginal wall. Vaginal mesh exposure was common in women who were largely not sexually active; however, 80% of the cases could be managed in the outpatient clinic, which did not affect patient satisfaction.
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Affiliation(s)
- Zhibo Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, 100730, China
| | - Jianbin Guo
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, 100730, China
| | - Weijie Tian
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, 100730, China
- Department of Gynecology, Guizhou Provincial People's Hospital, Medical College of Guizhou University, Guiyang, 550002, China
| | - Ye Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, 100730, China
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450000, China
| | - Yuelun Zhang
- Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Tianshu Sun
- Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Jiali Duan
- Medical Doctor Program, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, China
| | - Xinmiao Bao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, 100730, China
| | - Yuan Wang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, 100730, China
- Department of Pathology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Yang Ye
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, 100730, China
| | - Qianqian Gao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, 100730, China
| | - Honghui Shi
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, 100730, China
| | | | - Juan Chen
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, 100730, China.
| | - Lan Zhu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, 100730, China.
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Naumann G, Huebner M, Taran FA, Tunn R, Reisenauer C, Neis F. Surgical Procedures for the Treatment of Stress Urinary Incontinence (SUI) in the Light of the Updated FDA-Warning and its Effects on Practice Patterns in Germany between 2010 and 2021. Geburtshilfe Frauenheilkd 2024; 84:256-263. [PMID: 38455998 PMCID: PMC10917608 DOI: 10.1055/a-2243-2341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 01/10/2024] [Indexed: 03/09/2024] Open
Abstract
Introduction Changes in surgical practice patterns to cure stress urinary incontinence (SUI) became evident after FDA warnings regarding vaginal mesh were issued. The primary aim was to describe nationwide numbers of suburethral alloplastic slings (SAS) inserted in 2010, 2015, 2018 and 2021 in Germany. Secondary, numbers were related to SUI specific non-alloplastic alternatives and bulking agents. Additionally, age distribution and overall inpatient surgeries in women were subject to analysis. Materials and Methods Descriptive study utilizing data gathered from the German Federal Statistical Office ( www.destatis.de ). Included were the following procedures of inpatient surgery: A. SAS; B. non-allplastic slings; C. open/laparoscopic colposuspension; D. Bulking agents; overall changes and changes in age distribution (groups of 5-years intervals) are described. Results Overall, n = 3599466 female inpatient procedures were analyzed. There was a considerable decrease of SAS surgeries of 28.49% between 2010 (n = 23464) and 2015 (n = 16778), and a decrease of 12.42% between 2015 and 2018 (n = 14695) and an additional decrease of 40.66% between 2018 and 2021 (n = 8720). Over time a 55.03% continuous decrease in non-alloplastic slings was observed (n = 725 in 2010 to n = 326 in 2021). Open and laparoscopic colposuspension numbers went down with a rate of 58.23% (n = 4415 in 2010, n = 1844 in 2021). Between 2010 and 2018, only bulking agent procedures increased with a rate of 5.89% from n = 1425 to n = 1509. Conclusions There was a considerable decrease in inpatient surgical procedures using SAS. Alternatives not only failed to compensate, but experienced also a major decline.
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Affiliation(s)
- Gert Naumann
- Department of Gynecology and Obstetrics, Helios Hospital Erfurt, Erfurt, Germany
- Department of Obstetrics and Gynecology, University of Düsseldorf, Düsseldorf, Germany
| | - Markus Huebner
- Department of Obstetrics and Gynecology, Medical Center – University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Faculty of Medicine, University of Tübingen, Tübingen, Germany
| | - Florin-Andrei Taran
- Department of Obstetrics and Gynecology, Medical Center – University of Freiburg, Freiburg, Germany
| | - Ralf Tunn
- Department of Urogynecology, German Pelvic Floor Center, St. Hedwig Hospital, Berlin, Germany
| | - Christl Reisenauer
- Faculty of Medicine, University of Tübingen, Tübingen, Germany
- Department of Womenʼs Health, University Hospital of Tübingen, Tübingen, Germany
| | - Felix Neis
- Faculty of Medicine, University of Tübingen, Tübingen, Germany
- Department of Womenʼs Health, University Hospital of Tübingen, Tübingen, Germany
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Degirmenci Y, Stewen K, Dionysopoulou A, Schiestl LJ, Hofmann K, Skala C, Hasenburg A, Schwab R. Trends in Urogynecology-Transvaginal Mesh Surgery in Germany. J Clin Med 2024; 13:987. [PMID: 38398300 PMCID: PMC10889587 DOI: 10.3390/jcm13040987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 01/23/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Pelvic organ prolapse constitutes a prevalent condition associated with a considerable impact on the quality of life. The utilization of transvaginal mesh surgery for managing POP has been a subject of extensive debate. Globally, trends in TVM surgery experienced significant shifts subsequent to warnings issued by the FDA. METHODS This study aims to explore temporal patterns in transvaginal mesh surgery in the German healthcare system. A comprehensive analysis was conducted on in-patient data from the German Federal Statistical Office spanning 2006 to 2021. A total of 1,150,811 operations, each associated with specific codes, were incorporated into the study. Linear regression analysis was employed to delineate discernible trends. RESULTS The trends in transvaginal mesh surgery within the anterior compartment exhibited relative stability (p = 0.147); however, a significant decline was noted in all other compartments (posterior: p < 0.001, enterocele surgery: p < 0.001). A subtle increasing trend was observed for uterine-preserving transvaginal mesh surgery (p = 0.045). CONCLUSION Surgical trends over the specified timeframe demonstrate how POP management has evolved globally. Notably, despite observed fluctuations, transvaginal mesh surgery remains a viable option, particularly for specific cases with a high risk of relapse and contraindications to alternative surgical approaches.
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Affiliation(s)
- Yaman Degirmenci
- Department of Gynecology and Obstetrics, University Medical Center of the Johannes Gutenberg University, 55131 Mainz, Germany; (K.S.); (A.D.); (L.J.S.); (K.H.); (C.S.); (A.H.); (R.S.)
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Darzi S, Alappadan J, Paul K, Mazdumder P, Rosamilia A, Truong YB, Gargett C, Werkmeister J, Mukherjee S. Immunobiology of foreign body response to composite PLACL/gelatin electrospun nanofiber meshes with mesenchymal stem/stromal cells in a mouse model: Implications in pelvic floor tissue engineering and regeneration. BIOMATERIALS ADVANCES 2023; 155:213669. [PMID: 37980818 DOI: 10.1016/j.bioadv.2023.213669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 10/18/2023] [Accepted: 10/20/2023] [Indexed: 11/21/2023]
Abstract
Pelvic Organ Prolapse (POP) is a common gynaecological disorder where pelvic organs protrude into the vagina. While transvaginal mesh surgery using non-degradable polymers was a commonly accepted treatment for POP, it has been associated with high rates of adverse events such as mesh erosion, exposure and inflammation due to serious foreign body response and therefore banned from clinical use after regulatory mandates. This study proposes a tissue engineering strategy using uterine endometrium-derived mesenchymal stem/stromal cells (eMSC) delivered with degradable poly L-lactic acid-co-poly ε-caprolactone (PLACL) and gelatin (G) in form of a composite electrospun nanofibrous mesh (P + G nanomesh) and evaluates the immunomodulatory mechanism at the material interfaces. The study highlights the critical acute and chronic inflammatory markers along with remodelling factors that determine the mesh surgery outcome. We hypothesise that such a bioengineered construct enhances mesh integration and mitigates the Foreign Body Response (FBR) at the host interface associated with mesh complications. Our results show that eMSC-based nanomesh significantly increased 7 genes associated with ECM synthesis and cell adhesion including, Itgb1, Itgb2, Vcam1, Cd44, Cdh2, Tgfb1, Tgfbr1, 6 genes related to angiogenesis including Ang1, Ang2, Vegfa, Pdgfa, Serpin1, Cxcl12, and 5 genes associated with collagen remodelling Col1a1, Col3a1, Col6a1, Col6a2, Col4a5 at six weeks post-implantation. Our findings suggest that cell-based tissue-engineered constructs potentially mitigate the FBR response elicited by biomaterial implants. From a clinical perspective, this construct provides an alternative to current inadequacies in surgical outcomes by modulating the immune response, inducing angiogenesis and ECM synthesis during the acute and chronic phases of the FBR.
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Affiliation(s)
- Saeedeh Darzi
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC 3168, Australia; Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia
| | - Janet Alappadan
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC 3168, Australia; Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia
| | - Kallyanashis Paul
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC 3168, Australia; Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia
| | - Permita Mazdumder
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC 3168, Australia
| | - Anna Rosamilia
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC 3168, Australia; Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia; Pelvic Floor Disorders Unit, Monash Health, Clayton, VIC 3168, Australia
| | | | - Caroline Gargett
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC 3168, Australia; Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia
| | - Jerome Werkmeister
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC 3168, Australia; Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia
| | - Shayanti Mukherjee
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC 3168, Australia; Department of Obstetrics and Gynaecology, Monash University, Clayton, VIC 3168, Australia.
