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Russo Serafini M, Mowat A, Mustafa S, Saifzadeh S, Shabab T, Bas O, O’Rourke N, W. Hutmacher D, Medeiros Savi F. 3D-Printed Medical-Grade Polycaprolactone (mPCL) Scaffold for the Surgical Treatment of Vaginal Prolapse and Abdominal Hernias. Bioengineering (Basel) 2023; 10:1242. [PMID: 38002366 PMCID: PMC10669821 DOI: 10.3390/bioengineering10111242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/27/2023] [Accepted: 10/03/2023] [Indexed: 11/26/2023] Open
Abstract
The expected outcome after a scaffold augmented hernia repair is the regeneration of a tissue composition strong enough to sustain biomechanical function over long periods. It is hypothesised that melt electrowriting (MEW) medical-grade polycaprolactone (mPCL) scaffolds loaded with platelet-rich plasma (PRP) will enhance soft tissue regeneration in fascial defects in abdominal and vaginal sheep models. A pre-clinical evaluation of vaginal and abdominal hernia reconstruction using mPCL mesh scaffolds and polypropylene (PP) meshes was undertaken using an ovine model. Each sheep was implanted with both a PP mesh (control group), and a mPCL mesh loaded with PRP (experimental group) in both abdominal and vaginal sites. Mechanical properties of the tissue-mesh complexes were assessed with plunger tests. Tissue responses to the implanted meshes were evaluated via histology, immunohistochemistry and histomorphometry. At 6 months post-surgery, the mPCL mesh was less stiff than the PP mesh, but stiffer than the native tissue, while showing equitable collagen and vascular ingrowth when compared to PP mesh. The results of this pilot study were supportive of mPCL as a safe and effective biodegradable scaffold for hernia and vaginal prolapse repair, hence a full-scale long-term study (over 24-36 months) with an adequate sample size is recommended.
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Affiliation(s)
- Mairim Russo Serafini
- Department of Pharmacy, Universidade Federal de Sergipe, São Cristóvão 49100-000, Brazil;
- Centre in Regenerative Medicine, Faculty of Engineering, Queensland University of Technology, Brisbane, QLD 4059, Australia; (S.S.); (T.S.); (O.B.); (D.W.H.)
| | - Alexandra Mowat
- Faculty of Medicine, University of Queensland, Brisbane, QLD 4072, Australia
- Queen Elisabeth II Jubilee Hospital, Brisbane, QLD 4108, Australia;
| | - Susanah Mustafa
- Queen Elisabeth II Jubilee Hospital, Brisbane, QLD 4108, Australia;
| | - Siamak Saifzadeh
- Centre in Regenerative Medicine, Faculty of Engineering, Queensland University of Technology, Brisbane, QLD 4059, Australia; (S.S.); (T.S.); (O.B.); (D.W.H.)
- Medical Engineering Research Facility, Queensland University of Technology, Brisbane, QLD 4032, Australia
| | - Tara Shabab
- Centre in Regenerative Medicine, Faculty of Engineering, Queensland University of Technology, Brisbane, QLD 4059, Australia; (S.S.); (T.S.); (O.B.); (D.W.H.)
- Australian Research Council Industrial Transformation Training Centre in Additive Biomanufacturing, Queensland University of Technology, Brisbane, QLD 4059, Australia
| | - Onur Bas
- Centre in Regenerative Medicine, Faculty of Engineering, Queensland University of Technology, Brisbane, QLD 4059, Australia; (S.S.); (T.S.); (O.B.); (D.W.H.)
- Australian Research Council Industrial Transformation Training Centre in Additive Biomanufacturing, Queensland University of Technology, Brisbane, QLD 4059, Australia
| | - Nicholas O’Rourke
- Department of Hepato-Pancreato-Biliary Surgery, Royal Brisbane and Women’s Hospital, University of Queensland, Brisbane, QLD 4029, Australia;
| | - Dietmar W. Hutmacher
- Centre in Regenerative Medicine, Faculty of Engineering, Queensland University of Technology, Brisbane, QLD 4059, Australia; (S.S.); (T.S.); (O.B.); (D.W.H.)
- Australian Research Council Industrial Transformation Training Centre in Additive Biomanufacturing, Queensland University of Technology, Brisbane, QLD 4059, Australia
- ARC Training Centre for Multiscale 3D Imaging, Modelling and Manufacturing, Brisbane, QLD 4059, Australia
| | - Flavia Medeiros Savi
- Centre in Regenerative Medicine, Faculty of Engineering, Queensland University of Technology, Brisbane, QLD 4059, Australia; (S.S.); (T.S.); (O.B.); (D.W.H.)
- Australian Research Council Industrial Transformation Training Centre in Additive Biomanufacturing, Queensland University of Technology, Brisbane, QLD 4059, Australia
- ARC Training Centre for Multiscale 3D Imaging, Modelling and Manufacturing, Brisbane, QLD 4059, Australia
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Pero M, Castells-Sala C, Alserawan L, Casani L, Juan Babot JO, Jorba I, Pérez ML, Moga E, Otero J, López-Chicón P, Badimon L, Vilarrodona Serrat A, Porta-Roda O. Comparison of a human acellular dermal matrix and a polypropylene mesh for pelvic floor reconstruction: a randomized trial study in a rabbit model. Sci Rep 2022; 12:20698. [PMID: 36450745 PMCID: PMC9712341 DOI: 10.1038/s41598-022-22190-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 10/11/2022] [Indexed: 12/02/2022] Open
Abstract
Non-absorbable polypropylene (PP) meshes have been widely used in surgical reconstruction of the pelvic floor disorders. However, they are associated with serious complications. Human acellular dermal matrices (hADM) have demonstrated safety and efficacy in reconstructive medicine, but their suitability and efficacy at vaginal level is not known. This study compares the biological performance of PP mesh and a newly developed hADM. 20 rabbits were randomized to receive the hADM graft or the PP mesh. Grafts were surgically implanted in the abdominal wall and vagina. After 180 days, grafts were explanted and evaluated. The vaginal mesh extrusion rate was higher in the PP group (33% vs. 0%, p = 0.015). Full integration of the vaginal grafts was more frequent in the hADM group, where 35% of the grafts were difficult to recognize. In the PP group, the vaginal mesh was identified in 100% of the animals (p = 0.014). In PP group, the infiltrates had a focal distribution and were mostly located in the internal part of the epithelium, while in the hADM group, the infiltrates had a diffuse distribution. Additionally, the hADM group also presented more B-lymphocytes and less T-lymphocytes. Biomechanical analysis showed that hADM had lower resistance to stress. Moreover, PP mesh stiffness and elasticity were higher. Then, hADM is associated with fewer clinical complications, as well as better tissue integration. However, it shows greater incorporation into the surrounding native tissue, especially in the vaginal location, undergoing a reduction in its biomechanical properties 6 months after implantation.
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Affiliation(s)
- Marta Pero
- Department of Obstetrics and Gynecology, Hospital de La Santa Creu I Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Carrer Sant Quintí 89, 08041, Barcelona, Spain.
| | - Cristina Castells-Sala
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- Barcelona Tissue Bank. Banc de Sang I Teixits (BST), Barcelona, Spain
| | - Leticia Alserawan
- Department of Immunology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Laura Casani
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | | | - Ignasi Jorba
- Department of Biomedical Engineering, Institute for Complex Molecular Systems (ICMS), Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Maria Luisa Pérez
- Barcelona Tissue Bank. Banc de Sang I Teixits (BST), Barcelona, Spain
- Vall Hebron Institute of Research (VHIR), Barcelona, Spain
| | - Esther Moga
- Department of Immunology, Hospital de La Santa Creu I Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jorge Otero
- Biophysics and Bioengineering Unit, University of Barcelona, Barcelona, Spain
| | - Patricia López-Chicón
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- Barcelona Tissue Bank. Banc de Sang I Teixits (BST), Barcelona, Spain
| | - Lina Badimon
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Anna Vilarrodona Serrat
- Barcelona Tissue Bank. Banc de Sang I Teixits (BST), Barcelona, Spain
- Vall Hebron Institute of Research (VHIR), Barcelona, Spain
| | - Oriol Porta-Roda
- Department of Obstetrics and Gynecology, Hospital Universitari Mútua Terrassa, Universitat de Barcelona, Barcelona, Spain
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Cao Y, Shi X, Zhao X, Chen B, Li X, Li Y, Chen Y, Chen C, Lu H, Liu J. Acellular dermal matrix decorated with collagen-affinity peptide accelerate diabetic wound healing through sustained releasing Histatin-1 mediated promotion of angiogenesis. Int J Pharm 2022; 624:122017. [PMID: 35839983 DOI: 10.1016/j.ijpharm.2022.122017] [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: 01/17/2022] [Revised: 06/19/2022] [Accepted: 07/09/2022] [Indexed: 11/26/2022]
Abstract
Treating diabetic ulcers is a major challenge in clinical practice, persecuting millions of patients with diabetes and increasing the medical burden. Recombinant growth factor application can accelerate diabetic wound healing via angiogenesis. The local administration of recombinant growth factors has no robust clinical efficiency because of the degradation of append short duration of the molecules in the hostile inflammatoryenvironment.The present study focused on the pathophysiology of impaired neovascularization and growth factor short duration in the diabetic wound. We prepared a collagen-binding domain (CBD)-fused recombinant peptide (C-Histatin-1) that had both pro-angiogenesis capacity and collagen-affinity properties. Next, we created a biocompatible acellular dermal matrix (ADM) as a drug delivery carrier that featured collagen-richness, high porosity, and non-cytotoxicity. C-Histatin-1 was then tethered on ADM to obtain a sustained-release effect. Finally, a functional scaffold (C-Hst1/ADM) was developed. C-Hst1/ADM can sustain-release Histatin-1 to promote the adhesion, migration, and angiogenesisof vascular endothelial cells in vitro. Using a diabetic wound model, we showed that C-Hst1/ADM could significantly promote angiogenesis, reduce scar widths, and improve extracellular collagen accumulation. Therefore, the results of this study provide a foundation for the clinical application of C-Hst1/ADM covering scaffold in the treatment of diabetic wounds.
