The use of prosthetics in pelvic reconstructive surgery

Designing Double-Layer Multi-Material Composite Patch Scaffold with Adhesion Resistance for Hernia Repair

Hernia repair mesh is associated with a number of complications, including adhesions and limited mobility, due to insufficient mechanical strength and non-resorbability. Among them, visceral adhesions are one of the most serious complications of patch repair. In this study, a degradable patch with an anti-adhesive layer was prepared for hernia repair by 3D printing and electrospinning techniques using polycaprolactone (PCL), polyvinyl alcohol (PVA), and soybean peptide (SP). The study into the physicochemical properties of the patch was found that it had adequate mechanical strength requirements (16 N cm^-1 ) and large elongation at break, which were superior than commercial polypropylene (PP) patches. In vivo and in vitro experiments showed that human umbilical vein endothelial cells (HUVECs) proliferated well on composite patches, and showed excellent biocompatibility with the host and little adhesion through a rat abdominal wall defect model. In conclusion, the results of this study show that composite patch can effectively reduce the occurrence of adhesions, while the addition of SP in the patch further enhances its biocompatibility. We believe that a regenerative biological patch with great potential in hernia repair provides a new strategy for the development of new biomimetic biodegradable patches. This article is protected by copyright. All rights reserved.

Composite Outcomes After Posterior Colporrhaphy With and Without Biologic Graft Augmentation

OBJECTIVES

To compare subjective and objective failure after posterior colporrhaphy with and without biologic graft augmentation.

METHODS

We conducted a retrospective chart review and telephone survey of patients who underwent a posterior colporrhaphy with and without biologic graft augmentation from 2005 to 2019. Patients who underwent a sacrocolpopexy, uterosacral ligament suspensions, or anterior sacrospinous ligament fixation were excluded. We determined objective, subjective, and composite failure rates.

RESULTS

Although 137 patients met eligibility criteria, 56 did not have valid contact information and, therefore, were excluded from the study. Of the 81 with valid contact information, 67 (83%) agreed to participate. There were 24 (36%) who had a native tissue repair and 43 (64%) who had biologic graft augmentation. Median telephone follow-up was 73 months (interquartile range [IQR], 36-117). Objective failure was similar for the biologic graft (37%) and the native tissue (42%) groups (P = 0.72). Subjective failure was twice as likely among the biologic graft group (60%) compared with the native tissue group (33%, P = 0.03). Patients with a biologic graft reported a median Pelvic Floor Distress Inventory-Short Form 20 improvement of 31 (IQR, 8-33), while those with a native tissue repair reported a median improvement of 45 (IQR, 4-46). Overall, 78% were satisfied, 85% would recommend the procedure, and 84% reported symptomatic improvement. Reoperation occurred for 15% of patients.

CONCLUSIONS

Although biologic graft-augmented posterior colporrhaphy may be a safe and effective treatment option, the use of biologic grafts in the posterior compartment does not appear to confer a significant long-term benefit to traditional posterior colporrhaphy.

Long-term outcome (5-10 years) after non absorbable mesh insertion compared to partially absorbable mesh insertion for anterior vaginal wall prolapse repair

Objective:

To evaluate long-term (5-10 years) outcomes of Minimally Invasive Surgical (MIS) kit insertion with Prolift^® (non-absorbable) mesh compared to the use of Prolift M^® (partially absorbable), for anterior vaginal wall prolapse repair.

Study design:

In this retrospective study we compared women undergoing MIS kit Prolift^® insertion (n=90) vs. Prolift M^® insertion (n=79) for anterior vaginal wall prolapse repair between 2006 and 2012 at our Institution. A number of 169 women fulfilled the inclusion criteria and were included in the study.

Results:

During the study period 128 women (76%) completed full follow-up; of them 58 (73%) following MIS kit Prolift^® insertion, and 70 (88%) following MIS kit ProliftM^® insertion. There was no significant difference between the Prolift® and Prolift M^® regarding parity (3.04 vs. 2.88, p=0.506), presence of hypertension (24.1% vs. 39.1%, p=0.088), diabetes mellitus (3.4% vs. 11.6%, p=0.109), or urinary stress incontinence (39.7% vs. 47.1%, p=0.475). All participants had been diagnosed with POP grade 3 or 4 before the procedure. No significant complications during the procedure or postoperative period were identified in the study groups. The follow-up period was at least five years in duration for both groups. Both groups were comparable according to questionnaires focused on function and satisfaction.

Conclusion:

Patients undergoing MIS kit Prolift^® and Prolift M^® insertion for anterior vaginal wall prolapse repair had comparable early and late postoperative outcomes. No differences in patient's function and satisfaction between the two groups were identified. According to our findings, there is no superiority to either of the two studied mesh devices.