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Ács J, Szabó A, Fehérvári P, Harnos A, Skribek B, Tenke M, Szarvas T, Nyirády P, Ács N, Hegyi P, Majoros A. Safety and Efficacy of Vaginal Implants in Pelvic Organ Prolapse Surgery: A Meta-analysis of 161 536 Patients. Eur Urol Focus 2023:S2405-4569(23)00243-2. [PMID: 37968187 DOI: 10.1016/j.euf.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 11/02/2023] [Indexed: 11/17/2023]
Abstract
CONTEXT Among the many surgical treatments for pelvic organ prolapse (POP), better results can be achieved with the use of vaginal implants. However, owing to perceived complications, vaginal implant surgeries have been restricted or banned in many countries. OBJECTIVE To assess the real value of vaginal implants in POP surgery and compare the safety and efficacy of operations with and without implants. EVIDENCE ACQUISITION A systematic search was performed in three medical databases. Randomised controlled trials and observational studies comparing the safety and efficacy of vaginal POP surgery with implants versus native tissue were included. Safety outcomes were defined as different types of complications (functional and non-functional) and reoperations for complications. Efficacy outcomes were parameters of anatomical success and the rate of reoperations due to recurrence. A multivariate meta-analysis framework was used to estimate pooled odds ratios (ORs) with confidence intervals (CIs) with simultaneous control for study correlations and estimation of multiple correlated outcomes. EVIDENCE SYNTHESIS We included 50 comparative studies in the analysis. Rates of reoperation for complications (OR 2.15, 95% CI 1.20-3.87), vaginal erosion (OR 14.05, 95% CI 9.07-21.77), vaginal bleeding (OR 1.67, 95% CI 1.25-2.23), and de novo stress urinary incontinence (OR 1.44, 95% CI 1.18-1.75) were significantly higher in the implant group. Rates of anatomical success (OR 3.22, 95% CI 2.06-5.0) and reoperation for recurrence (OR 0.55, 95% CI 0.36-0.85) were superior in the implant group. CONCLUSIONS POP surgeries with vaginal implants are more effective than surgeries without implants, with acceptable complication rates. Therefore, the complete prohibition of implants for POP surgeries should be reconsidered. PATIENT SUMMARY We compared vaginal surgery with and without implants for repair of pelvic organ prolapse. Despite higher complication rates, vaginal implants provide better long-term results overall than surgery without implants.
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Affiliation(s)
- Júlia Ács
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary; Department of Urology, Semmelweis University, Budapest, Hungary
| | - Anett Szabó
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary; Department of Urology, Semmelweis University, Budapest, Hungary
| | - Péter Fehérvári
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary; Department of Biostatistics, University of Veterinary Medicine Budapest, Budapest, Hungary
| | - Andrea Harnos
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary; Department of Biostatistics, University of Veterinary Medicine Budapest, Budapest, Hungary
| | - Benjamin Skribek
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Martin Tenke
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary; Department of Urology, Semmelweis University, Budapest, Hungary
| | - Tibor Szarvas
- Department of Urology, Semmelweis University, Budapest, Hungary; Department of Urology, University of Duisburg-Essen and German Cancer Consortium, Essen, Germany
| | - Péter Nyirády
- Department of Urology, Semmelweis University, Budapest, Hungary
| | - Nándor Ács
- Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary; Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary; Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
| | - Attila Majoros
- Department of Urology, Semmelweis University, Budapest, Hungary.
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Lin CJ, Liu CK, Hsieh HY, Chen MJ, Tsai CP. Modified Vaginal Mesh Procedure with DynaMesh ®-PR4 for the Treatment of Anterior/Apical Vaginal Prolapse. Diagnostics (Basel) 2023; 13:2991. [PMID: 37761358 PMCID: PMC10528822 DOI: 10.3390/diagnostics13182991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/14/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
(1) Background: Treating female pelvic organ prolapse (POP) is challenging. Surgical meshes have been used in transvaginal surgeries since the 1990s, but complications such as mesh exposure and infection have been reported. Polyvinylidene fluoride (PVDF) mesh, known for its stability and non-reactive properties, has shown promise in urogynecological surgeries. (2) Methods: A retrospective analysis was conducted on 27 patients who underwent a modified PVDF vaginal mesh repair procedure using DynaMesh®-PR4 and combined trans-obturator and sacrospinous fixation techniques. Additional surgeries were performed as needed. (3) Results: The mean operation time was 56.7 min, and the mean blood loss was 66.7 mL. The average hospitalization period was 4.2 days with Foley catheter removal after 2 days. Patients experienced lower pain scores from the day of the operation to the following day. Postoperative follow-up revealed that 85.2% of patients achieved anatomic success, with 14.8% experiencing recurrent stage II cystocele. No recurrence of apical prolapse was observed. Complications were rare, with one case (3.7%) of asymptomatic mesh protrusion. (4) Conclusions: The modified vaginal mesh procedure using DynaMesh®-PR4 showed favorable outcomes with a short operation time, low recurrence rate, rare complications, and improved functional outcomes. This surgical option could be considered for anterior and apical pelvic organ prolapse in women.
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Affiliation(s)
- Chia-Ju Lin
- Department of Obstetrics and Gynecology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (C.-J.L.); (M.-J.C.)
| | - Chih-Ku Liu
- Department of Obstetrics and Gynecology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (C.-J.L.); (M.-J.C.)
| | - Hsiao-Yun Hsieh
- Department of Obstetrics and Gynecology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (C.-J.L.); (M.-J.C.)
| | - Ming-Jer Chen
- Department of Obstetrics and Gynecology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (C.-J.L.); (M.-J.C.)
| | - Ching-Pei Tsai
- Department of Obstetrics and Gynecology, Taichung Veterans General Hospital, Taichung 40705, Taiwan; (C.-J.L.); (M.-J.C.)
- Ph.D. Program in Translational Medicine, National Chung Hsing University, Taichung 40204, Taiwan
- Rong Hsing Research Center for Translational Medicine, National Chung Hsing University, Taichung 40204, Taiwan
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Gaultier V, Martel C, Boisramé T, Faller E, Lecointre L, Akladios C. Bilateral posterior Richter sacrospinous fixation with native tissue: anatomical and functional results and quality of life assessment over 10 years. J Gynecol Obstet Hum Reprod 2023; 52:102575. [PMID: 36972736 DOI: 10.1016/j.jogoh.2023.102575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 03/09/2023] [Indexed: 03/28/2023]
Abstract
INTRODUCTION Pelvic organ prolapse (POP) is a common condition that affects 50% of women who have given birth in their lifetime. With stop of vaginal mesh sale in 2019, the sacrospinous fixation technique according to Richter with native tissue has seen its incidence tripled in 15 years. Classically, sacrospinous fixation according to Richter is performed unilaterally, however its unilateral or bilateral character is controversial. Objective of this work is to evaluate the efficacy and safety of bilateral sacrospinous fixation according to Richter by the posterior approach with native tissue (SSB). METHODS We performed a retrospective single-center study. From March 12, 2010 to March 23, 2020, all first-time operated patients who underwent SSB in CHU Strasbourg gynecological surgery unit for symptomatic POP management were included. The main endpoint of our work is the anatomical and functional success rate at 12 and 24 months. The secondary judgment criteria of our work were based on the postoperative evaluation of patient's quality of life according to the PFDI-20 score as well as the rate of postoperative complications. RESULTS 77 patients were included in our work. The anatomical success rate at 12 months is 94% and 81% at 24 months regardless of the compartment affected. The functional success rate is 94% at 12 months and 82% at 24 months. Quality of life evaluation through the PFDI-20 scale revealed a clear improvement in the symptomatology related to POP: 127/300 +/- 27.3. preoperatively and 59.8 ± 14.7 postoperatively. CONCLUSION Bilateral sacrospinous fixation according to Richter by posterior approach with native tissue is a safe and effective surgical technique allowing a clear improvement in patients quality of life.
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Diedrich CM, Verhorstert KWJ, Riool M, Schuster H, de Boer L, Kikhney J, Moter A, Zaat SAJ, Roovers JPWR. Transvaginal Mesh-related Complications and the Potential Role of Bacterial Colonization: An Exploratory Observational Study. J Minim Invasive Gynecol 2023; 30:205-215. [PMID: 36442754 DOI: 10.1016/j.jmig.2022.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/12/2022] [Accepted: 11/19/2022] [Indexed: 11/27/2022]
Abstract
STUDY OBJECTIVE This study aimed to investigate the potential role of transvaginal mesh bacterial colonization in the development of mesh-related complications (MRCs). DESIGN An observational and exploratory study. SETTING Tertiary referral center (Amsterdam UMC, location AMC, Amsterdam, The Netherlands). PATIëNTS: 49 patients indicated for mesh removal and 20 women of whom vaginal tissue was retrieved during prolapse surgery as a reference cohort. INTERVENTIONS collection of mesh-tissue complex (patient cohort) or vaginal tissue (reference cohort) MEASUREMENTS AND MAIN RESULTS: Homogenized samples were used for quantitative microbiological culture. Inflammation and fibrosis were semiquantitatively histologically scored; Gram staining and fluorescence in situ hybridization were used to detect bacteria and bacterial biofilms. Of the 49 patients, 44 samples (90%) were culture positive, with a higher diversity of species and more Gram-negative bacteria and polymicrobial cultures in the MRC cohort than the reference cohort, with mostly staphylococci, streptococci, Actinomyces spp., Cutibacterium acnes, and Escherichia coli. Patients with clinical signs of infection or exposure had the highest bacterial counts. Histology demonstrated moderate to severe inflammation in most samples. Gram staining showed bacteria in 57% of culture-positive samples, and in selected samples, fluorescence in situ hybridization illustrated a polymicrobial biofilm. CONCLUSION In this study, we observed distinct differences in bacterial numbers and species between patients with MRCs and a reference cohort. Bacteria were observed at the mesh-tissue interface in a biofilm. These results strongly support the potential role of bacterial mesh colonization in the development of MRCs.