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Affiliation(s)
- Yanpeng Cao
- Department of Limbs (Foot and Hand) Microsurgery, Chenzhou No.1 people's hospital, Chenzhou, China
| | - Xin Shi
- Key Laboratory of Organ Injury, Aging and Regenerative Medicine of Hunan Province, Changsha, China; Hunan Engineering Research Center of Sports and Health, Changsha, China
| | - Xin Zhao
- Department of Limbs (Foot and Hand) Microsurgery, Chenzhou No.1 people's hospital, Chenzhou, China
| | - Bei Chen
- Department of Limbs (Foot and Hand) Microsurgery, Chenzhou No.1 people's hospital, Chenzhou, China
| | - Xiying Li
- Department of Limbs (Foot and Hand) Microsurgery, Chenzhou No.1 people's hospital, Chenzhou, China
| | - Yabei Li
- Department of Limbs (Foot and Hand) Microsurgery, Chenzhou No.1 people's hospital, Chenzhou, China
| | - Yaowu Chen
- Department of Limbs (Foot and Hand) Microsurgery, Chenzhou No.1 people's hospital, Chenzhou, China
| | - Can Chen
- Key Laboratory of Organ Injury, Aging and Regenerative Medicine of Hunan Province, Changsha, China; Hunan Engineering Research Center of Sports and Health, Changsha, China; Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, China
| | - Hongbin Lu
- Key Laboratory of Organ Injury, Aging and Regenerative Medicine of Hunan Province, Changsha, China; Hunan Engineering Research Center of Sports and Health, Changsha, China; Mobile Health Ministry of Education - China Mobile Joint Laboratory, Changsha, China; Xiangya Hospital-International Chinese Musculeskeletal Research Society Sports Medicine Research Centre, Changsha, China; National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China.
| | - Jun Liu
- Department of Limbs (Foot and Hand) Microsurgery, Chenzhou No.1 people's hospital, Chenzhou, China; The First School of Clinical Medicine, Southern Medical University, Guangzhou, China; The First School of Clinical Medicine, Xiangnan University, Chenzhou, China.
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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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Abhari RE, Izett-Kay ML, Morris HL, Cartwright R, Snelling SJB. Host-biomaterial interactions in mesh complications after pelvic floor reconstructive surgery. Nat Rev Urol 2021; 18:725-738. [PMID: 34545239 DOI: 10.1038/s41585-021-00511-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2021] [Indexed: 02/08/2023]
Abstract
Polypropylene (PPL) mesh is widely used in pelvic floor reconstructive surgery for prolapse and stress urinary incontinence. However, some women, particularly those treated using transvaginal PPL mesh placement for prolapse, experience intractable pain and mesh exposure or extrusion. Explanted tissue from patients with complications following transvaginal implantation of mesh is typified by a dense fibrous capsule with an immune cell-rich infiltrate, suggesting that the host immune response has a role in transvaginal PPL mesh complications through the separate contributions of the host (patient), the biological niche within which the material is implanted and biomaterial properties of the mesh. This immune response might be strongly influenced by both the baseline inflammatory status of the patient, surgical technique and experience, and the unique hormonal, immune and microbial tissue niche of the vagina. Mesh porosity, surface area and stiffness also might have an effect on the immune and tissue response to transvaginal mesh placement. Thus, a regulatory pathway is needed for mesh development that recognizes the roles of host and biological factors in driving the immune response to mesh, as well as mandatory mesh registries and the longitudinal surveillance of patients.
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Affiliation(s)
- Roxanna E Abhari
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK.
| | - Matthew L Izett-Kay
- Department of Urogynaecology, Oxford University Hospitals NHS Trust, Oxford, UK.,Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | - Hayley L Morris
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Rufus Cartwright
- Department of Urogynaecology, London North West Hospitals NHS Trust, London, UK.,Department of Epidemiology & Biostatistics, Imperial College London, London, UK
| | - Sarah J B Snelling
- Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford, UK
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Wang X, Chen Y, Fan Z, Hua K. Evaluating tissue-engineered repair material for pelvic floor dysfunction: a comparison of in vivo response to meshes implanted in rats. Int Urogynecol J 2021; 33:2143-2150. [PMID: 34741620 DOI: 10.1007/s00192-021-05008-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 10/04/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Achieving better anatomic restoration and decreasing the associated complications are necessary for material repair of pelvic floor dysfunction (PFD). This study was aimed to investigate host response to tissue-engineered repair material (TERM) in rat models by comparing different materials and study the changes in biomechanical properties over time. METHODS TERM was constructed by seeding adipose-derived stem cells (ADSCs) on electrospun poly(L-lactide)-trimethylene carbonate-glycolide (PLTG) terpolymers. The TERM, PLTG, porcine small intestine submucosa mesh (SIS), and polypropylene (PP) (n = 6 / group per time point) were implanted in rats for 7, 30, 60, and 90 days. Hematoxylin-eosin and Masson's trichrome staining were used to assess the host response, and mechanical testing was used to evaluate the changes in biomechanical properties. RESULTS In vivo imaging showed that the ADSCs were confined to the abdominal wall and did not migrate to other organs or tissues. The TERM was encapsulated by a thicker layer of connective tissue and was associated with less reduced inflammatory scores compared with PLTG and PP over time. The vascularization of the TERM was greater than that with PP and PLTG over time (p < 0.05) and was greater than that with SIS on day 90. The ultimate tensile strain and Young's modulus of the PP group showed the greatest increases, and the TERM group followed on day 90. CONCLUSIONS This TERM achieved better host integration in rat models and better biomechanical properties, and it may be an alternative material for PFD.
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Affiliation(s)
- Xiaojuan Wang
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, 128 Shenyang Road, Shanghai, 200090, People's Republic of China
| | - Yisong Chen
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, 128 Shenyang Road, Shanghai, 200090, People's Republic of China
| | - Zhongyong Fan
- Department of Materials Science, Fudan University, No. 220 Handan Road, Shanghai, 200433, People's Republic of China
| | - Keqin Hua
- Department of Gynecology, Obstetrics and Gynecology Hospital, Fudan University, 128 Shenyang Road, Shanghai, 200090, People's Republic of China.
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7
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O'Shaughnessy D, Grande D, El-Neemany D, Sajjan S, Pillalamarri N, Shalom D, Winkler H. Evaluation of the histological and biomechanical properties of poly-4-hydroxybutyrate scaffold for pelvic organ prolapse, compared with polypropylene mesh in a rabbit model. Int Urogynecol J 2021; 33:2213-2220. [PMID: 34125243 DOI: 10.1007/s00192-021-04851-6] [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: 11/07/2020] [Accepted: 05/09/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Poly-4-hydroxybutyrate (P4HB) is a biopolymer produced by Escherichia coli K12 bacteria. P4HB is fully resorbed in vivo by 18-24 months post-implantation. The aim of this study is to evaluate P4HB in the rabbit abdomen and vagina to determine that the biomechanical and histological properties are similar to the standard polypropylene mesh. Our hypothesis is that the histological and biomechanical properties of a fully absorbable graft will be similar to a lightweight polypropylene (PP) mesh when implanted in rabbit vagina and abdomen. METHODS Sixteen (n = 16) female New Zealand White (retired breeder) rabbits were equally divided between two time points (3 and 9 months). A total of 17 rabbits were used owing to one death secondary to suspected cardiomyopathy. P4HB scaffold and PP mesh were subcutaneously and peri-vaginally implanted into the rabbit abdomen and vagina respectively. All rabbits had both posterior and anterior vaginal implants, and half of the rabbits had four abdominal implants in addition to the vaginal implants. The abdominal implants were 4.5 cm long × 1.5 cm wide whereas the vaginal implants were 1.5 cm long × 0.5 cm wide. At 3 and 9 months, gross necropsy was performed and samples were obtained, sectioned, stained and evaluated via histological analysis. Specimens were assessed for host inflammatory response, neovascularization, elastin content, and collagen deposition/maturation. Specimens were also biomechanically evaluated via uniaxial tensile test to determine the stiffness, ultimate tensile strength and load at ultimate tensile strength of the device/tissue composite. RESULTS No abdominal mesh exposures were noted. A comparable number of asymptomatic partial vaginal exposures were observed at 3 months (P4HB: n = 3; PP: n = 2) and 9 months (P4HB: n = 3; PP: n = 2) respectively. Histological analysis of specimens showed comparable results in the P4HB and PP groups at 3 and 9 months post-implantation. Although no acute inflammation was seen, chronic inflammation was demonstrated in all specimens. Elastic fibers were present in the 3-month vaginal PP and P4HB specimens, but were not seen again. There was an increase in type I/III collagen noted over time. Biomechanical evaluation of the vaginal mesh tissue complex showed ultimate tensile strength was not significantly different between P4HB and PP groups at 3 (P = 0.625) and 9 months (P = 0.250) respectively. CONCLUSIONS P4HB scaffold may represent a fully absorbable alternative to permanent mesh for pelvic organ prolapse (POP) repair.