Induction of human umbilical cord mesenchymal stem cells into tissue-forming cells in a murine model: implications for pelvic floor reconstruction

HUMSCs were isolated, differentiated and characterized in vitro. Both HUMSCs and smooth muscle cells differentiated from HUMSCs were used to fabricate tissue-engineered fascia equivalents. Forty-eight mature female Sprague Dawley rats were randomly assigned to four groups: group A (GynemeshTMPS, n = 12), group B (GynemeshTMPS + HUMSCs; n = 12), group C (GynemeshTMPS + smooth muscle cells differentiated from HUMSCs; n = 12) and group D (GynemeshTMPS + HUMSCs + smooth muscle cells differentiated from HUMSCs; n = 12). The posterior vaginal wall was incised from the introitus and the mesh was then implanted. Three implants of each type were tested at 1, 4, 8 and 12 weeks. Fibrotic remodeling, inflammation, vascularization and tissue regeneration were histologically assessed. The levels of type I and type III collagen were determined. There was no difference in fibrotic remodeling between cell-seeded and unseeded meshes at any time (p > 0.05). At 12 weeks, there did not appear to be fewer inflammatory cells around the filament bundles in the mesh with cells compared with the mesh alone (P > 0.05). Group D showed a trend toward better vascularization at 12 weeks compared with group A (P < 0.05). Twelve weeks after implantation, a thin layer of new tissue growth covered the unseeded scaffold and a thicker layer covered the cell-seeded scaffold (P < 0.05). No significant difference in the ratio of collagen type I/III could be detected among the different groups after 12 weeks (P > 0.05). HUMSCs with differentiated smooth muscle cells might have a potential role in fascia tissue engineering to repair POP in the future.

Nanofibrous biomimetic mesh can be used for pelvic reconstructive surgery: A randomized study

BACKGROUND

Implantation of nonabsorbable polypropylene (PP) mesh in the vagina is the main surgical treatment for pelvic organ prolapse (POP); however, clinical outcomes remain controversial and far from satisfactory. In particular, reducing the exposure or erosion of vaginal implants to obtain improved functional reconstruction is challenging. There is an urgent need for the development of new materials and/or products for POP treatment. A nanofibrous biomimetic mesh was recently developed to address this issue.

OBJECTIVE

In this study, the basic properties of the newly developed mesh, including structural characteristics, mechanical properties, biological response of human umbilical cord mesenchymal stem cells in vitro, and tissue regeneration and biocompatibility in vivo, were evaluated and compared with those of Gynemesh™PS.

METHODS

Scanning electron microscopy and uniaxial tensile methods were used to evaluate microstructure and mechanical properties, respectively. Mesenchymal stem cell growth on the meshes was observed by fluorescence microscopy to visualize the expression of enhanced red fluorescent protein. Twenty-four mature female Sprague Dawley rats were randomly assigned to two groups: group 1 (nanofibrous biomimetic mesh, Medprin, Germany, n=12) and group 2 (Gynemesh(TM)PS, Ethicon, USA; n=12). The posterior vaginal wall was incised from the introitus, and the mesh was then implanted. Three implants of each type were tested for 1, 4, 8 and 12 weeks. Connective tissue organization, inflammation, vascularization, and regenerated tissue were histologically assessed.

RESULTS

The nanofibrous biomimetic mesh is a relatively heavy material and exhibited lower porosity than Gynemesh(TM)PS. The new mesh was stiffer than Gynemesh(TM)PS (p<0.001) but supported human umbilical cord mesenchymal stem cell attachment. Erosion of the grafts did not occur in any animal. The nanofibrous biomimetic mesh was encapsulated by a thicker layer of connective tissue and was associated with significantly greater inflammatory scores compared with Gynemesh(TM)PS. At 12 weeks, the vascularization of the new mesh was greater than that of Gynemesh(TM)PS (p<0.05). No significant difference in the thickness of the smooth muscle layer following implantation was observed between the two groups (p>0.05).

CONCLUSIONS

The nanofibrous biomimetic mesh is a candidate for reinforcing pelvic reconstruction. The mesh could be improved by decreasing its weight and stiffness and increasing its porosity. This mesh could serve as a carrier for stem cells in future regenerative medicine and tissue engineering research.

In vivo biomechanical properties of heavy versus light weight monofilament polypropylene meshes. Does the knitting pattern matter?

AIMS

This work evaluated the post-implant biomechanical properties of light-weight (LW) and heavy-weight (HW) monofilament polypropylene (PP) meshes with different knitting patterns in an animal model in vivo.

METHODS

Forty-five adult female Wistar rats were divided into three groups and randomly implanted with 32 × 32 mm HW-PP (62 gm^-2 ) orLW-PP (16 gm^-2 ) in the lower abdomen. LW-PPwas tested orthogonally (called LWL and LWT) to reproduce the longitudinal and transverse planes of the vaginal wall, respectively. Abdominal walls were removed at 7, 30, and 60 days, and then tested for tensile load (maximum load until avulsion from the tissue), deflection, and stiffness to maximum load. Explants were compared over time and between groups.