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Affiliation(s)
- Chantal M Diedrich
- Department of Obstetrics and Gynecology, Amsterdam Reproduction and Development, Amsterdam UMC, University of Amsterdam, Meibergdreef 9 (Drs. Diedrich, Verhorstert, Schuster, and Roovers), Amsterdam, The Netherlands; Department of Medical Microbiology and Infection Prevention, Amsterdam institute for Infection and Immunity, Amsterdam UMC, University of Amsterdam, Meibergdreef 9 (Drs. Diedrich, Verhorstert, Riool, Zaa, and Schuster, Ms. de Boer), Amsterdam, The Netherlands.
| | - Kim W J Verhorstert
- Department of Obstetrics and Gynecology, Amsterdam Reproduction and Development, Amsterdam UMC, University of Amsterdam, Meibergdreef 9 (Drs. Diedrich, Verhorstert, Schuster, and Roovers), Amsterdam, The Netherlands; Department of Medical Microbiology and Infection Prevention, Amsterdam institute for Infection and Immunity, Amsterdam UMC, University of Amsterdam, Meibergdreef 9 (Drs. Diedrich, Verhorstert, Riool, Zaa, and Schuster, Ms. de Boer), Amsterdam, The Netherlands
| | - Martijn Riool
- Department of Medical Microbiology and Infection Prevention, Amsterdam institute for Infection and Immunity, Amsterdam UMC, University of Amsterdam, Meibergdreef 9 (Drs. Diedrich, Verhorstert, Riool, Zaa, and Schuster, Ms. de Boer), Amsterdam, The Netherlands
| | - Heleen Schuster
- Department of Obstetrics and Gynecology, Amsterdam Reproduction and Development, Amsterdam UMC, University of Amsterdam, Meibergdreef 9 (Drs. Diedrich, Verhorstert, Schuster, and Roovers), Amsterdam, The Netherlands; Department of Medical Microbiology and Infection Prevention, Amsterdam institute for Infection and Immunity, Amsterdam UMC, University of Amsterdam, Meibergdreef 9 (Drs. Diedrich, Verhorstert, Riool, Zaa, and Schuster, Ms. de Boer), Amsterdam, The Netherlands
| | - Leonie de Boer
- Department of Medical Microbiology and Infection Prevention, Amsterdam institute for Infection and Immunity, Amsterdam UMC, University of Amsterdam, Meibergdreef 9 (Drs. Diedrich, Verhorstert, Riool, Zaa, and Schuster, Ms. de Boer), Amsterdam, The Netherlands
| | - Judith Kikhney
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute for Microbiology, Infectious Diseases, and Immunology, Biofilmcenter, Hindenburgdamm 30 (Drs. Kikhney and Moter), 12203 Berlin, Germany; MoKi Analytics GmbH, Hindenburgdamm 30 (Drs. Kikhney and Moter) 12203 Berlin, Germany
| | - Annette Moter
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute for Microbiology, Infectious Diseases, and Immunology, Biofilmcenter, Hindenburgdamm 30 (Drs. Kikhney and Moter), 12203 Berlin, Germany; MoKi Analytics GmbH, Hindenburgdamm 30 (Drs. Kikhney and Moter) 12203 Berlin, Germany; Practice Moter Diagnostics (practice), Marienplatz 9 (Dr. Moter), 12207 Berlin, Germany
| | - Sebastian A J Zaat
- Department of Medical Microbiology and Infection Prevention, Amsterdam institute for Infection and Immunity, Amsterdam UMC, University of Amsterdam, Meibergdreef 9 (Drs. Diedrich, Verhorstert, Riool, Zaa, and Schuster, Ms. de Boer), Amsterdam, The Netherlands
| | - Jan-Paul W R Roovers
- Department of Obstetrics and Gynecology, Amsterdam Reproduction and Development, Amsterdam UMC, University of Amsterdam, Meibergdreef 9 (Drs. Diedrich, Verhorstert, Schuster, and Roovers), Amsterdam, The Netherlands
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Tunn R, Baessler K, Knüpfer S, Hampel C. Urinary Incontinence and Pelvic Organ Prolapse in Women. DEUTSCHES ARZTEBLATT INTERNATIONAL 2023; 120:71-80. [PMID: 36647585 PMCID: PMC10080228 DOI: 10.3238/arztebl.m2022.0406] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 03/01/2022] [Accepted: 12/19/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Pelvic floor disorders are common, especially in pregnancy and after delivery, in the postmenopausal period, and old age, and they can significantly impact on the patient's quality of life. METHODS This narrative review is based on publications retrieved by a selective search of the literature, with special consideration to original articles and AWMF guidelines. RESULTS Pelvic floor physiotherapy (evidence level [EL] 1), the use of pessaries (EL2), and local estrogen therapy can help alleviate stress/urge urinary incontinence and other symptoms of urogenital prolapse. Physiotherapy can reduce urinary incontinence by 62% during pregnancy and by 29% 3-6 months post partum. Anticholinergic and β-sympathomimetic drugs are indicated for the treatment of an overactive bladder with or without urinary urge incontinence (EL1). For patients with stress urinary incontinence, selective serotonin-noradrenaline reuptake inhibitors can be prescribed (EL1). The tension-free tape is the current standard of surgical treatment (EL1); in an observational follow-up study, 87.2% of patients were satisfied with the outcome 17 years after surgery. Fascial reconstruction techniques are indicated for the treatment of primary pelvic organ prolapse, and mesh-based surgical procedures for recurrences and severe prolapse (EL1). CONCLUSION Urogynecological symptoms should be specifically asked about by physicians of all relevant specialties; if present, they should be treated conservatively at first. Structured surgical techniques with and without mesh are available for the treatment of urinary incontinence and pelvic organ prolapse. Preventive measures against pelvic floor dysfunction should be offered during pregnancy and post partum.
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Affiliation(s)
- Ralf Tunn
- Department of Urogynecology, German Pelvic Floor Center, Alexianer St. Hedwig Hospital, Berlin
| | - Kaven Baessler
- Pelvic Floor CenterFranziskus and St Joseph Hospitals Berlin
| | - Stephanie Knüpfer
- Clinic and Policlinic for Urology and Pediatric Urology, University Hospital of Bonn
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12
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Schütze S, Lindner A, Deniz M, Tunn R. [Innovative prolapse surgery without mesh implants]. UROLOGIE (HEIDELBERG, GERMANY) 2023; 62:125-131. [PMID: 36690726 DOI: 10.1007/s00120-022-02021-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/21/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND In many countries, such as France, England, USA, Canada, Australia, and New Zealand, alloplastic material in prolapse surgery has been paused due to the US Food and Drug Administration (FDA) warning, and restricted in other countries like the Netherlands and Sweden. For Europe and thus Germany, the SCENIHR report allows alloplastic material to be used for prolapse repair after recurrence and in other special situations. QUESTION Which established and innovative prolapse surgeries without alloplastic material are currently available? METHODS A literature search was carried out on established, guideline-compliant pelvic floor surgeries without alloplastic material as well as innovative new approaches. RESULTS An established procedure for a defect in the anterior compartment is anterior colporrhaphy, which is associated with a high recurrence rate. The double-layered anterior colporrhaphy is a new approach and so far is associated with an improved 19-month outcome. Apical pelvic organ prolapse can be corrected by sacrouterine ligament fixation and vaginal sacrospinous fixation. New innovative techniques include laparoscopic unilateral pectineal suspension and the use of the semitendinosus tendon autograft to perform pectopexy or sacropexy. However, long-term data are still pending. In case of a posterior vaginal wall prolapse, posterior colporrhaphy is the therapy of choice and is associated with good success rates. CONCLUSION Well-known surgical procedures with native tissue are experiencing a renaissance and new, innovative surgical approaches with good postoperative results are being developed. However, long-term studies are still necessary.
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Affiliation(s)
- S Schütze
- Frauenheilkunde und Geburtshilfe, Universitätsklinikum Ulm, Prittwitzstr. 43, 89075, Ulm, Deutschland.
| | - A Lindner
- Frauenheilkunde und Geburtshilfe, Universitätsklinikum Ulm, Prittwitzstr. 43, 89075, Ulm, Deutschland
| | - M Deniz
- Frauenheilkunde und Geburtshilfe, Universitätsklinikum Ulm, Prittwitzstr. 43, 89075, Ulm, Deutschland
| | - R Tunn
- Klinik für Urogynäkologie, Deutsches Beckenbodenzentrum, St. Hedwig Krankenhaus Berlin, Berlin, Deutschland
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13
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Rusavy Z, Grinstein E, Gluck O, Abdelkhalek Y, Deval B. Long-term development of surgical outcome of laparoscopic sacrohysteropexy with anterior and posterior mesh extension. Int Urogynecol J 2023; 34:191-200. [PMID: 35416498 DOI: 10.1007/s00192-022-05102-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 01/14/2022] [Indexed: 01/14/2023]
Abstract
INTRODUCTION AND HYPOTHESIS Long-term durability and functional outcome of laparoscopic sacrohysteropexy (LSH) remains to be confirmed. We set out to assess the development of surgical outcome in women with increasing minimal follow-up. METHODS All women after LSH with anterior and posterior mesh extension operated for advanced apical uterine prolapse at Geoffroy Saint-Hilaire clinic from July 2005 to June 2020 were enrolled in this retrospective study. Last known follow-up information was used for the analysis and allocation into groups. The surgical success was defined as no prolapse beyond hymen, no symptomatic recurrence or no retreatment. Functional outcome was evaluated from validated questionnaires and presence of pelvic floor disorders. The outcomes were compared with preoperative state using chi-square and Fisher's test; p < 0.05 was considered significant. RESULTS In total, 270 patients after LSH with a follow-up of up to 14.5 years were enrolled and divided into groups according to their last follow-up length: ≥ 1 year 242, ≥ 3 years 112, ≥ 5 years 76, ≥ 7 years 45 and ≥ 10 years 18 women. Increase of minimal follow-up was associated with gradual decrease in surgical success. Rates of stress urinary incontinence were unchanged by the surgery, while anal incontinence and constipation rates decreased significantly; 14.5% of women were operated on for SUI in the follow-up. The PFDI-20, PFIQ-7 and VAS bother scores decreased significantly regardless of minimal follow-up length. CONCLUSIONS LSH with anterior and posterior mesh extension is a safe, effective and durable surgery with a positive long-term effect on quality of life. Although the surgical success gradually decreases, LSH remains a surgical success in most women.