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Affiliation(s)
- Danielle O'Shaughnessy
- Division of Female Pelvic Medicine and Reconstructive Surgery, Donald and Barbara Zucker School of Medicine at Northwell Health, Long Island, NY, USA.
| | - Daniel Grande
- The Feinstein Institute of Medical Research at Northwell Health, Manhasset, NY, USA
| | - Diana El-Neemany
- Division of Female Pelvic Medicine and Reconstructive Surgery, Donald and Barbara Zucker School of Medicine at Northwell Health, Long Island, NY, USA
| | - Sujata Sajjan
- Department of Pathology, Donald and Barbara Zucker School of Medicine at Northwell Health, Manhasset, NY, USA
| | - Nirmala Pillalamarri
- Division of Female Pelvic Medicine and Reconstructive Surgery, Donald and Barbara Zucker School of Medicine at Northwell Health, Long Island, NY, USA
| | - Dara Shalom
- Division of Female Pelvic Medicine and Reconstructive Surgery, Donald and Barbara Zucker School of Medicine at Northwell Health, Long Island, NY, USA
| | - Harvey Winkler
- Division of Female Pelvic Medicine and Reconstructive Surgery, Donald and Barbara Zucker School of Medicine at Northwell Health, Long Island, NY, USA
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Peró M, Casani L, Castells-Sala C, Pérez ML, Moga Naranjo E, Juan-Babot O, Alserawan De Lamo L, López-Chicón P, Vilarrodona Serrat A, Badimon L, Porta Roda O. Rabbit as an animal model for the study of biological grafts in pelvic floor dysfunctions. Sci Rep 2021; 11:10545. [PMID: 34006889 PMCID: PMC8131625 DOI: 10.1038/s41598-021-89698-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 04/22/2021] [Indexed: 11/28/2022] Open
Abstract
The aims of this study were to evaluate the feasibility of the New Zealand White (NZW) rabbit for studying implanted biomaterials in pelvic reconstructive surgery; and to compare the occurrence of graft-related complications of a commercial polypropylene (PP) mesh and new developed human dermal matrix implanted at vaginal and abdominal level. 20 white female NZW rabbits were randomized into two groups, experimental group (human acellular dermal matrices-hADM-graft) and control group (commercial PP graft). In each animal, grafts were surgically implanted subcutaneously in the abdominal wall and in the vaginal submucosa layer for 180 days. The graft segments were then removed and the surgical and clinical results were analyzed. The main surgical challenges during graft implantation were: (a) an adequate vaginal exposure while maintaining the integrity of the vaginal mucosa layer; (b) to keep aseptic conditions; (c) to locate and dissect the breast vein abdominal surgery; and (d) to withdraw blood samples from the ear artery. The most abnormal findings during the explant surgery were found in the PP group (33% of vaginal mesh extrusion) in comparison with the hADM group (0% of vaginal graft extrusion), p = 0.015. Interestingly, macroscopic observation showed that the integration of the vaginal grafts was more common in the hADM group (40%) than in the PP group, in which the vaginal mesh was identified in 100% of the animals (p = 0.014). The NZW rabbit is a good model for assessing materials to be used as grafts for pelvic reconstructive surgery and vaginal surgery. Animals are easily managed during the procedures, including surgical intervention and vaginal mucosa approach. Additionally, hADM is associated with fewer clinical complications, as well as better macroscopic tissue integration, compared to PP mesh.
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Affiliation(s)
- Marta Peró
- Department of Obstetrics and Gynecology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Carrer Sant Quintí, 89, 08041, Barcelona, Spain.
| | - Laura Casani
- Research Institute of the Hospital de Sant Pau-IIB Sant Pau, Barcelona, Spain
| | - Cristina Castells-Sala
- Barcelona Tissue Bank, Banc de Sang i Teixits (BST), Barcelona, Spain.,Biomedical Research Institute (IIB-Sant Pau; SGR1113), Barcelona, Spain
| | - Maria Luisa Pérez
- Barcelona Tissue Bank, Banc de Sang i Teixits (BST), Barcelona, Spain.,Biomedical Research Institute (IIB-Sant Pau; SGR1113), Barcelona, Spain
| | - Esther Moga Naranjo
- Department of Immunology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Oriol Juan-Babot
- Research Institute of the Hospital de Sant Pau-IIB Sant Pau, Barcelona, Spain
| | - Leticia Alserawan De Lamo
- Department of Immunology, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute Sant Pau (IIB Sant Pau), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Patricia López-Chicón
- Barcelona Tissue Bank, Banc de Sang i Teixits (BST), Barcelona, Spain.,Biomedical Research Institute (IIB-Sant Pau; SGR1113), Barcelona, Spain
| | - Anna Vilarrodona Serrat
- Barcelona Tissue Bank, Banc de Sang i Teixits (BST), Barcelona, Spain.,Biomedical Research Institute (IIB-Sant Pau; SGR1113), Barcelona, Spain
| | - Lina Badimon
- Research Institute of the Hospital de Sant Pau-IIB Sant Pau, Barcelona, Spain
| | - Oriol Porta Roda
- Department of Obstetrics and Gynecology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Carrer Sant Quintí, 89, 08041, Barcelona, Spain
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9
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Characterization of innate and adaptive immune cells involved in the foreign body reaction to polypropylene meshes in the human abdomen. Hernia 2021; 26:309-323. [PMID: 33788008 PMCID: PMC8881270 DOI: 10.1007/s10029-021-02396-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 03/10/2021] [Indexed: 12/25/2022]
Abstract
Background Polypropylene (PP) mesh is widely used to reinforce tissues. The foreign body reaction (FBR) to the implant is dominated by innate immune cells, especially macrophages. However, considerable numbers of adaptive immune cells, namely T cells, have also been regularly observed, which appear to play a crucial role in the long-term host response. Methods This study investigated the FBR to seven human PP meshes, which were removed from the abdomen for recurrence after a median of one year. Using immunofluorescence microscopy, the FBR was examined for various innate (CD11b+ myeloid, CD68+ macrophages, CD56+ NK) and adaptive immune cells (CD3+ T, CD4+ T-helper, CD8+ cytotoxic, FoxP3+ T-regulatory, CD20+ B) as well as “conventional” immune cells (defined as cells expressing their specific immune cell marker without co-expressing CD68). Results T-helper cells (19%) and regulatory T-cells (25%) were present at comparable rates to macrophages, and clustered significantly toward the mesh fibers. For all cell types the lowest proportions of “conventional” cells (< 60%) were observed at the mesh–tissue interface, but increased considerably at about 50–100 µm, indicating reduced stimulation with rising distance to the mesh fibers. Conclusion Both innate and adaptive immune cells participate in the chronic FBR to PP meshes with T cells and macrophages being the predominant cell types, respectively. In concordance with the previous data, many cells presented a “hybrid” pattern near the mesh fibers. The complexity of the immune reaction seen within the foreign body granuloma may explain why approaches focusing on specific cell types have not been very successful in reducing the chronic FBR. Supplementary Information The online version contains supplementary material available at 10.1007/s10029-021-02396-7.
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10
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Bickhaus JA, Fraser MO, Weidner AC, Jayes FL, Amundsen CL, Gall K, Marini FC, Robboy SJ, Siddiqui NY. Evaluation of Host Immune Cellular and Extracellular Matrix Responses to Prolapse Mesh With and Without Tension in a Rat Model. Female Pelvic Med Reconstr Surg 2021; 27:e385-e391. [PMID: 32910082 DOI: 10.1097/spv.0000000000000943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We sought to determine whether vaginal host immune cellular and extracellular matrix responses are altered in a rat sacrocolpopexy model when lightweight polypropylene mesh is attached on tension versus without tension. METHODS We performed hysterectomy and ovariectomy in 32 Sprague-Dawley rats. Animals were assigned to 4 groups (n = 8/group): (1) controls with sham operation only (control), (2) mesh sutured only on the vagina (vaginal mesh), (3) sacrocolpopexy without tension, and (4) sacrocolpopexy with tension. Ninety days later, we excised vagina-mesh complexes. A histomorphologic scoring system of hematoxylin/eosin and Masson trichrome stained slides was used to assess host inflammatory responses. The cellular inflammatory response was further quantified using (1) identification of M1 and M2 macrophage subsets and (2) quantification of proinflammatory and anti-inflammatory cytokines. The extracellular matrix response was evaluated by measuring (1) matrix metalloproteinase-2 and matrix metalloproteinase-9 levels and (2) type I/III collagen. RESULTS Histomorphological tissue responses were greater in all groups with mesh compared with sham controls. Both sacrocolpopexy groups had similar scores, but each group scored significantly higher than the vaginal mesh group. Among the 4 groups, there were no statistically significant differences in M1 or M2 macrophage subsets, proinflammatory or anti-inflammatory cytokines, or extracellular matrix remodeling responses. CONCLUSIONS Attachment of prolapse mesh resulted in an increased histologic inflammatory response independent of tension. Other markers of cellular inflammation and extracellular matrix remodeling showed no differences among experimental groups. Tension on lightweight polypropylene mesh did not significantly alter the host response in this rat sacrocolpopexy model.
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Affiliation(s)
- Jennifer A Bickhaus
- From the Department of Obstetrics and Gynecology, Duke University Medical Center
| | - Matthew O Fraser
- Departments of Surgery and Research & Development, Duke University and Durham Veterans Affairs Medical Centers
| | - Alison C Weidner
- From the Department of Obstetrics and Gynecology, Duke University Medical Center
| | - Friederike L Jayes
- From the Department of Obstetrics and Gynecology, Duke University Medical Center
| | - Cindy L Amundsen
- From the Department of Obstetrics and Gynecology, Duke University Medical Center
| | - Ken Gall
- Department of Mechanical Engineering and Materials Science, Duke University, Durham
| | - Frank C Marini
- Wake Forest Institute for Regenerative Medicine, Wake Forest University, Winston-Salem
| | - Stanley J Robboy
- Department of Pathology, Duke University Medical Center, Durham, NC
| | - Nazema Y Siddiqui
- From the Department of Obstetrics and Gynecology, Duke University Medical Center
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11
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Tissue remodeling macrophages morphologically dominate at the interface of polypropylene surgical meshes in the human abdomen. Hernia 2020; 24:1175-1189. [PMID: 33030647 PMCID: PMC7701072 DOI: 10.1007/s10029-020-02315-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 09/23/2020] [Indexed: 12/14/2022]
Abstract
Background Mesh implants are widely used to reinforce the abdominal wall, although the inevitable inflammatory foreign body reaction (FBR) at the interface leads to complications. Macrophages are suspected to regulate the subsequent scar formation, but it is still unclear whether adequate fibrous scar formation with collagen deposition depends mainly on the presence of M1 or M2 macrophages. Methods This study investigated the FBR to seven human polypropylene meshes, which were removed after a median incorporation time of 1 year due to the primary complaint of recurrence. Using immunofluorescence, the FBR was examined in six regional zones with increasing distance from the mesh fibers up to 350 µm, based on the cell densities, macrophage M1 (CD86) and M2 (CD163, CD206) phenotypes, deposition of collagen-I and -III, and expression of matrix metalloproteinase-2 (MMP-2) and -8 as indicator of collagen degradation. Results All mesh–tissue complexes demonstrated a decrease in cell density and macrophages with distance to the mesh fibers. Overall, about 60% of the macrophages presented an M2 phenotype, whereas only 6% an M1 phenotype. Over 70% of macrophages showed co-expression with collagen-I or -III and over 50% with MMP-2. Conclusions The chronic FBR to polypropylene meshes is associated with an M2 macrophage response, which is accompanied by collagen deposition and MMP-2 expression. These findings challenge the idea that mainly M1 macrophages are related to inflammation and highlights that iatrogenic attempts to polarize these cells towards the M2 phenotype may not be a solution to ameliorate the long-term foreign body reaction. Electronic supplementary material The online version of this article (10.1007/s10029-020-02315-2) contains supplementary material, which is available to authorized users.