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Affiliation(s)
- Zdenek Rusavy
- Department of Obstetrics and Gynaecology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.
- Department of Functional Pelvic Surgery & Oncology, Geoffroy Saint-Hilaire, Ramsay, Générale de Santé, Paris, France.
| | - Ehud Grinstein
- Department of Functional Pelvic Surgery & Oncology, Geoffroy Saint-Hilaire, Ramsay, Générale de Santé, Paris, France
- Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon, Israel, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ohad Gluck
- Department of Functional Pelvic Surgery & Oncology, Geoffroy Saint-Hilaire, Ramsay, Générale de Santé, Paris, France
- Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon, Israel, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yara Abdelkhalek
- Department of Functional Pelvic Surgery & Oncology, Geoffroy Saint-Hilaire, Ramsay, Générale de Santé, Paris, France
| | - Bruno Deval
- Department of Functional Pelvic Surgery & Oncology, Geoffroy Saint-Hilaire, Ramsay, Générale de Santé, Paris, France
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Zhou Q, Lu M, Li GS, Peng GL, Song YF. Knowledge mapping and visualization analysis of pelvic organ prolapse repair with mesh from 2001 to 2021. Front Bioeng Biotechnol 2023; 11:1104724. [PMID: 37091336 PMCID: PMC10113510 DOI: 10.3389/fbioe.2023.1104724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/22/2023] [Indexed: 04/25/2023] Open
Abstract
Aims: In recent decades, extensive attention has been paid to the application of mesh to repair pelvic floor defects. However, a large body of related literature has not been system summarized. The purpose of this study is to summarize and visualize the literature on pelvic organ prolapse (POP) repair with mesh using bibliometrics. Methods: Medical literature regarding POP repair with mesh were searched and obtained in the Web of Science™ Core (WoSCC) database from 2001 to 2021. Microsoft Excel 2020, CiteSpace and VOSviewer were used to conduct the bibliometric and knowledge-map analysis. Results: In the past 20 years, a total of 2,550 articles and reviews have been published in 35 journals, and the published and cited results show a growing trend. Cosson M and International Urogynecology Journal were the authors and journals with the highest output, respectively. The United States, France and the United Kingdom are among the top three countries/organizations in relevant publications in worldwide. 584 key words in the literature are divided into 8 clusters, which are mainly related to prolapse type, risk factors, surgical methods, imaging, quality of life and bioengineering. Using clinical research and tissue engineering technology to reduce mesh complications is the current hot spot in this field. Conclusion: Reasonable application of mesh and avoiding mesh complications are still the most concerned topics in POP research. Although clinical research, surgical improvement, biological mesh and bioengineering technology have shown promising results, it is still urgent to carry out clinical transformation application research.
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Affiliation(s)
- Quan Zhou
- Department of Gynecology and Obstetrics, The People’s Hospital of China Three Gorges University/The First People’s Hospital of Yichang, Yichang, China
- Department of Gynecology and Obstetrics, The 900th Hospital of Joint Logistic Support Force, Fuzhou, Fujian, China
- *Correspondence: Quan Zhou, ; Yan-Feng Song,
| | - Man Lu
- Department of Gynecology and Obstetrics, The People’s Hospital of China Three Gorges University/The First People’s Hospital of Yichang, Yichang, China
| | - Guo-Sheng Li
- Department of Gynecology and Obstetrics, The People’s Hospital of China Three Gorges University/The First People’s Hospital of Yichang, Yichang, China
| | - Gan-Lu Peng
- Department of Gynecology and Obstetrics, The People’s Hospital of China Three Gorges University/The First People’s Hospital of Yichang, Yichang, China
| | - Yan-Feng Song
- Department of Gynecology and Obstetrics, The 900th Hospital of Joint Logistic Support Force, Fuzhou, Fujian, China
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15
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Development of a conceptual framework for a new patient-reported outcome measure for pain in women following mesh surgery for pelvic floor disorders: a qualitative study. Int Urogynecol J 2022:10.1007/s00192-022-05425-w. [DOI: 10.1007/s00192-022-05425-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 11/17/2022] [Indexed: 12/24/2022]
Abstract
Abstract
Introduction and hypothesis
The Australasian Pelvic Floor Procedure Registry (APFPR) collects both clinical and health-related quality of life (HRQoL) data on women undergoing surgery using a prosthesis such as mesh for pelvic organ prolapse (POP) and stress urinary incontinence (SUI). The registry lacks a suitable instrument to assess pain in women following mesh surgery for SUI and POP. This qualitative study describes the views on pain following mesh surgery in women and clinicians through the development of a conceptual framework, which may inform the development of a new instrument for the APFPR.
Methods
We conducted semi-structured interviews with women following mesh surgery for POP and SUI (n=17) and clinicians (n=6) in Victoria, Australia. We sought to reveal aspects of any sort of pain after a pelvic floor procedure. Interviews covered sensation, region, continuity of pain, triggers, and the mode and method of administration for a new pain-specific patient-reported outcome measure. Data were analysed using thematic analysis.
Results
We identified the important components of pain felt by women with POP and SUI after surgery using mesh. From the seven themes outlined, a conceptual framework was developed compiling related components of pain into six specific domains.
Conclusions
This study identifies the important components of pain felt by women following mesh surgery. It is hoped that the development of a pain-specific PROM, as supported by clinicians, will assist in the timely and appropriate diagnosis and management of POP and SUI.
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Oxlad M, Edwards G, McKinlay KA. Patients' perspectives about doctor-patient communication regarding transvaginal mesh implant surgery. PATIENT EDUCATION AND COUNSELING 2022; 105:3534-3539. [PMID: 36114043 DOI: 10.1016/j.pec.2022.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 08/10/2022] [Accepted: 08/31/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Many women experience pelvic floor disorders which may require medical intervention such as transvaginal mesh implant surgeries (TVM; the abdominal or vaginal insertion of woven netting to support pelvic tissue). We examined women's perceptions of communication with their health professionals concerning TVM. DESIGN We analysed 153 women's written submissions to an Australian Government Inquiry regarding their experiences of transvaginal mesh surgery to explore their perceptions of TVM-related doctor-patient communication. Data were analysed using deductive and inductive reflexive thematic analysis. RESULTS Women expressed several challenges in their communication with their health professionals. Three themes regarding communication were generated: Insufficient information was abundant; Normalisation and minimisation of the procedure and risks; and, Desired communication interactions. CONCLUSIONS According to women's accounts, doctor-patient communication was poor. Health professionals must be knowledgeable about medical procedures and their potential complications and provide their patients with adequate, accurate information to make informed choices about their health. Health professionals should also document informed consent. PRACTICE IMPLICATIONS Health professionals should be well-informed about TVM, including best-practice treatments for pelvic floor disorders, indications for TVM, the risks, outcomes and potential complications from various forms of TVM, and ways to adequately communicate sufficient information to women.
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Affiliation(s)
- Melissa Oxlad
- School of Psychology, The University of Adelaide, Adelaide, Australia.
| | - Georgina Edwards
- School of Psychology, The University of Adelaide, Adelaide, Australia.
| | - Kate A McKinlay
- School of Psychology, The University of Adelaide, Adelaide, Australia
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Chen J, Yu J, Morse A, Tao G, Gong J, Wang B, Wang Y, Ababaikeli G, Jiang X, Liu P, Zhang X, Nisier H, Wang P, Fünfgeld C, Huang K, Zhang H, Sun X, Zhu L. Effectiveness of Self-cut vs Mesh-Kit Titanium-Coated Polypropylene Mesh for Transvaginal Treatment of Severe Pelvic Organ Prolapse: A Multicenter Randomized Noninferiority Clinical Trial. JAMA Netw Open 2022; 5:e2231869. [PMID: 36112377 PMCID: PMC9482053 DOI: 10.1001/jamanetworkopen.2022.31869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
IMPORTANCE Transvaginal mesh (TVM) can increase the durability of vaginal surgical procedures for pelvic organ prolapse (POP) and may be indicated in certain situations despite concerns about mesh-related complications. In addition, the expense of commercial mesh kits has limited their use. The effectiveness, safety, and cost of a self-cut mesh procedure compared with a commercial mesh-kit procedure for the surgical treatment of women with POP is unclear. OBJECTIVE To assess the 1-year effectiveness and safety of self-cut titanium-coated polypropylene mesh compared with a precut commercial mesh kit for the transvaginal surgical treatment of women with severe symptomatic POP. DESIGN, SETTING, AND PARTICIPANTS This multicenter randomized noninferiority clinical trial was conducted at 11 hospitals in 8 provinces of China. A total of 336 women with symptomatic stage 3 to 4 POP were enrolled between January 22, 2018, and November 11, 2019, with follow-up through December 11, 2020. INTERVENTIONS Participants were randomized to receive a TVM procedure using either self-cut mesh (self-cut mesh group) or a precut commercial mesh kit (mesh-kit group), both of which used the same titanium-coated polypropylene mesh. MAIN OUTCOMES AND MEASURES The primary outcome measure was composite surgical success at 1 year, which was defined as the absence of vaginal bulge symptoms, no additional retreatment for POP, and no vaginal prolapse at or beyond the hymen. Secondary outcomes included symptom-specific pelvic floor function and quality-of-life measures as well as perioperative complications, including mesh-related complications and hospitalization costs. Complications were categorized using the Clavien-Dindo system (with grade 1 indicating any deviation from the normal postoperative course but not requiring grade 2-4 interventions; grade 2, need for pharmacological treatment, blood transfusion, and/or total parenteral nutrition; grade 3, the need for surgical, endoscopic, and/or interventional radiological procedures; and grade 4, life threatening). RESULTS Among 336 female participants (mean [SD] age, 63.3 [5.9] years; all of Chinese ethnicity), 169 patients were randomized to the self-cut mesh group, and 167 were randomized to the mesh-kit group. Three patients were unavailable for follow-up after 1 year. In the intention-to-treat analysis, 162 women (95.9%) in the self-cut mesh group had outcomes that met the definition of surgical success; this result was noninferior to the surgical success rate observed in the mesh-kit group (146 women [87.4%]; risk difference, 8.5%; 95% CI, 2.2%-14.3%; P = .006). The frequency of Clavien-Dindo grade 1 to 3 perioperative complications was not significant between groups (12 of 166 women [7.2%] in the self-cut mesh group vs 20 of 161 women [12.4%] in the mesh-kit group; P = .14). Vaginal mesh exposure rates in women examined at 1 year were similar (4 women [2.4%] in the self-cut mesh group vs 8 women [4.8%] in the mesh-kit group; P = .23). Median (IQR) total hospitalization costs were $3663.00 ($3258.90-$4495.10) in the self-cut mesh group vs $6144.00 ($5434.90-$7160.20) in the mesh-kit group (P < .01), representing savings of $2481.00 (40.4%) with the use of self-cut mesh. CONCLUSIONS AND RELEVANCE In this clinical trial, the composite surgical success rate of a self-cut mesh procedure was noninferior to that of a commercial mesh-kit procedure using the same titanium-coated polypropylene mesh and reduced hospitalization expenses by 40.4%. These findings suggest that the use of self-cut mesh procedures may be advantageous for the surgical treatment of some women with severe POP, particularly those in countries with low and middle income. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03283124.
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Affiliation(s)
- Juan Chen
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - Jiajie Yu
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Abraham Morse
- Department of Obstetrics and Gynecology, Tufts University School of Medicine, Boston, Massachusetts
| | - Guangshi Tao
- Department of Obstetrics and Gynecology, The Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Jian Gong
- Department of Obstetrics and Gynecology, Wuxi Maternal and Child Health Care Hospital, Wuxi, Jiangsu, China
| | - Binan Wang
- Department of Obstetrics and Gynecology, Changsha Maternal and Child Health Care Hospital, Changsha, Hunan, China
| | - Yuling Wang
- Department of Gynecology, Foshan Women and Children Hospital, Southern Medical University, Foshan, Guangdong, China
| | - Gulina Ababaikeli
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Xinjiang Medical University, Ürümqi, Xinjiang, China
| | - Xiangyang Jiang
- Department of Obstetrics and Gynecology, Shaanxi Provincial People’s Hospital, Xi'an, Shaanxi, China
| | - Peishu Liu
- Department of Obstetrics and Gynecology, Qilu Hospital of Shandong University, Jinan, Shandong, China
| | - Xiaowei Zhang
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Hatiguli Nisier
- Department of Gynecology, The People's Hospital of Xinjiang, Uygur, Autonomous Region Ürümqi15, Xinjiang, China
| | - Ping Wang
- Department of Gynecology, West China Second Hospital of Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, West China Second Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Christian Fünfgeld
- Department of Obstetrics and Gynecology, Klinik Tettnang, Tettnang, Germany
| | - Kuanhui Huang
- Department of Obstetrics and Gynecology, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung City, Taiwan
- Department of Obstetrics and Gynecology, Xiamen Chang Gung Memorial Hospital, Xiamen, Fujian, China
| | - Heping Zhang
- Department of Biostatistics, Yale University School of Public Health, New Haven, Connecticut
| | - Xin Sun
- Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- NMPA Key Laboratory for Real World Data Research and Evaluation, Hainan, Chengdu, China
- Sichuan Center of Technology Innovation for Real World Data, Chengdu, China
| | - Lan Zhu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
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Ludwin A, Tudorache S, Martins WP. ASRM Müllerian Anomalies Classification 2021: a critical review. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:7-21. [PMID: 35678250 DOI: 10.1002/uog.24905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 01/21/2022] [Accepted: 02/14/2022] [Indexed: 06/15/2023]
Affiliation(s)
- A Ludwin
- Department of Gynecology and Oncology, Jagiellonian University, Krakow, Poland
- Ludwin & Ludwin Gynecology, Private Medical Center, Krakow, Poland
| | - S Tudorache
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Medicine and Pharmacy of Craiova, Craiova, Romania
| | - W P Martins
- SEMEAR Fertilidade, Reproductive Medicine, Ribeirão Preto, Brazil
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Rusavy Z, Najib B, Abdelkhalek Y, Grinstein E, Gluck O, Deval B. Outcomes of sacrocolpopexy/sacrohysteropexy with mesh placement targeted to affected compartment. Eur J Obstet Gynecol Reprod Biol 2022; 272:188-192. [PMID: 35364554 DOI: 10.1016/j.ejogrb.2022.03.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 03/19/2022] [Accepted: 03/24/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE No recommendation regarding the number of meshes to be implanted in laparoscopic genital prolapse surgery exists. Is it necessary to implant a mesh into a compartment that is not affected to prevent its prolapse in the follow-up? Our objective was to compare the long-term outcomes of laparoscopic sacrocolpopexy according to compartments where mesh was implanted. STUDY DESIGN This is a retrospective cohort study of 328 patients after laparoscopic sacrocolpopexy at our centre in 7/2005 - 3/2021. 294 patients with perioperative data and POP-Q and/or prolapse symptoms in mean follow-up of 42.8 months was available for the outcome analysis. Surgical failure was defined as prolapse beyond hymen, subjective recurrence or retreatment. The women were divided into four groups depending on compartments, where the mesh was implanted. Group A - anterior, group P - posterior, Group AP - compound of patients with anterior or posterior single arm mesh placement and (B), with anterior and posterior arm placement. Groups AP and B were compared for feasibility of single compartment mesh implantation. Comparison of groups A and P allowed assessment of non-inferiority of single anterior vs. posterior compartment placement. The data were compared using Wilcoxon Two Sample test, Chi-square test or Fisheŕs Exact test, p-value < 0.05 was considered statistically significant. RESULTS A single compartment mesh implantation was associated with shorter operating time and hospital stay and comparable incidence of complications. A statistically significant difference in all POP-Q points in favour of group B was observed, however, with comparable rate of prolapse beyond hymen(6.3%AP vs. 7.8%B). Similar frequency of surgical failure (17.5%AP vs. 13.8%B) and incidence of de novo pelvic floor disorders or pain was observed. Comparison of groups A and P showed higher suspension of point C in group P(-2.6 vs. -4.0, p < 0.05) with no difference in points Ba, Bp, surgical failure rate and de novo pelvic floor disorders. CONCLUSION Implantation of a single sheet of mesh was not associated with inferior outcome to implantation of mesh to both compartments. Laparoscopic sacrocolpopexy with a single mesh arm placed into the affected compartment along with apical suspension does not induce a de novo prolapse in unoperated compartment.
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Affiliation(s)
- Zdenek Rusavy
- Department of Obstetrics and Gynaecology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic; Department of Functional Pelvic Surgery & Oncology, Geoffroy Saint-Hilaire, Ramsay, Générale de Santé, Paris, France.
| | - Bernard Najib
- Department of Functional Pelvic Surgery & Oncology, Geoffroy Saint-Hilaire, Ramsay, Générale de Santé, Paris, France
| | - Yara Abdelkhalek
- Department of Functional Pelvic Surgery & Oncology, Geoffroy Saint-Hilaire, Ramsay, Générale de Santé, Paris, France
| | - Ehud Grinstein
- Department of Functional Pelvic Surgery & Oncology, Geoffroy Saint-Hilaire, Ramsay, Générale de Santé, Paris, France; Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon, Israel, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ohad Gluck
- Department of Functional Pelvic Surgery & Oncology, Geoffroy Saint-Hilaire, Ramsay, Générale de Santé, Paris, France; Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon, Israel, affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Bruno Deval
- Department of Functional Pelvic Surgery & Oncology, Geoffroy Saint-Hilaire, Ramsay, Générale de Santé, Paris, France
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Verhorstert KW, Riool M, Bulten T, Guler Z, de Boer L, Roovers JPW, Zaat SA. The impact of bacterial contamination on the host response towards fully absorbable poly-4-hydroxybutyrate and nonabsorbable polypropylene pelvic floor implants. Mater Today Bio 2022; 15:100268. [PMID: 35517580 PMCID: PMC9062440 DOI: 10.1016/j.mtbio.2022.100268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/11/2022] [Accepted: 04/17/2022] [Indexed: 11/03/2022] Open
Abstract
Polypropylene (PP) implants for the vaginal surgical correction of pelvic organ prolapse (POP) are known for adverse events, like vaginal or visceral exposures. It is hypothesized that this is a result of a prolonged inflammatory response. One of the triggering factors of prolonged inflammation might be bacterial contamination. A possible solution might lie in an absorbable biomaterial, which provides initial mechanical support while being gradually replaced by the host tissue. With this study we aimed to compare the host response, in a subcutaneous mouse implant infection model, to delayed absorbable poly-4-hydroxybutyrate (P4HB) and a latest generation PP implant. By comparing non-infected to Staphylococcus aureus infected mice, we assessed how bacterial contamination affects the host response and its role in the development of complications. Further, we included sham surgery as a control, mimicking the wound response in native tissue repair. Despite the higher surface area of the P4HB implants, the clearance of infection was similarly delayed in the presence of a P4HB or PP implant, as compared to sham. Further, the host response towards P4HB and PP was quite comparable, yet collagen deposition was significantly increased around infected P4HB implants at early time points. Adverse event rates were similar, though implant exposures were only seen in infected mice and more often with PP (11.1%) than P4HB implants (5.6%). Infected mice overall had significantly higher levels of infiltration of inflammatory cells and lower levels of vascularization and collagen deposition compared to non-infected mice. Thus, for both P4HB and PP, bacterial contamination negatively affected mesh integration by increased inflammation and an increased adverse event rate. Altogether, our results from this subcutaneous mouse implant infection study suggest that P4HB could be a promising degradable alternative to PP, warranting further research to study its potential as a new surgical solution for women with POP. Absorbable poly-4-hydroxybutyrate (P4HB) is studied as a novel pelvic floor implant. Comparable host response to P4HB and polypropylene in a subcutaneous mouse implant infection model. Implant exposures exclusively occurred upon Staphylococcus aureus infection. Exposures occurred less with P4HB (5.6%) compared to polypropylene (11.1%). S. aureus infection increased inflammation and deranged the host response.