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12
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Lo TS, Lin YH, Chua S, Chu HC, Uy-Patrimonio MC, Ng KL. Immunochemical analysis on polypropylene mesh: does mesh size make a difference? Int Urogynecol J 2020; 32:47-55. [PMID: 32651643 DOI: 10.1007/s00192-020-04399-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: 04/21/2020] [Accepted: 06/17/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The aim of the study is to demonstrate the impact of the size of implanted mesh in relation to its immunohistochemical reaction implanted into animal models. METHODS An experimental study utilizing 54 female Sprague Dawley (SD) rats was divided into five groups: control, sham, and study groups (mesh-small [M-S], mesh-medium [M-M], mesh-large [M-L]). The M-S group used a mesh size of 0.2 × 0.2 cm, the M-M group a mesh size of 0.5 × 0.5 cm, and the M-L a mesh size of 0.7 × 1.0 cm. The sham group underwent vaginal dissection with no mesh implantation. The rats were sacrificed using isoflurane overdose on days 7 and 30. The mesh with the surrounding vaginal and bladder wall tissues were removed and processed for histochemical and western blot analysis. RESULTS There is a significant increase in IL-1 and TNF-α immunoreactivity in the M-M and M-L groups on day 7 when compared with the sham group with p values of 0.001 and < 0.001 respectively. M-L showed significantly higher immunoreactivity to TNF-α persisting until day 30. All study groups presented a significantly higher immunoreactivity to MMP-2 and NGF on day 7. However, reactivity to NGF does not persist to day 30 in all groups. Immunoreactivity to CD 31 on days 7 and 30 appears significantly greater in the M-M and M-L groups, with the reaction in the M-L group continuing until day 30. CONCLUSION Mesh size is directly proportional to the inflammatory reaction in the host tissue. The prolonged inflammatory process leads to delayed tissue remodeling and angiogenesis, which could delay mesh-tissue integration.
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Affiliation(s)
- Tsia-Shu Lo
- Division of Urogynecology, Department of Obstetrics and Gynecology, Linkou, Chang Gung Memorial Hospital, Linkou Medical Center, 5, Fu-Hsin Street, Kwei-shan, Tao-Yuan City, Taiwan, 333, Republic of China. .,Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Keelung Medical Center, Keelung, Taiwan, Republic of China. .,Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Medical Center, Taipei, Taiwan, Republic of China. .,School of Medicine, Chang Gung University, Taoyuan, Taiwan, Republic of China.
| | - Yi-Hao Lin
- Division of Urogynecology, Department of Obstetrics and Gynecology, Linkou, Chang Gung Memorial Hospital, Linkou Medical Center, 5, Fu-Hsin Street, Kwei-shan, Tao-Yuan City, Taiwan, 333, Republic of China.,School of Medicine, Chang Gung University, Taoyuan, Taiwan, Republic of China
| | - Sandy Chua
- Department of Obstetrics and Gynecology, Cebu Institute of Medicine-Cebu Velez General Hospital, Cebu City, Philippines
| | - Hsiao-Chien Chu
- Division of Urogynecology, Department of Obstetrics and Gynecology, Linkou, Chang Gung Memorial Hospital, Linkou Medical Center, 5, Fu-Hsin Street, Kwei-shan, Tao-Yuan City, Taiwan, 333, Republic of China.,Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Keelung Medical Center, Keelung, Taiwan, Republic of China
| | - Ma Clarissa Uy-Patrimonio
- Department of Obstetrics and Gynecology, Corazon Locsin Montelibano Memorial Regional Hospital, Bacolod City, Philippines
| | - Kai Lyn Ng
- Department of Obstetrics and Gynecology, National University Hospital of Singapore, Singapore, Singapore
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13
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Barone WR, Knight KM, Moalli PA, Abramowitch SD. Deformation of Transvaginal Mesh in Response to Multiaxial Loading. J Biomech Eng 2020; 141:2709738. [PMID: 30347035 DOI: 10.1115/1.4041743] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Indexed: 11/08/2022]
Abstract
Synthetic mesh for pelvic organ prolapse (POP) repair is associated with high complication rates. While current devices incorporate large pores (>1 mm), recent studies have shown that uniaxial loading of mesh reduces pore size, raising the risk for complications. However, it is difficult to translate uniaxial results to transvaginal meshes, as in vivo loading is multidirectional. Thus, the aim of this study was to (1) experimentally characterize deformation of pore diameters in a transvaginal mesh in response to clinically relevant multidirectional loading and (2) develop a computational model to simulate mesh behavior in response to in vivo loading conditions. Tension (2.5 N) was applied to each of mesh arm to simulate surgical implantation. Two loading conditions were assessed where the angle of the applied tension was altered and image analysis was used to quantify changes in pore dimensions. A computational model was developed and used to simulate pore behavior in response to these same loading conditions and the results were compared to experimental findings. For both conditions, between 26.4% and 56.6% of all pores were found to have diameters <1 mm. Significant reductions in pore diameter were noted in the inferior arms and between the two superior arms. The computational model identified the same regions, though the model generally underestimated pore deformation. This study demonstrates that multiaxial loading applied clinically has the potential to locally reduce porosity in transvaginal mesh, increasing the risk for complications. Computational simulations show potential of predicting this behavior for more complex loading conditions.
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Affiliation(s)
- William R Barone
- Musculoskeletal Research Center, Department of Bioengineering, University of Pittsburgh, 405 Center for Bioengineering, 300 Technology Drive, Pittsburgh, PA 15219 e-mail:
| | - Katrina M Knight
- Musculoskeletal Research Center, Department of Bioengineering, University of Pittsburgh, , 300 Technology Drive, Pittsburgh, PA 15219 e-mail:
| | - Pamela A Moalli
- Magee-Womens Research Institute, 204 Craft Avenue, Lab A320, Pittsburgh, PA 15213 e-mail:
| | - Steven D Abramowitch
- Musculoskeletal Research Center, Department of Bioengineering, University of Pittsburgh, 405 Center for Bioengineering, 300 Technology Drive, Pittsburgh, PA 15219; Magee-Womens Research Institute, 204 Craft Avenue, Lab A320, Pittsburgh, PA 15213 e-mail
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14
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Knight KM, Artsen AM, Routzong MR, King GE, Abramowitch SD, Moalli PA. New Zealand white rabbit: a novel model for prolapse mesh implantation via a lumbar colpopexy. Int Urogynecol J 2019; 31:91-99. [PMID: 31418044 DOI: 10.1007/s00192-019-04071-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/24/2019] [Indexed: 01/04/2023]
Abstract
INTRODUCTION AND HYPOTHESIS New Zealand white rabbits are an inexpensive large-animal model. This study explored the rabbit as a model for mesh-augmented colpopexy using the intra-abdominal vagina. We hypothesized that polypropylene mesh would negatively impact rabbit vaginal smooth muscle (VSM) morphology and contractile function, similar to the nonhuman primate (NHP)-the established model for prolapse mesh evaluation. METHODS Restorelle was implanted onto the vagina of ten rabbits via lumbar colpopexy after a hysterectomy. Ten rabbits served as sham. Twelve weeks post-implantation, the vagina was excised and VSM morphology and vaginal contractility were assessed. Outcome measures were compared using independent samples t and Mann-Whitney U tests with a Bonferroni correction, where appropriate. Results from the rabbits were compared with published NHP data. RESULTS Animals had similar age, parity and BMI. VSM was 18% thinner after Restorelle implantation, P = 0.027. Vaginal contractility was 43% decreased in response to 120 mM KCl (P = 0.003), similar to the 46% reduction observed in the NHP vagina implanted with Restorelle (P = 0.027). Three meshes wrinkled in vivo, resulting in dramatic thinning of the underlying vagina in the area of the mesh causing a mesh exposure. CONCLUSIONS Polypropylene mesh negatively impacts VSM morphology and vaginal contractility in the rabbit, similar to the NHP, suggesting that the rabbit may serve as an alternative large-animal model. The vaginal thinning and appearance of a mesh exposure in the area of a mesh wrinkle suggest the rabbit may also serve as a model for understanding the pathophysiology of mesh exposure.
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Affiliation(s)
- Katrina M Knight
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA. .,Magee-Womens Research Institute, 204 Craft Avenue, Lab A320, Pittsburgh, PA, 15213, USA.
| | - Amanda M Artsen
- Magee-Womens Research Institute, Department of Obstetrics and Gynecology and Reproductive Sciences at Magee Womens Hospital, University of Pittsburgh, Pittsburgh, PA, USA
| | - Megan R Routzong
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Gabrielle E King
- Magee-Womens Research Institute, Department of Obstetrics and Gynecology and Reproductive Sciences at Magee Womens Hospital, University of Pittsburgh, Pittsburgh, PA, USA
| | - Steven D Abramowitch
- Magee-Womens Research Institute, Department of Obstetrics and Gynecology and Reproductive Sciences at Magee Womens Hospital, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Pamela A Moalli
- Magee-Womens Research Institute, Department of Obstetrics and Gynecology and Reproductive Sciences at Magee Womens Hospital, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
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15
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Powers SA, Burleson LK, Hannan JL. Managing female pelvic floor disorders: a medical device review and appraisal. Interface Focus 2019; 9:20190014. [PMID: 31263534 DOI: 10.1098/rsfs.2019.0014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2019] [Indexed: 02/07/2023] Open
Abstract
Pelvic floor disorders (PFDs) will affect most women during their lifetime. Sequelae such as pelvic organ prolapse, stress urinary incontinence, chronic pain and dyspareunia significantly impact overall quality of life. Interventions to manage or eliminate symptoms from PFDs aim to restore support of the pelvic floor. Pessaries have been used to mechanically counteract PFDs for thousands of years, but do not offer a cure. By contrast, surgically implanted grafts or mesh offer patients a more permanent resolution but have been in wide use within the pelvis for less than 30 years. In this perspective review, we provide an overview of the main theories underpinning PFD pathogenesis and the animal models used to investigate it. We highlight the clinical outcomes of mesh and grafts before exploring studies performed to elucidate tissue level effects and bioengineering considerations. Considering recent turmoil surrounding transvaginal mesh, the role of pessaries, an impermanent method, is examined as a means to address patients with PFDs.
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Affiliation(s)
- Shelby A Powers
- Department of Physiology, Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Mailstop 634, Greenville, NC 27834-4354, USA
| | - Lindsey K Burleson
- Department of Physiology, Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Mailstop 634, Greenville, NC 27834-4354, USA
| | - Johanna L Hannan
- Department of Physiology, Brody School of Medicine, East Carolina University, 600 Moye Boulevard, Mailstop 634, Greenville, NC 27834-4354, USA
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16
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Izett M, Kupelian A, Vashisht A. Safety and efficacy of non-absorbable mesh in contemporary gynaecological surgery. ACTA ACUST UNITED AC 2018. [DOI: 10.1186/s10397-018-1051-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
AbstractMesh-augmented pelvic floor surgery evolved to address the limitations of native tissue repair in reconstructive surgery. The development of the synthetic mid-urethral tape signalled a revolution in the treatment of stress urinary incontinence, whilst the use of mesh in abdominal apical prolapse repair may confer benefits over native tissue alternatives. However, these procedures can be associated with mesh-specific complications, underlining the need for shared decision-making between physicians and patients prior to mesh surgery.Transvaginal non-absorbable mesh implants for pelvic organ prolapse are associated with a high risk of serious adverse events, leading to withdrawal or restricted use in many countries. Increased scrutiny has led to growing concerns about complications associated with all types of mesh-augmented reconstructive surgery, attracting widespread media attention.National and international reports have been commissioned examining the safety and efficacy of mesh surgery in gynaecology. They have all highlighted systemic failures in the development, regulation and clinical adoption of medical devices. The widespread application of novel devices prior to the availability of reliable safety and efficacy data, and delayed recognition of adverse events, is of serious concern. Notwithstanding, the available data continue to support a role for mesh augmentation. This review outlines the evolution of gynaecological mesh, the safety and efficacy of pelvic floor surgery using non-absorbable mesh materials, and an overview of specific complications.
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17
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Przydacz M, Adli OEY, Mahfouz W, Loutochin O, Bégin LR, Corcos J. Structural differences and architectural features of two different polypropylene slings (TVT-O and I-STOP) have no impact on biocompatibility and tissue reactions. Cent European J Urol 2017; 70:154-162. [PMID: 28721282 PMCID: PMC5510338 DOI: 10.5173/ceju.2017.1189] [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: 11/23/2016] [Revised: 12/21/2016] [Accepted: 04/10/2017] [Indexed: 11/22/2022] Open
Abstract
Introduction To evaluate the impact of design features of the synthetic mid-urethral slings on tissue integrity and inflammatory responses. Material and methods In total 30 female Sprague-Dawley rats were implanted with type I monofilamentous, macroporous polypropylene meshes: Gynecare TVT-Obturator tape® (Ethicon Inc., Johnson & Johnson, Somerville, NJ, USA) and I-STOP® (CL Medical Inc., Lyon, France). All animal groups were sacrificed at set time intervals – 6 weeks, 3 months, 6 months, 9 months and 12 months – and the abdominal wall was harvested with mesh strips for histological evaluation. Results All mesh strips appeared to be well incorporated into the abdominal wall, and no signs of shrinkage was noticed. All specimens showed a thin/delicate, loose, fibrous interface between the synthetic graft plate and abdominal wall, along with mild inflammatory reactions from 6 weeks to 12 months. Conclusions Both mesh brands induced comparable, minimal foreign body reactions and integrated well into the host tissues despite differences in architectural features. TVT-O® and I-STOP® evoked similar low-grade inflammatory responses up to 12 months in this animal model. Structural differences and architectural features of polypropylene slings used in this study have had no impact on tissue integrity and inflammatory responses.
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Affiliation(s)
- Mikolaj Przydacz
- Department of Urology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Oussama El Yazami Adli
- Department of Urology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Wally Mahfouz
- Department of Urology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Oleg Loutochin
- Department of Urology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Louis R Bégin
- Division of Anatomical Pathology, Hôpital du Sacré-Coeur de Montréal, Montreal, Quebec, Canada
| | - Jacques Corcos
- Department of Urology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
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18
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Prudente A, Favaro WJ, Latuf P, Riccetto CLZ. Host inflammatory response to polypropylene implants: insights from a quantitative immunohistochemical and birefringence analysis in a rat subcutaneous model. Int Braz J Urol 2017; 42:585-93. [PMID: 27286125 PMCID: PMC4920579 DOI: 10.1590/s1677-5538.ibju.2015.0289] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 08/18/2015] [Indexed: 01/22/2023] Open
Abstract
Objectives To describe acute and sub acute aspects of histological and immunohistochemical response to PP implant in a rat subcutaneous model based on objective methods. Materials and Methods Thirty rats had a PP mesh subcutaneously implanted and the same dissection on the other side of abdomen but without mesh (sham). The animals were euthanized after 4 and 30 days. Six slides were prepared using the tissue removed: one stained with hematoxylin-eosin (inflammation assessment); one unstained (birefringence evaluation) and four slides for immunohistochemical processing: IL-1 and TNF-α (pro-inflammatory cytokines), MMP-2 (collagen metabolism) and CD-31 (angiogenesis). The area of inflammation, the birefringence index, the area of immunoreactivity and the number of vessels were objectively measured. Results A larger area of inflammatory reaction was observed in PP compared to sham on the 4th and on the 30th day (p=0.0002). After 4 days, PP presented higher TNF (p=0.0001) immunoreactivity than sham and no differences were observed in MMP-2 (p=0.06) and IL-1 (p=0.08). After 30 days, a reduction of IL-1 (p=0.010) and TNF (p=0.016) for PP and of IL-1 (p=0.010) for sham were observed. Moreover, area of MMP-2 immunoreactivity decreased over time for PP group (p=0.018). Birefringence index and vessel counting showed no differences between PP and sham (p=0.27 and p=0.58, respectively). Conclusions The implantation of monofilament and macroporous polypropylene in the subcutaneous of rats resulted in increased inflammatory activity and higher TNF production in the early post implant phase. After 30 days, PP has similar cytokines immunoreactivity, vessel density and extracellular matrix organization.
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Affiliation(s)
- Alessandro Prudente
- Faculdade de Ciências Médicas da Universidade de Campinas, Campinas, SP, Brasil
| | | | - Paulo Latuf
- Laboratório de Investigação Patologica, Centro de Investigação em Pediatria,Universidade de Campinas, Campinas, SP, Brasil
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19
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Brown BN, Haschak MJ, Lopresti ST, Stahl EC. Effects of age-related shifts in cellular function and local microenvironment upon the innate immune response to implants. Semin Immunol 2017; 29:24-32. [PMID: 28539184 DOI: 10.1016/j.smim.2017.05.001] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 04/18/2017] [Accepted: 05/11/2017] [Indexed: 12/14/2022]
Abstract
The host macrophage response is now well recognized as a predictor of the success or failure of biomaterial implants following placement. More specifically, shifts from an "M1" pro-inflammatory towards a more "M2-like" anti-inflammatory macrophage polarization profile have been shown to result in enhanced material integration and/or tissue regeneration downstream. As a result, a number of biomaterials-based approaches to controlling macrophage polarization have been developed. However, the ability to promote such activity is predicated upon an in-depth, context-dependent understanding of the host response to biomaterials. Recent work has shown the impacts of both tissue location and tissue status (i.e. underlying pathology) upon the host innate immune response to implants, representing a departure from a focus upon implant material composition and form. Thus, the ideas of "biocompatibility," the host macrophage reaction, and ideal material requirements and modification strategies may need to be revisited on a patient, tissue, and disease basis. Immunosenescence, dysregulation of macrophage function, and delayed resolution of immune responses in aged individuals have all been demonstrated, suggesting that the host response to biomaterials in aged individuals should differ from that in younger individuals. However, despite the increasing usage of implantable medical devices in aged patients, few studies examining the effects of aging upon the host response to biomaterials and the implications of this response for long-term integration and function have been performed. The objective of the present manuscript is to review the putative effects of aging upon the host response to implanted materials and to advance the hypothesis that age-related changes in the local microenvrionement, with emphasis on the extracellular matrix, play a previously unrecognized role in determining the host response to implants.
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Affiliation(s)
- Bryan N Brown
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, 450 Technology Drive, Pittsburgh, PA 15219, United States; Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, 3700 O'Hara Street, Pittsburgh, PA 15260, United States; Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, University of Pittsburgh, 300 Halket Street, Pittsburgh, PA 15213, United States.
| | - Martin J Haschak
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, 450 Technology Drive, Pittsburgh, PA 15219, United States; Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, 3700 O'Hara Street, Pittsburgh, PA 15260, United States
| | - Samuel T Lopresti
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, 450 Technology Drive, Pittsburgh, PA 15219, United States; Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, 3700 O'Hara Street, Pittsburgh, PA 15260, United States
| | - Elizabeth C Stahl
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, 450 Technology Drive, Pittsburgh, PA 15219, United States; Department of Pathology, University of Pittsburgh School of Medicine, University of Pittsburgh, 200 Lothrop St., Pittsburgh, PA 15261, United States
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20
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Hachim D, Wang N, Lopresti ST, Stahl EC, Umeda YU, Rege RD, Carey ST, Mani D, Brown BN. Effects of aging upon the host response to implants. J Biomed Mater Res A 2017; 105:1281-1292. [PMID: 28130823 DOI: 10.1002/jbm.a.36013] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 01/05/2017] [Accepted: 01/23/2017] [Indexed: 01/11/2023]
Abstract
Macrophage polarization during the host response is now a well-accepted predictor of outcomes following material implantation. Immunosenescence, dysregulation of macrophage function, and delayed resolution of immune responses in aged individuals have all been demonstrated, suggesting that host responses to materials in aged individuals should differ from those in younger individuals. However, few studies examining the effects of aging upon the host response have been performed. The present work sought to elucidate the impacts of aging upon the host response to polypropylene mesh implanted into 8-week-old and 18-month-old mice. The results showed that there are significant differences in macrophage surface marker expression, migration, and polarization during the early host macrophage response and delayed resolution of the host response in 18-month-old versus 8-week-old mice. These differences could not be attributed to cell-intrinsic defects alone, suggesting that the host macrophage response to implants is likely also dictated to a significant degree by the local tissue microenvironment. These results raise important questions about the design and testing of materials and devices often intended to treat aged individuals and suggest that an improved understanding of patient- and context-dependent macrophage responses has the potential to improve outcomes in aged individuals. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part A: 105A: 1281-1292, 2017.