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Luchristt D, Weidner AC, Siddiqui NY. Urinary basement membrane graft-augmented sacrospinous ligament suspension: a description of technique and short-term outcomes. Int Urogynecol J 2022; 33:1347-1350. [PMID: 35294566 DOI: 10.1007/s00192-022-05159-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 02/07/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Since the discontinuation of manufacture and distribution of surgical mesh for transvaginal prolapse repair, the use of biologic grafts for transvaginal apical suspension has gained renewed attention. However, there is no FDA-approved device and minimal published data describing such an approach. The objective of this video is to describe a technique and to present limited short-term outcomes utilizing a porcine urinary basement membrane (UBM) graft to perform an augmented bilateral sacrospinous ligament suspension (SSLS). METHODS We present a step-by-step overview of our technique to perform an augmented SSLS with off-label utilization of a 7- × 10-cm porcine UBM graft. We demonstrate graft shaping and application during transvaginal repair along with data describing perioperative outcomes associated with a series of 25 cases performed at our institution using the technique described. RESULTS No perioperative complications related to the graft were observed in our cohort. The most common postoperative concern was buttock pain, which spontaneously resolved within 6 months. Two individuals (8%) developed recurrent prolapse within 1 year of surgery. CONCLUSIONS The UBM-augmented apical suspension allows for reinforced transvaginal prolapse repair without the use of permanent mesh material. We have observed good clinical success in our application of this technique, but dedicated research assessing long-term outcomes compared with a native tissue repair is needed.
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Affiliation(s)
- Douglas Luchristt
- Division of Urogynecology, Department of Obstetrics & Gynecology, Duke University, 5324 McFarland Drive, Suite 310, Durham, NC, 27707, USA.
| | - Alison C Weidner
- Division of Urogynecology, Department of Obstetrics & Gynecology, Duke University, 5324 McFarland Drive, Suite 310, Durham, NC, 27707, USA
| | - Nazema Y Siddiqui
- Division of Urogynecology, Department of Obstetrics & Gynecology, Duke University, 5324 McFarland Drive, Suite 310, Durham, NC, 27707, USA
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22
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Marquini GV, Bella ZIKDJD, Sartori MGF. Burch Procedure: A Historical Perspective. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRICIA : REVISTA DA FEDERACAO BRASILEIRA DAS SOCIEDADES DE GINECOLOGIA E OBSTETRICIA 2022; 44:511-518. [PMID: 35181882 PMCID: PMC9948263 DOI: 10.1055/s-0042-1744312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION The Burch procedure (1961) was considered the gold standard treatment for stress urinary incontinence (SUI) before the midurethral slings (MUSs) were introduced, in 2001. OBJECTIVE This historical perspective of the Burch's timeline can encourage urogynecological surgeons to master the Burch technique as one of the options for surgical treatment of SUI. SEARCH STRATEGY AND SELECTION CRITERIA A bibliographic search was performed in the PubMed and National Library of Medicine (NIH) databases with the terms Burch colposuspension AND history AND stress urinary incontinence in the last 20 years. The original article by Burch (1961) was included. The references were read by three authors. The exclusion criterion was studies in non-English languages. Biomedical Library Special Collections were included as historical relevant search. DATA COLLECTION, ANALYSIS AND MAIN RESULTS Some modifications of the technique have been made since the Burch procedure was first described. The interest in this technique has been increasing due to the negative publicity associated with vaginal synthetic mesh products. Twenty-nine relevant articles were included in the present review article, and numerous trials have compared Burch colposuspension with MUS. CONCLUSION This historical perspective enables the scientific community to review a standardized technique for SUI. Burch colposuspension should be considered an appropriate surgical treatment for women with SUI, and an option in urogynecological training programs worldwide.
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Mardina Z, Venezuela J, Maher C, Shi Z, Dargusch M, Atrens A. Design, mechanical and degradation requirements of biodegradable metal mesh for pelvic floor reconstruction. Biomater Sci 2022; 10:3371-3392. [DOI: 10.1039/d2bm00179a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Pelvic organ prolapse (POP) is the herniation of surrounding tissue and organs into the vagina and or rectum, and is a result of weakening of pelvic floor muscles, connective tissue,...
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24
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Drage KJ, Aghera M, MacKellar P, Twentyman R, Jacques A, Chalmers KJ, Neumann P, Nurkic I, Thompson J. The relationship between symptom severity, bother and psychological factors in women with pelvic organ prolapse: A cross-sectional observational study. Neurourol Urodyn 2021; 41:423-431. [PMID: 34888916 DOI: 10.1002/nau.24842] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 09/23/2021] [Accepted: 10/21/2021] [Indexed: 11/09/2022]
Abstract
AIM The primary aim is to explore the relationship between symptom severity and prolapse bother in women with pelvic organ prolapse (POP). The secondary aim is to determine the association between psychological variables and prolapse bother. METHODS A cross-sectional observational study was conducted via online surveys assessing POP bother (visual analog scale for bother), POP symptom severity (International Consultation on Incontinence Questionnaire-Vaginal Symptoms), and psychological measures of depression and anxiety (Kessler psychological distress scale [K-10]), catastrophizing (modified pain catastrophizing scale [mPCS]), and self-efficacy (modified pain self-efficacy questionnaire [mPSEQ]) in women with self-reported POP. Symptom severity, bother and psychological variables were analyzed using linear regression. RESULTS Seventy-six women with a mean (SD) age of 42.8 (14.57) years were included in analysis. A moderate to strong positive linear relationship (R2 = 0.449, p < 0.001) was found between symptom severity and POP bother. Prolapse bother and psychological variables were moderately correlated, where increased K-10 scores (R2 = 0.230, p = 0.001), higher mPCS scores (R2 = 0.460, p < 0.001), and lower mPSEQ scores (R2 = 0.460, p < 0.001) were associated with increased POP bother. Moderate and severe catastrophizing was associated with significantly higher POP bother, with mean POP bother scores of 7.861 ± 0.45 (p < 0.001) and 8.652 ± 0.45 (p < 0.001), respectively. CONCLUSION A moderate positive relationship between POP bother and symptom severity was found, with greater psychological distress and lower self-efficacy associated with increasing POP bother. Women presenting with POP should be screened for psychological factors to guide management.
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Affiliation(s)
- Katie-Jay Drage
- Masters of Clinical Physiotherapy (Continence and Women's Health) Program, Curtin University, Perth, Western Australia, Australia
| | - Mansi Aghera
- Masters of Clinical Physiotherapy (Continence and Women's Health) Program, Curtin University, Perth, Western Australia, Australia
| | - Phoebe MacKellar
- Masters of Clinical Physiotherapy (Continence and Women's Health) Program, Curtin University, Perth, Western Australia, Australia
| | - Rhea Twentyman
- Masters of Clinical Physiotherapy (Continence and Women's Health) Program, Curtin University, Perth, Western Australia, Australia
| | - Angela Jacques
- School of Allied Health, Curtin University, Perth, Western Australia, Australia
| | - K Jane Chalmers
- IIMPACT in Health, University of South Australia, Adelaide, South Australia, Australia.,School of Health Sciences, Western Sydney University, Penrith, New South Wales, Australia
| | - Patricia Neumann
- Allied Health and Human Performance, University of South Australia, Adelaide, South Australia, Australia
| | - Irena Nurkic
- School of Allied Health, Curtin University, Perth, Western Australia, Australia
| | - Judith Thompson
- School of Allied Health, Curtin University, Perth, Western Australia, Australia
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25
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Chang CL, Chen CH, Yang SSD, Chang SJ. An updated systematic review and network meta-analysis comparing open, laparoscopic and robotic-assisted sacrocolpopexy for managing pelvic organ prolapse. J Robot Surg 2021; 16:1037-1045. [PMID: 34779989 DOI: 10.1007/s11701-021-01329-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/24/2021] [Indexed: 10/19/2022]
Abstract
Abdominal sacrocolpopexy is considered as the gold standard treatment for pelvic organ prolapse. Sacrocolpopexy can be performed using open (OSC), laparoscopic (LSC), and robotic-assisted (RSC) approaches. The aim of this study is to compare the outcomes between these three approaches for managing pelvic organ prolapse by conducting a systematic review and network meta-analysis. A systematic search was performed in different databases from their earliest records to April 2021 with no restriction on languages. Only randomized controlled trials that compared the outcomes between OSC, LSC, and RSC were included in this study. A total of 6 studies with 486 participants were included in this study. Operative time was significantly shorter in OSC than in RSC and LSC. The probability rank showed less estimated blood loss in RSC and lowest overall postoperative complications in LSC. Probability scores also showed best anatomical outcomes for postoperative points C and Bp in RSC and for point Ba in LSC. Despite significantly longer operative time, RSC and LSC may provide better anatomical outcomes, less estimated blood loss, and less overall postoperative complications than OSC. However, this study did not find significant differences between RSC and LSC in efficacy and safety.