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Affiliation(s)
- Daniel Hachim
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, 450 Technology Drive, Pittsburgh, Pennsylvania, 15219.,Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, 3700 O'Hara Street, Pittsburgh, Pennsylvania, 15260
| | - Na Wang
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, 450 Technology Drive, Pittsburgh, Pennsylvania, 15219
| | - Samuel T Lopresti
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, 450 Technology Drive, Pittsburgh, Pennsylvania, 15219.,Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, 3700 O'Hara Street, Pittsburgh, Pennsylvania, 15260
| | - Elizabeth C Stahl
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, 450 Technology Drive, Pittsburgh, Pennsylvania, 15219.,Department of Pathology, University of Pittsburgh School of Medicine, University of Pittsburgh, 200 Lothrop St, Pittsburgh, Pennsylvania, 15261
| | - Yuta U Umeda
- Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, 3700 O'Hara Street, Pittsburgh, Pennsylvania, 15260
| | - Rahul D Rege
- Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, 3700 O'Hara Street, Pittsburgh, Pennsylvania, 15260
| | - Sean T Carey
- Department of Chemical Engineering, Swanson School of Engineering, University of Pittsburgh, 3700 O'Hara Street, Pittsburgh, Pennsylvania, 15260
| | - Deepa Mani
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, 450 Technology Drive, Pittsburgh, Pennsylvania, 15219
| | - Bryan N Brown
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, 450 Technology Drive, Pittsburgh, Pennsylvania, 15219.,Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, 3700 O'Hara Street, Pittsburgh, Pennsylvania, 15260.,Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, University of Pittsburgh, 300 Halket Street, Pittsburgh, Pennsylvania, 15213
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Prudente A, Favaro WJ, Reis LO, Riccetto CLZ. Nitric oxide coating polypropylene mesh increases angiogenesis and reduces inflammatory response and apoptosis. Int Urol Nephrol 2017; 49:597-605. [PMID: 28181115 DOI: 10.1007/s11255-017-1520-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 01/18/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To evaluate the effect of implanted S-nitrosoglutathione (GSNO) coating polypropylene mesh in foreign-body response of rats. METHODS Thirty female rats underwent to subcutaneous implant of five polypropylene (PP) fragments: uncoated PP (control); PP polyvinylalcohol (PVA) coated and PP PVA + GSNO (1, 10 and 70 mMol) coated. After euthanasia (4 and 30 days), eight slides were prepared from each animal: hematoxylin-eosin (inflammatory response); unstained (birefringence collagen evaluation); TUNEL technique (apoptosis); and five for immunohistochemical processing: CD-31 (angiogenesis), IL-1 and TNF-α (proinflammatory cytokynes), iNOS (NO synthesis) and MMP-2 (collagen metabolism). The inflammation area, birefringence index, apoptotic index, immunoreactivity and vessel density were objectively measured. RESULTS Inflammatory reaction area at 4 days was 11.3, 15.2, 25.1, 17.1 and 19.3% of pure PP, PVA, GSNO 1, 10 and 70 mM, respectively, p = 0.0006 (PP × Others). At 30 days lower inflammatory area was observed in GSNO 10 and 70 mM compared to pure PP (5.3, 5.2 and 11.1%, respectively, p = 0.0001). Vessel density was higher for GSNO 1 mM (25.5%) compared to pure PP (19.6%) at 30 days only, p = 0.0081. Apoptotic index at 4 days was lower for GSNO 1 mM (49.3%) than pure PVA (60.6%), p = 0.0124. GSNO 10 and 70 mM reduced their apoptotic index at 30 days compared to 4 days (49.9 vs. 36.9 and 59.1 vs. 47.5%, respectively, p = 0.0397). Birefringence index, IL-1, TNF, MMP-2 and iNOS were not different. CONCLUSIONS Depending on concentrations, GSNO can increase angiogenesis, reduce inflammation and apoptosis compared to pure PP, without impact on cytokine, collagen organization/metabolism and endogenous NO synthesis.
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Affiliation(s)
- Alessandro Prudente
- School of Medical Sciences, University of Campinas, Campinas, São Paulo, Brazil. .,, 4405, Engenheiro Anysio da Rocha Compasso st, Porto Velho, Rondônia, 76821-331, Brazil.
| | - Wágner José Favaro
- Institute of Biology, University of Campinas, Campinas, São Paulo, Brazil
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Hachim D, LoPresti ST, Yates CC, Brown BN. Shifts in macrophage phenotype at the biomaterial interface via IL-4 eluting coatings are associated with improved implant integration. Biomaterials 2016; 112:95-107. [PMID: 27760399 DOI: 10.1016/j.biomaterials.2016.10.019] [Citation(s) in RCA: 138] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 10/03/2016] [Accepted: 10/11/2016] [Indexed: 10/20/2022]
Abstract
The present study tests the hypothesis that transient, early-stage shifts in macrophage polarization at the tissue-implant interface from a pro-inflammatory (M1) to an anti-inflammatory/regulatory (M2) phenotype mitigates the host inflammatory reaction against a non-degradable polypropylene mesh material and improves implant integration downstream. To address this hypothesis, a nanometer-thickness coating capable of releasing IL-4 (an M2 polarizing cytokine) from an implant surface at early stages of the host response has been developed. Results of XPS, ATR-FTIR and Alcian blue staining confirmed the presence of a uniform, conformal coating consisting of chitosan and dermatan sulfate. Immunolabeling showed uniform loading of IL-4 throughout the surface of the implant. ELISA assays revealed that the amount and release time of IL-4 from coated implants were tunable based upon the number of coating bilayers and that release followed a power law dependence profile. In-vitro macrophage culture assays showed that implants coated with IL-4 promoted polarization to an M2 phenotype, demonstrating maintenance of IL-4 bioactivity following processing and sterilization. Finally, in-vivo studies showed that mice with IL-4 coated implants had increased percentages of M2 macrophages and decreased percentages of M1 macrophages at the tissue-implant interface during early stages of the host response. These changes were correlated with diminished formation of fibrotic capsule surrounding the implant and improved tissue integration downstream. The results of this study demonstrate a versatile cytokine delivery system for shifting early-stage macrophage polarization at the tissue-implant interface of a non-degradable material and suggest that modulation of the innate immune reaction at early stages of the host response may represent a preferred strategy for promoting biomaterial integration and success.
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Affiliation(s)
- Daniel Hachim
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, 450 Technology Drive, Suite 300, Pittsburgh, PA 15219, United States; Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, 302 Benedum Hall, 3700 O'Hara Street, Pittsburgh, PA 15260, United States
| | - Samuel T LoPresti
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, 450 Technology Drive, Suite 300, Pittsburgh, PA 15219, United States; Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, 302 Benedum Hall, 3700 O'Hara Street, Pittsburgh, PA 15260, United States
| | - Cecelia C Yates
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, 450 Technology Drive, Suite 300, Pittsburgh, PA 15219, United States; Department of Health Promotion and Development, School of Nursing, University of Pittsburgh, 440 Victoria Building, 3500 Victoria Street, Pittsburgh, PA 15213, United States
| | - Bryan N Brown
- McGowan Institute for Regenerative Medicine, University of Pittsburgh, 450 Technology Drive, Suite 300, Pittsburgh, PA 15219, United States; Department of Bioengineering, Swanson School of Engineering, University of Pittsburgh, 302 Benedum Hall, 3700 O'Hara Street, Pittsburgh, PA 15260, United States; Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, 300 Halket Street, Pittsburgh, PA 15213, United States.
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Nolfi AL, Brown BN, Liang R, Palcsey SL, Bonidie MJ, Abramowitch SD, Moalli PA. Host response to synthetic mesh in women with mesh complications. Am J Obstet Gynecol 2016; 215:206.e1-8. [PMID: 27094962 PMCID: PMC5201165 DOI: 10.1016/j.ajog.2016.04.008] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Revised: 03/31/2016] [Accepted: 04/08/2016] [Indexed: 01/11/2023]
Abstract
BACKGROUND Despite good anatomic and functional outcomes, urogynecologic polypropylene meshes that are used to treat pelvic organ prolapse and stress urinary incontinence are associated with significant complications, most commonly mesh exposure and pain. Few studies have been performed that specifically focus on the host response to urogynecologic meshes. The macrophage has long been known to be the key cell type that mediates the foreign body response. Conceptually, macrophages that respond to a foreign body can be dichotomized broadly into M1 proinflammatory and M2 proremodeling subtypes. A prolonged M1 response is thought to result in chronic inflammation and the formation of foreign body giant cells with potential for ongoing tissue damage and destruction. Although a limited M2 predominant response is favorable for tissue integration and ingrowth, excessive M2 activity can lead to accelerated fibrillar matrix deposition and result in fibrosis and encapsulation of the mesh. OBJECTIVE The purpose of this study was to define and compare the macrophage response in patients who undergo mesh excision surgery for the indication of pain vs a mesh exposure. STUDY DESIGN Patients who were scheduled to undergo a surgical excision of mesh for pain or exposure at Magee-Womens Hospital were offered enrollment. Twenty-seven mesh-vagina complexes that were removed for the primary complaint of a mesh exposure (n = 15) vs pain in the absence of an exposure (n = 12) were compared with 30 full-thickness vaginal biopsy specimens from women who underwent benign gynecologic surgery without mesh. Macrophage M1 proinflammatory vs M2 proremodeling phenotypes were examined via immunofluorescent labeling for cell surface markers CD86 (M1) vs CD206 (M2) and M1 vs M2 cytokines via enzyme-linked immunosorbent assay. The amount of matrix metalloproteinase-2 (MMP-2) and matrix metalloproteinase-9 (MMP-9) proteolytic enzymes were quantified by zymography and substrate degradation assays, as an indication of tissue matrix degradation. Statistics were performed with the use of 1-way analysis of variance with appropriate post hoc tests, t-tests, and Fisher's Exact test. RESULTS Twenty-seven mesh-vaginal tissue complexes were excised from 27 different women with mesh complications: 15 incontinence mid urethral slings and 12 prolapse meshes. On histologic examination, macrophages surrounded each mesh fiber in both groups, with predominance of the M1 subtype. M1 and M2 cytokines/chemokines, MMP-9 (pro- and active), and MMP-2 (active) were increased significantly in mesh-vagina explants, as compared with vagina without mesh. Mesh explants that were removed for exposure had 88.4% higher pro-MMP-9 (P = .035) than those removed for pain. A positive correlation was observed between the profibrotic cytokine interleukin-10 and the percentage of M2 cells (r = 0.697; P = .037) in the pain group. CONCLUSION In women with complications, mesh induces a proinflammatory response that persists years after implantation. The increase in MMP-9 in mesh explants that were removed for exposure indicates degradation; the positive association between interleukin-10 and M2 macrophages in mesh explants that are removed for pain is consistent with fibrosis.
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Affiliation(s)
- Alexis L Nolfi
- Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, PA; Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Bryan N Brown
- Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, PA; Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Rui Liang
- Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, PA; Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Stacy L Palcsey
- Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, PA
| | - Michael J Bonidie
- Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA
| | | | - Pamela A Moalli
- Magee-Womens Research Institute, University of Pittsburgh, Pittsburgh, PA; Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA; Department of Obstetrics, Gynecology, and Reproductive Sciences, School of Medicine, University of Pittsburgh, Pittsburgh, PA.
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Kelly M, Macdougall K, Olabisi O, McGuire N. In vivo response to polypropylene following implantation in animal models: a review of biocompatibility. Int Urogynecol J 2016; 28:171-180. [PMID: 27216918 PMCID: PMC5306078 DOI: 10.1007/s00192-016-3029-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 04/17/2016] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Polypropylene is a material that is commonly used to treat pelvic floor conditions such as pelvic organ prolapse (POP) and stress urinary incontinence (SUI). Owing to the nature of complications experienced by some patients implanted with either incontinence or prolapse meshes, the biocompatibility of polypropylene has recently been questioned. This literature review considers the in vivo response to polypropylene following implantation in animal models. The specific areas explored in this review are material selection, impact of anatomical location, and the structure, weight and size of polypropylene mesh types. METHODS All relevant abstracts from original articles investigating the host response of mesh in vivo were reviewed. Papers were obtained and categorised into various mesh material types: polypropylene, polypropylene composites, and other synthetic and biologically derived mesh. RESULTS Polypropylene mesh fared well in comparison with other material types in terms of host response. It was found that a lightweight, large-pore mesh is the most appropriate structure. CONCLUSION The evidence reviewed shows that polypropylene evokes a less inflammatory or similar host response when compared with other materials used in mesh devices.
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Affiliation(s)
- Michelle Kelly
- Devices Division, The Medicines and Healthcare products Regulatory Agency (MHRA), 151 Buckingham Palace Road, London, SW1W 9SZ, UK
| | - Katherine Macdougall
- Devices Division, The Medicines and Healthcare products Regulatory Agency (MHRA), 151 Buckingham Palace Road, London, SW1W 9SZ, UK
| | - Oluwafisayo Olabisi
- Devices Division, The Medicines and Healthcare products Regulatory Agency (MHRA), 151 Buckingham Palace Road, London, SW1W 9SZ, UK.
| | - Neil McGuire
- Devices Division, The Medicines and Healthcare products Regulatory Agency (MHRA), 151 Buckingham Palace Road, London, SW1W 9SZ, UK
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Blaivas JG, Purohit RS, Benedon MS, Mekel G, Stern M, Billah M, Olugbade K, Bendavid R, Iakovlev V. Safety considerations for synthetic sling surgery. Nat Rev Urol 2015; 12:481-509. [DOI: 10.1038/nrurol.2015.183] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Gigliobianco G, Roman Regueros S, Osman NI, Bissoli J, Bullock AJ, Chapple CR, MacNeil S. Biomaterials for pelvic floor reconstructive surgery: how can we do better? BIOMED RESEARCH INTERNATIONAL 2015; 2015:968087. [PMID: 25977927 PMCID: PMC4419215 DOI: 10.1155/2015/968087] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 08/19/2014] [Indexed: 12/21/2022]
Abstract
Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) are major health issues that detrimentally impact the quality of life of millions of women worldwide. Surgical repair is an effective and durable treatment for both conditions. Over the past two decades there has been a trend to enforce or reinforce repairs with synthetic and biological materials. The determinants of surgical outcome are many, encompassing the physical and mechanical properties of the material used, and individual immune responses, as well surgical and constitutional factors. Of the current biomaterials in use none represents an ideal. Biomaterials that induce limited inflammatory response followed by constructive remodelling appear to have more long term success than biomaterials that induce chronic inflammation, fibrosis and encapsulation. In this review we draw upon published animal and human studies to characterize the changes biomaterials undergo after implantation and the typical host responses, placing these in the context of clinical outcomes.
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Affiliation(s)
| | | | - Nadir I. Osman
- Material Science Engineering, University of Sheffield, Sheffield S1 3JD, UK
- Royal Hallamshire Hospital, Sheffield S10 2JF, UK
| | - Julio Bissoli
- Hospital das Clínicas da Faculdade de Medicina, Universidade de Sao Paulo, 05410-020 São Paulo, Brazil
| | - Anthony J. Bullock
- Material Science Engineering, University of Sheffield, Sheffield S1 3JD, UK
| | | | - Sheila MacNeil
- Material Science Engineering, University of Sheffield, Sheffield S1 3JD, UK
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Endo M, Urbankova I, Vlacil J, Sengupta S, Deprest T, Klosterhalfen B, Feola A, Deprest J. Cross-linked xenogenic collagen implantation in the sheep model for vaginal surgery. ACTA ACUST UNITED AC 2015; 12:113-122. [PMID: 25960708 PMCID: PMC4417472 DOI: 10.1007/s10397-015-0883-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 01/19/2015] [Indexed: 02/05/2023]
Abstract
The properties of meshes used in reconstructive surgery affect the host response and biomechanical characteristics of the grafted tissue. Whereas durable synthetics induce a chronic inflammation, biological grafts are usually considered as more biocompatible. The location of implantation is another determinant of the host response: the vagina is a different environment with specific function and anatomy. Herein, we evaluated a cross-linked acellular collagen matrix (ACM), pretreated by the anti-calcification procedure ADAPT® in a sheep model for vaginal surgery. Ten sheep were implanted with a cross-linked ACM, and six controls were implanted with a polypropylene (PP; 56 g/m2) control. One implant was inserted in the lower rectovaginal septum, and one was used for abdominal wall defect reconstruction. Grafts were removed after 180 days; all graft-related complications were recorded, and explants underwent bi-axial tensiometry and contractility testing. Half of ACM-implanted animals had palpable induration in the vaginal implantation area, two of these also on the abdominal implant. One animal had a vaginal exposure. Vaginal ACMs were 63 % less stiff compared to abdominal ACM explants (p = 0.01) but comparable to vaginal PP explants. Seven anterior vaginal ACM explants showed areas of graft degradation on histology. There was no overall difference in vaginal contractility. Considering histologic degradation in the anterior vaginal implant as representative for the host, posterior ACM explants of animals with degradation had a 60 % reduced contractility as compared to PP (p = 0.048). Three abdominal implants showed histologic degradation; those were more compliant than non-degraded implants. Vaginal implantation with ACM was associated with graft-related complications (GRCs) and biomechanical properties comparable to PP. Partially degraded ACM had a decreased vaginal contractility.
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Affiliation(s)
- Masayuki Endo
- Centre for Surgical Technologies, Faculty of Medicine, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Development and Regeneration, Organ Systems Cluster, Faculty of Medicine, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
- Pelvic Floor Unit, University Hospitals KU Leuven, Leuven, Belgium
| | - Iva Urbankova
- Centre for Surgical Technologies, Faculty of Medicine, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Development and Regeneration, Organ Systems Cluster, Faculty of Medicine, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
- Institute for Care of Mother and Child, Prague, Czech Republic
| | - Jaromir Vlacil
- Centre for Surgical Technologies, Faculty of Medicine, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Development and Regeneration, Organ Systems Cluster, Faculty of Medicine, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
- Institute for Care of Mother and Child, Prague, Czech Republic
| | - Siddarth Sengupta
- Department of Development and Regeneration, Organ Systems Cluster, Faculty of Medicine, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Thomas Deprest
- Department of Development and Regeneration, Organ Systems Cluster, Faculty of Medicine, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | | | - Andrew Feola
- Centre for Surgical Technologies, Faculty of Medicine, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Development and Regeneration, Organ Systems Cluster, Faculty of Medicine, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Jan Deprest
- Centre for Surgical Technologies, Faculty of Medicine, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
- Department of Development and Regeneration, Organ Systems Cluster, Faculty of Medicine, KU Leuven, Herestraat 49, 3000 Leuven, Belgium
- Pelvic Floor Unit, University Hospitals KU Leuven, Leuven, Belgium
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Histopathology of excised midurethral sling mesh. Int Urogynecol J 2014; 26:591-5. [PMID: 25377295 DOI: 10.1007/s00192-014-2553-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 10/18/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The objective of this study was to compare the histological characteristics of pathological specimens of excised midurethral sling mesh and surrounding vaginal tissue in patients who presented preoperatively with pain and/or exposure of mesh to patients who underwent mesh excision for voiding dysfunction without pain and/or erosion. METHODS This is a retrospective case-control study of women who underwent excision of midurethral sling mesh between 2008 and 2013. Three groups were identified: (1) voiding dysfunction without pain or exposure (control group), (2) pain and/or mesh exposure, and (3) voiding dysfunction with pain and/or mesh exposure. All original pathological specimens were rereviewed by one pathologist blinded to indication for excision and the previous pathology report. Degree of inflammation and fibrosis were recorded based on a 4-point scale along with the presence of giant cell reaction. RESULTS A total of 130 subjects met inclusion criteria: 60 (46.2 %) with voiding dysfunction only, 21 (16.2 %) with pain/erosion, and 49 (37.7 %) with both pain/exposure and voiding dysfunction. The voiding dysfunction only group was found to have significantly higher levels of inflammation, median grade 2 (1-3), compared to the other two groups with a p value of 0.007. There were no statistical differences in fibrosis and giant cell reaction between the three groups. CONCLUSIONS Midurethral sling mesh excised for voiding dysfunction demonstrates elevated levels of inflammation compared to mesh that is excised for pain and/or exposure. The vaginal tissue fibrosis and giant cell reaction are similar in patients who undergo mesh excision for voiding dysfunction and pain, and/or mesh exposure.