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Affiliation(s)
- Chia-Lun Chang
- Division of Urology, Taipei Tzu Chi Hospital, Tzu Chi Medical Foundation, New Taipei City, 231, Taiwan.,School of Medicine, Tzu Chi University, Hualien City, 970, Taiwan
| | - Chun-Hua Chen
- Department of Neurology, Taipei Municipal Wanfang Hospital, Taipei, Taiwan
| | - Stephen Shei-Dei Yang
- Division of Urology, Taipei Tzu Chi Hospital, Tzu Chi Medical Foundation, New Taipei City, 231, Taiwan.,School of Medicine, Tzu Chi University, Hualien City, 970, Taiwan
| | - Shang-Jen Chang
- Division of Urology, Taipei Tzu Chi Hospital, Tzu Chi Medical Foundation, New Taipei City, 231, Taiwan. .,School of Medicine, Tzu Chi University, Hualien City, 970, Taiwan.
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26
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Muller P, Gurol-Urganci I, Thakar R, Ehrenstein MR, Van Der Meulen J, Jha S. Impact of a mid-urethral synthetic mesh sling on long-term risk of systemic conditions in women with stress urinary incontinence: a national cohort study. BJOG 2021; 129:664-670. [PMID: 34524725 PMCID: PMC9292923 DOI: 10.1111/1471-0528.16917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/02/2021] [Indexed: 11/29/2022]
Abstract
Objective To compare the incidence of systemic conditions between women who had surgical treatment for stress incontinence with mesh and without mesh. Design National cohort study. Setting English National Health Service. Population Women with no previous record of systemic disease who had first‐time urinary incontinence surgery between 1 January 2006 and 31 December 2013, followed up to the earliest of 10 years or 31 March 2019. Methods Competing‐risks regression was used to estimate hazard ratios (HR), adjusted for patient characteristics, with HR > 1 indicating increased incidence following mesh surgery. Main outcome measures First postoperative admission with a record of autoimmune disease, fibromyalgia or myalgic encephalomyelitis up to 10 years following the first incontinence procedure. Results The cohort included 88 947 women who had mesh surgery and 3389 women who had non‐mesh surgery. Both treatment groups were similar with respect to age, socio‐economic deprivation, comorbidity and ethnicity. The 10‐year cumulative incidence of autoimmune disease, fibromyalgia or myalgic encephalomyelitis was 8.1% (95% CI 7.9–8.3%) in the mesh group and 9.0% (95% CI 8.0–10.1%) in the non‐mesh group (adjusted HR 0.89, 95% CI 0.79–1.01; P = 0.07). A sensitivity analysis including only autoimmune diseases as an outcome returned a similar result. Conclusions These findings do not support claims that synthetic mesh slings cause systemic disease. Tweetable abstract No evidence of increased risk of systemic conditions after stress incontinence treatment with a mesh sling. No evidence of increased risk of systemic conditions after stress incontinence treatment with a mesh sling.
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Affiliation(s)
- P Muller
- London School of Hygiene & Tropical Medicine, London, UK.,Royal College of Obstetricians and Gynaecologists, London, UK
| | - I Gurol-Urganci
- London School of Hygiene & Tropical Medicine, London, UK.,Royal College of Obstetricians and Gynaecologists, London, UK
| | - R Thakar
- Royal College of Obstetricians and Gynaecologists, London, UK.,Croydon University Hospital, Croydon, UK
| | | | - J Van Der Meulen
- London School of Hygiene & Tropical Medicine, London, UK.,Royal College of Obstetricians and Gynaecologists, London, UK
| | - S Jha
- British Society of Urogynaecology, London, UK.,Sheffield Teaching Hospitals, Sheffield, UK
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Beckenbodeninsuffizienz und Sexualität aus gynäkologischer Sicht. COLOPROCTOLOGY 2021. [DOI: 10.1007/s00053-021-00552-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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28
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Kanji S, Pascali D, Clancy AA. Short term complications in mesh augmented vaginal repair of pelvic organ prolapse are not higher when compared with native tissue repair. Int Urogynecol J 2021; 33:1941-1947. [PMID: 34331076 DOI: 10.1007/s00192-021-04915-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 06/07/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Accumulating evidence regarding the negative long-term consequences of transvaginal mesh-based procedures for pelvic organ prolapse has led to a sharp decline in mesh-based procedures. We aimed to evaluate the short-term complications of mesh-based procedures for carefully selected patients with pelvic organ prolapse after Food and Drug Administration warnings. METHODS A retrospective database review of the ACS NSQIP database was completed to examine 30-day complications including re-operation, prolonged length of stay, blood transfusion, surgical site infection, urinary tract infection, readmission and wound dehiscence in mesh-augmented and native tissue-based transvaginal procedures for pelvic organ prolapse. RESULTS A total of 36,234 patients were included in the analysis, with only 7.1% (2574 women) having mesh-augmented repair. Using a multivariable logistical regression analysis adjusting for confounders, we found that the primary composite outcome (re-operation, hospital stay, blood transfusion and surgical site infection) was less common in the mesh group compared with the native tissue repair group (adjusted OR 0.80, CI 0.67-0.95, p = 0.009). The secondary outcomes (urinary tract infection, re-admission and wound dehiscence) were not different between the group. CONCLUSION These results suggest that in well-chosen patients, short-term complications are not increased when using transvaginal mesh for pelvic organ prolapse repair.
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Affiliation(s)
- Sarah Kanji
- Department of Obstetrics and Gynecology, The Ottawa Hospital, Ottawa, ON, Canada
| | - Dante Pascali
- Department of Obstetrics and Gynecology, Division of Urogynecology and Pelvic Reconstructive Surgery, The Ottawa Hospital, Ottawa, ON, Canada.,University of Ottawa, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada
| | - Aisling A Clancy
- Department of Obstetrics and Gynecology, Division of Urogynecology and Pelvic Reconstructive Surgery, The Ottawa Hospital, Ottawa, ON, Canada. .,University of Ottawa, 501 Smyth Road, Ottawa, ON, K1H 8L6, Canada.
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Silva MET, Bessa JNM, Parente MPL, Mascarenhas T, Natal Jorge RM, Fernandes AA. Effect of mesh anchoring technique in uterine prolapse repair surgery: A finite element analysis. J Biomech 2021; 127:110649. [PMID: 34375905 DOI: 10.1016/j.jbiomech.2021.110649] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 05/28/2021] [Accepted: 07/25/2021] [Indexed: 11/17/2022]
Abstract
The female pelvic cavity involves muscles, ligaments, endopelvic fasciae and multiple organs where different pathologies may occur, namely the pelvic organ prolapse (POP). The synthetic implants are used for the reconstructive surgery of POP, but severe complications associated with their use have been reported, mainly related to their mechanical properties (e.g., implant stiffness) and microstructure. In this study, we mimicked a transvaginal reconstructive surgery to repair the apical ligaments (uterosacral ligaments (USLs) and cardinal ligaments (CLs)), by modeling, their impairment (90% and 50%) and/or total rupture. The implants to reinforce/replace these ligaments were built based on literature specifications and their mechanical properties were obtained through uniaxial tensile tests. The main aim of this study was to simulate the effect of mesh anchoring technique (simple stich and continuous stitch), and compare the displacement magnitude of the pelvic tissues, during Valsalva maneuver. The absence/presence of the synthetic implant was simulated when total rupture of the CLs and USLs occurs, causing a variation of the vaginal displacement (9% for the CLs and 27% for the USLs). Additionally, the simulations showed that there was a variation of the supero-inferior displacement of the vaginal wall between different anchoring techniques (simple stich and continuous stitch) being approximately of 10% for the simulation USLs and CLs implant. The computational simulation was able to mimic the biomechanical behavior of the USLs and CLs, in response to different anchoring techniques, which can be help improving the outcomes of the prolapse surgery.
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Affiliation(s)
- M E T Silva
- LAETA, INEGI, Faculty of Engineering, University of Porto, Rua Dr. Roberto Frias s/n, Porto 4200 - 465, Portugal.
| | - J N M Bessa
- Faculty of Engineering, University of Porto, Rua Dr. Roberto Frias s/n, Porto 4200 - 465, Portugal.
| | - M P L Parente
- LAETA, INEGI, Faculty of Engineering, University of Porto, Rua Dr. Roberto Frias s/n, Porto 4200 - 465, Portugal.
| | - T Mascarenhas
- Dep. of Obstetrics and Gynecology, CHSJ-EPE / Faculty of Medicine, University of Porto, Alameda Professor Hernâni Monteiro, Porto 4200 - 319, Portugal.
| | - R M Natal Jorge
- LAETA, INEGI, Faculty of Engineering, University of Porto, Rua Dr. Roberto Frias s/n, Porto 4200 - 465, Portugal.
| | - A A Fernandes
- LAETA, INEGI, Faculty of Engineering, University of Porto, Rua Dr. Roberto Frias s/n, Porto 4200 - 465, Portugal.