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Comparison of polypropylene mesh and porcine-derived, cross-linked urinary bladder matrix materials implanted in the rabbit vagina and abdomen. Int Urogynecol J 2013; 25:683-9. [DOI: 10.1007/s00192-013-2283-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 11/12/2013] [Indexed: 10/26/2022]
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Abstract
Successful repair of most hernias requires the use of a prosthetic implant for reinforcement of the defect. Because of the need for prosthetic implants to resist infections as well to support repairs in contaminated or potentially contaminated fields, biological meshes have been developed to take the place of nondegradable synthetic meshes in cases where mesh infection is of high concern. The ideal is a biological matrix that resists infection while providing durable reinforcement of a hernia repair. This article reviews the validity of assumptions that support the purported notion of the biological behavior of biological meshes.
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Deprest J, Feola A. The need for preclinical research on pelvic floor reconstruction. BJOG 2013; 120:141-143. [PMID: 23240796 DOI: 10.1111/1471-0528.12088] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/11/2012] [Indexed: 11/28/2022]
Affiliation(s)
- J Deprest
- Research Unit Biomechanics, Bioimplants and Tissue Engineering, Department of Development and Regeneration, Faculty of Medicine.,Pelvic Floor Unit, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - A Feola
- Research Unit Biomechanics, Bioimplants and Tissue Engineering, Department of Development and Regeneration, Faculty of Medicine
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Prolapse surgery in octogenarians: are we pushing the limits too far? World J Urol 2012; 31:623-8. [DOI: 10.1007/s00345-012-0863-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Accepted: 03/23/2012] [Indexed: 11/26/2022] Open
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Patel H, Ostergard DR, Sternschuss G. Polypropylene mesh and the host response. Int Urogynecol J 2012; 23:669-79. [PMID: 22430945 DOI: 10.1007/s00192-012-1718-y] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Accepted: 02/09/2012] [Indexed: 11/30/2022]
Abstract
The use of polypropylene (PP) mesh for pelvic floor repair has been increasing dramatically over the past decade; however, tissue response in humans has not been extensively studied. This review discusses PP mesh and postimplantation host tissue response. Emphasis is placed on studies investigating the relationship between individual mesh properties and specific responses. There is an immediate inflammatory response after PP mesh implantation that lays the framework for tissue ingrowth and subsequent mesh integration. This response varies based on physical properties of individual mesh, such as pore size, weight, coatings, bacterial colonization, and biofilm production.
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Affiliation(s)
- Hiren Patel
- Long Beach Memorial Medical Center, Women's Hospital, Long Beach, CA 90806, USA.
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A standardized description of graft-containing meshes and recommended steps before the introduction of medical devices for prolapse surgery. Int Urogynecol J 2012; 23 Suppl 1:S15-26. [DOI: 10.1007/s00192-012-1678-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Accepted: 01/16/2012] [Indexed: 02/04/2023]
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Pierce LM, Asarias JR, Nguyen PT, Mings JR, Gehrich AP. Inflammatory cytokine and matrix metalloproteinase expression induced by collagen-coated and uncoated polypropylene meshes in a rat model. Am J Obstet Gynecol 2011; 205:82.e1-9. [PMID: 21497787 DOI: 10.1016/j.ajog.2011.02.045] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2010] [Revised: 01/29/2011] [Accepted: 02/14/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The objective of the study was to compare the influence of collagen-coated vs uncoated polypropylene meshes on the expression of genes critical for wound healing. STUDY DESIGN In 54 rats, abdominal wall defects were created, repaired by polypropylene sutures, and covered by an overlay of coated polypropylene (n = 20), uncoated polypropylene (n = 18), or no mesh (n = 16). Explants were harvested 7 or 90 days after repair and divided for histological, immunohistochemical, and messenger ribonucleic acid (mRNA) analyses. Real-time quantitative polymerase chain reaction arrays were used to profile the expression of 84 genes at the tissue-mesh interface. RESULTS One week after implantation, coated mesh elicited a slightly greater inflammatory response and increased mRNA expression of 4 proinflammatory cytokines compared with uncoated mesh. Both materials, however, induced a comparable expression of cytokines and matrix metalloproteinases relative to suture repair 90 days after implantation. CONCLUSION Collagen-coated polypropylene mesh induces elevated inflammatory cytokine expression compared with uncoated mesh early in the healing process, but the response to both meshes is similar 90 days after implantation.
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Affiliation(s)
- Lisa M Pierce
- Department of Clinical Investigation, Tripler Army Medical Center, Honolulu, HI, USA
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Melman L, Jenkins ED, Hamilton NA, Bender LC, Brodt MD, Deeken CR, Greco SC, Frisella MM, Matthews BD. Early biocompatibility of crosslinked and non-crosslinked biologic meshes in a porcine model of ventral hernia repair. Hernia 2011; 15:157-64. [PMID: 21222009 DOI: 10.1007/s10029-010-0770-0] [Citation(s) in RCA: 92] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Accepted: 12/12/2010] [Indexed: 11/24/2022]
Abstract
PURPOSE Biologic meshes have unique physical properties as a result of manufacturing techniques such as decellularization, crosslinking, and sterilization. The purpose of this study is to directly compare the biocompatibility profiles of five different biologic meshes, AlloDerm(®) (non-crosslinked human dermal matrix), PeriGuard(®) (crosslinked bovine pericardium), Permacol(®) (crosslinked porcine dermal matrix), Strattice(®) (non-crosslinked porcine dermal matrix), and Veritas(®) (non-crosslinked bovine pericardium), using a porcine model of ventral hernia repair. METHODS Full-thickness fascial defects were created in 20 Yucatan minipigs and repaired with the retromuscular placement of biologic mesh 3 weeks later. Animals were euthanized at 1 month and the repair sites were subjected to tensile testing and histologic analysis. Samples of unimplanted (de novo) meshes and native porcine abdominal wall were also analyzed for their mechanical properties. RESULTS There were no significant differences in the biomechanical characteristics between any of the mesh-repaired sites at 1 month postimplantation or between the native porcine abdominal wall without implanted mesh and the mesh-repaired sites (P > 0.05 for all comparisons). Histologically, non-crosslinked materials exhibited greater cellular infiltration, extracellular matrix (ECM) deposition, and neovascularization compared to crosslinked meshes. CONCLUSIONS While crosslinking differentiates biologic meshes with regard to cellular infiltration, ECM deposition, scaffold degradation, and neovascularization, the integrity and strength of the repair site at 1 month is not significantly impacted by crosslinking or by the de novo strength/stiffness of the mesh.
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Affiliation(s)
- L Melman
- Department of Surgery, Washington University School of Medicine, 660 South Euclid Avenue, 63110, St. Louis, MO 63110, USA
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Boennelycke M, Christensen L, Nielsen LF, Everland H, Lose G. Tissue response to a new type of biomaterial implanted subcutaneously in rats. Int Urogynecol J 2010; 22:191-6. [PMID: 20838988 DOI: 10.1007/s00192-010-1257-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2010] [Accepted: 08/18/2010] [Indexed: 10/19/2022]
Abstract
INTRODUCTION AND HYPOTHESIS A new type of resorbable biomaterial intended for pelvic reconstruction was tested with respect to tissue regeneration and biocompatibility in rats. The biomaterial consisted of methoxypolyethyleneglycol-poly(lactic-co-glycolic acid) (MPEG-PLGA). Implants were pure, enriched with extra-cellular matrix (ECM) or estrogen. METHODS Ten implants of each type were tested for 3 and 8 weeks, respectively. Histological assessment of connective tissue organization, inflammation, vascularization, and thickness of regenerated tissue was undertaken. RESULTS All implants had a high degree of biocompatibility. ECM-enriched implants had significantly higher inflammatory scores compared to pure implants at 3 weeks. At 8 weeks, neither of the parameters differed significantly. No trace of the implants remained. CONCLUSIONS The MPEG-PLGA is highly biocompatible, degrades quickly, and seems inert in the process of tissue regeneration. Thus, it is hardly a candidate per se in reinforcement of pelvic reconstruction, but it could have a future role as carrier for stem cells.
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Affiliation(s)
- Marie Boennelycke
- Department of Obstetrics and Gynecology, Copenhagen University Hospital Herlev, Herlev Ringvej 75, 2730, Herlev, Denmark.
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Discussion: Adipose Tissue–Derived Stem Cells Enhance Bioprosthetic Mesh Repair of Ventral Hernias. Plast Reconstr Surg 2010; 126:855-857. [DOI: 10.1097/prs.0b013e3181e606b5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Higgins EW, Rao A, Baumann SS, James RL, Kuehl TJ, Muir TW, Pierce LM. Effect of estrogen replacement on the histologic response to polypropylene mesh implanted in the rabbit vagina model. Am J Obstet Gynecol 2009; 201:505.e1-9. [PMID: 19683695 DOI: 10.1016/j.ajog.2009.05.050] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2008] [Revised: 04/24/2009] [Accepted: 05/27/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The aim of this study was to determine the effect of estrogen replacement after ovariectomy on the histologic response to polypropylene mesh implanted in rabbit vagina. STUDY DESIGN Thirty rabbits were assigned to 5 groups: sham laparotomy, ovariectomy, ovariectomy-preoperative estrogen, ovariectomy-postoperative estrogen, or ovariectomy-preoperative and postoperative estrogen. Rabbits underwent sham surgery or ovariectomy and were infused with vehicle or 17beta-estradiol (200 microg/d) for 4 weeks ("preoperative" estrogen). Polypropylene mesh was implanted in the posterior vaginal wall, and rabbits were infused with vehicle or "postoperative" estrogen for an additional 8 weeks. Grafts were harvested and underwent histologic evaluation. RESULTS Vaginal atrophy in ovariectomized rabbits was reversed by estrogen replacement. Scores for inflammation (P = .33) and neovascularization (P = .23) at the graft site were not different among estrogen replacement groups, but estrogen administration was associated with increased collagen deposition (P = .005). CONCLUSION Estrogen replacement administered for 8 weeks postoperatively increases collagen deposition into polypropylene mesh.
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