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30
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Poutakidis G, Marsk A, Altman D, Falconer C, Morcos E. Ultrasound evaluation of anterior transvaginal mesh for pelvic organ prolapse: correlation to 5-year clinical outcomes. Int Urogynecol J 2021; 33:1907-1915. [PMID: 34185122 PMCID: PMC9270286 DOI: 10.1007/s00192-021-04889-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 05/26/2021] [Indexed: 01/02/2023]
Abstract
Introduction and hypothesis Vaginal prolapse mesh may effectively restore vaginal anatomy. The aim of this study was to investigate how the in vivo mesh position correlates to clinical outcomes. Methods Seventy-one women operated on using Uphold mesh for apical pelvic organ prolapse (POP-Q, C ≥ stage II) were examined 5 years after surgery by introital-perineal 2D ultrasound in a midsagittal plane at rest and Valsalva. The horizontal line and pubis symphysis were considered the reference for all measures. Ultrasound measures were statistically compared to clinical outcomes: POP-Q, Pelvic Floor Distress Inventory (PFDI-20) and subscales [Pelvic Organ Distress Inventory (PODI-6), and Urinary Distress Inventory (UDI-6)] and the VAS scale for pain. Results Original mesh length was preserved by 86% and correlated to improved pain as estimated by VAS scale (r 0.321). Valsalva was associated with a lowering of the superior and inferior mesh margins by 7.3 and 6.1 mm, respectively (p < 0.001) but a reduction of total mesh length by only 1 mm (30.2 ± 5.2 to 29.2 ± 4.7 mm, p < 0.001). Mobility of the anterior vaginal wall (bladder neck and midurethra) at Valsalva was parallel to downward movement of the mesh inferior margin (r 0.346 and 0.314) but inversely correlated to total UDI-6 (r − 0.254 and − 0.263). Mobility of the midurethra was inversely correlated to bladder emptying (PFDI-20 Question 19, r − 0.245). Conclusions Five years after surgery, preserved original length of the mesh with apical support was correlated to improved anatomical and patient-reported outcomes. Mesh support to the vaginal apex was associated with improved bladder emptying and total urinary distress outcomes but not stress urinary incontinence.
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Affiliation(s)
- Georgios Poutakidis
- Department of Clinical Sciences, Division of Obstetrics and Gynecology, Karolinska Institutet Danderyd Hospital, SE-176 77, Stockholm, Sweden
| | - Anna Marsk
- Department of Gynecological Ultrasound, UltraGyn, Stockholm, Sweden
| | - Daniel Altman
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Christian Falconer
- Department of Clinical Sciences, Division of Obstetrics and Gynecology, Karolinska Institutet Danderyd Hospital, SE-176 77, Stockholm, Sweden
| | - Edward Morcos
- Department of Clinical Sciences, Division of Obstetrics and Gynecology, Karolinska Institutet Danderyd Hospital, SE-176 77, Stockholm, Sweden. .,Department of Gynecology & Obstetrics, Karolinska Institutet, Danderyd University Hospital, SE-182 88 Danderyd, Stockholm, Sweden.
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Nakai K, Hamuro A, Kitada K, Tahara M, Misugi T, Nakano A, Koyama M, Tachibana D. Preliminary evaluation of the short-term outcomes of polytetrafluoroethylene mesh for pelvic organ prolapse. J Obstet Gynaecol Res 2021; 47:2529-2536. [PMID: 33949055 DOI: 10.1111/jog.14795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/13/2021] [Accepted: 04/02/2021] [Indexed: 11/30/2022]
Abstract
AIM Tension-free vaginal mesh (TVM) surgery using synthetic polypropylene (PP) soft mesh had spread rapidly. However, the frequency of mesh-related postoperative complications had increased, and PP was banned in April 2019. In Japan, however, transvaginal surgery using polytetrafluoroethylene (PTFE) mesh had been approved. In this study, we evaluated the clinical outcome and quality of life (QOL) of the postoperative course using PP mesh and PTFE mesh (named "ORIHIME™" ) in a combination surgery for utero-sacral ligament suspension and anterior vaginal support using anterior TVM. METHODS The vaginal hysterectomy and utero-sacral ligament colpopexy augmented by anterior vaginal mesh implants using PP mesh and PTFE mesh were performed on patients with stage III to IV cystocele and uterine prolapse. The clinical outcome and QOL changes in their postoperative course were evaluated by comparing 15 cases of PP mesh and 13 cases of PTFE mesh. RESULTS There was no difference between the PP group and PTFE group in characteristics. No mesh-related complications occurred during the follow-up period. With regard to the pelvic organ prolapse quantification (POP-Q) score, no significant difference was found between the two groups. Comparing the postoperative QOL of both groups, the PTFE group had significantly higher values in two domains than PP group (SF-12v2 questionnaire). CONCLUSIONS We used the world's first PTFE mesh to compare PP mesh with postoperative POP-Q and QOL after the same surgery, with the same operator, and at the same institution. The results showed no significant difference between both mesh materials in the short-term.
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Affiliation(s)
- Kensaku Nakai
- Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Akihiro Hamuro
- Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kohei Kitada
- Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Mie Tahara
- Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Takuya Misugi
- Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Akemi Nakano
- Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Masayasu Koyama
- Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Daisuke Tachibana
- Department of Obstetrics and Gynecology, Osaka City University Graduate School of Medicine, Osaka, Japan
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Comparing the outcomes and effectiveness of robotic-assisted sacrocolpopexy and laparoscopic sacrocolpopexy in the treatment of pelvic organ prolapse. Int Urogynecol J 2021; 33:297-308. [PMID: 33760992 DOI: 10.1007/s00192-021-04741-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/11/2021] [Indexed: 10/21/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Abdominal sacrocolpopexy is regarded as the gold standard for management of pelvic organ prolapse (POP). Nowadays, minimally invasive surgeries are preferred, and sacrocolpopexy can be performed using either a laparoscopic or robotic-assisted approach. The aim of the current study was to compare the efficacy and safety of robotic-assisted sacrocolpopexy (RASC) and laparoscopic sacrocolpopexy (LSC) through an updated systematic review and meta-analysis. METHODS We performed a systematic literature review of different databases and related references from their inception until July 2020 without language restrictions. All randomized control trials and comparative studies that compared RASC and LSC for the management of POP were included. RESULTS A total of 13 studies including 2115 participants were included for the pooled analysis. The pooled results revealed that RASC was associated with a significantly longer operative time (weighted mean difference, 29.53 min; 95% confidence interval [CI], 12.88 to 46.18 min, P = 0.0005), significantly less estimated blood loss (weighted mean difference, -86.52 ml; 95% CI -130.26 to -42.79 ml, P = 0.0001), significantly fewer overall intraoperative complications (odds ratio [OR] 0.6; 95% CI 0.40 to 0.91; P = 0.01) and significantly lower conversion rate (OR 0.39; 95% CI 0.19 to 0.82; P = 0.01) compared with LSC. There were no significant differences between the length of hospital stays, overall postoperative complications, postoperative stress incontinence, mesh erosion and effectiveness between the two groups. CONCLUSION The current study showed comparable efficacy between RASC and LSC. Though RASC was associated with less blood loss and a lower conversion rate, the differences were not clinically significant. The choice of surgical procedure with either RASC or LSC is according to surgeon discretion and patient preferences.
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Morcos E, Falconer C, Grip ET, Geale K, Hellgren K, Poutakidis G, Altman D. Association between surgical volumes and real-world healthcare cost when using a mesh capturing device for pelvic organ prolapse: A 5-years comparison between single- versus multicenter use. Int Urogynecol J 2021; 32:3007-3015. [PMID: 33635348 PMCID: PMC8536564 DOI: 10.1007/s00192-021-04698-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 01/10/2021] [Indexed: 12/05/2022]
Abstract
Introduction and hypothesis The aim of this study was to evaluate whether high surgical volume at a single center was associated with lower healthcare costs compared to lower surgical volume in a multicenter setting. Methods All patients had symptomatic and anatomical apical prolapse (POP-Q ≥ stage II) with or without cystocele and were operated on by a standard surgical procedure using the Uphold mesh. Data on time of resource use in terms of surgery time, hospital stay and re-interventions across 5 years were compared between the single center (97 patients) and multicenter (173 patients, at 24 clinics). Unit costs for surgical time, inpatient and outpatient visits were extracted from the single-center hospital’s operation analysis program and prime production cost. Total costs were estimated for primary surgery and during 5-year follow-up. Results Costs for primary surgery were comparable between the single and the multicenter ($13,561 ± 2688 and $13,867 ± 1177, P = 0.29). Follow-up costs 5 years after primary surgery were 2.8 times higher at the multicenter than single center ($3262 vs. $1149, P < 0.001). Mean cost per patient over 5 years was significantly lower at the single than multicenter [$14,710 (CI: 14,168–15,252) vs. $17,128 (CI: 16,952–17,305), P < 0.001)]. Conclusions Using a mesh kit for apical pelvic organ prolapse in a high surgical volume center was associated with reduced healthcare costs compared with a lower volume multiple-site setting. The cost reduction at the high surgical volume center increased over time because of lower surgical and medical re-intervention rates for postoperative complications and recurrence.
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Affiliation(s)
- Edward Morcos
- Department of Clinical Sciences, Division of Obstetrics and Gynecology, Karolinska Institutet Danderyd Hospital, SE-171 77, Stockholm, Sweden. .,Department of Gynecology & Obstetrics, Karolinska Institutet, Danderyd University Hospital, Danderyd, 182 88, Stockholm, Sweden.
| | - Christian Falconer
- Department of Clinical Sciences, Division of Obstetrics and Gynecology, Karolinska Institutet Danderyd Hospital, SE-171 77, Stockholm, Sweden
| | | | - Kirk Geale
- Quantify Research, Stockholm, Sweden.,Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Katarina Hellgren
- Department of Clinical Sciences, Division of Obstetrics and Gynecology, Karolinska Institutet Danderyd Hospital, SE-171 77, Stockholm, Sweden
| | - Georgios Poutakidis
- Department of Clinical Sciences, Division of Obstetrics and Gynecology, Karolinska Institutet Danderyd Hospital, SE-171 77, Stockholm, Sweden
| | - Daniel Altman
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.,Stockholm Urogynecological Clinic, Stockholm, Sweden
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