RESULTS

LW-PP meshes implanted in the LWT fashion (vaginal transverse plane) showed comparable maximum load and stiffness to HW-PP meshes, and LW-PP meshes implanted in the LWL fashion (vaginal longitudinal plane) presented lower maximum load and stiffness than the HW-PP meshes. There were no significant differences in the values of deflection at maximum load between the studied meshes as a function of time.

CONCLUSIONS

The final mechanical behavior of PP mesh can be changed by its weight and knitting pattern. These properties may be useful in making more biocompatible prostheses for pelvic organ prolapse (POP) with less foreign material to maintain longitudinal vaginal elasticity and minimize sexual symptoms while maintaining transverse resistance (i.e., between vaginal fornixes) to prevent POP recurrence. Neurourol. Urodynam. 36:73-79, 2017. © 2015 Wiley Periodicals, Inc.

The Use of Tutomesh for a Tension-Free and Tridimensional Repair of Uterovaginal and Vaginal Vault Prolapse: Preliminary Report

Objective. To evaluate efficacy in terms of vaginal capacity, coital function, and recurrence prevention of a new biological mesh of bovine pericardium (Tutomesh) in the repair of severe POP. Methods. Thirty cases of patients suffering from stage III uterine or apical prolapse undergone surgical repair by means of a modified sacrospinous ligament suspension combined with mesh attachment to both the cardinal ligaments, posterior and anterior colporrhaphy, and perineal body fixation. The mesh was replaced inside the pelvis with the goal of reconstructing the tridimensional fascial disposition of the structures sustaining the correct axis of vagina. Follow-up was done at 12 months with POPIQ analysis. Results. One total mesh failure occurred early after surgery due to marked deficiency of anatomy. Two cystoceles were observed at 12 months in two patients treated for apical prolapse where anterior repair was not performed. Two other patients developed a de novo SUI at 12 months. No reported abnormalities of coital function or dyspareunia were ever found after surgery. Conclusions. It is possible that the utilization of a tension-free and tridimensional placement of Tutomesh might favor a more physiologic reconstruction of the vaginal axis as compared with traditional sacrospinous ligament suspension.

The role of synthetic and biologic materials in the treatment of pelvic organ prolapse

Pelvic organ prolapse is a significant medical problem that poses a diagnostic and management dilemma. These diseases cause serious morbidity in those affected and treatment is sought for relief of pelvic pain, rectal bleeding, chronic constipation, obstructed defecation, and fecal incontinence. Numerous procedures have been proposed to treat these conditions; however, the search continues as colorectal surgeons attempt to find the procedure that would optimally treat these conditions. The use of prosthetics in the repair of pelvic organ prolapse has become prevalent as the benefits of their use are realized. While advances in biologic mesh and new surgical techniques promise improved functional outcomes with decreased complication rates without de novo symptoms, the debate concerning the best prosthetic material, synthetic or biologic, remains controversial. Furthermore, laparoscopic ventral mesh rectopexy has emerged as a procedure that could potentially fill this role and is rapidly becoming the procedure of choice for the surgical treatment of pelvic organ prolapse.

Acute in vivo response to an alternative implant for urogynecology

Purpose. To investigate in vivo the acute host response to an alternative implant designed for the treatment of stress urinary incontinence (SUI) and pelvic organ prolapse (POP). Methods. A biodegradable scaffold was produced from poly-L-lactic acid (PLA) using the electrospinning technique. Human and rat adipose-derived stem cells (ADSCs) were isolated and characterized by fluorescence-activated cell sorting and differentiation assays. PLA scaffolds were seeded and cultured for 2 weeks with human or rat ADSCs. Scaffolds with and without human or rat ADSCs were implanted subcutaneously on the abdominal wall of rats. After 3 and 7 days, 6 animals from each group were sacrificed. Sections from each sample were analyzed by Haematoxylin and Eosin staining, Sirius red staining, and immunohistochemistry for CD68, PECAM-1, and collagen I and III. Results. Animals responded to the scaffolds with an acute macrophage response. After 7 days of implantation, there was extensive host cell penetration, new blood vessel formation, and new collagen deposition throughout the full thickness of the samples without obvious differences between cell-containing and cell-free scaffolds. Conclusions. The acute in vivo response to an alternative implant (both with and without cells) for the treatment of SUI and POP showed good acute integration into the host tissues.

Update in management of vaginal mesh erosion

Mesh erosion is one of the major complications of prolapse surgery conducted by transvaginal approach. Following the extensive use of meshes and warning about potential complications, a new classification of mesh-related adverse events has been proposed. Due to the wide scope of clinical features, no standardized approach has been proposed. Surgery is required after failure of conservative management, mostly based on mesh partial or total excision by transvaginal route, following the classic rules of re-do vaginal surgery. Complex cases are best managed in tertiary reference centers.

Toward potent antibiofilm degradable medical devices: a generic method for the antibacterial surface modification of polylactide

The effects of biomaterials on their environment must be carefully modulated in most biomedical applications. Among other approaches, this modulation can be obtained through the modification of the biomaterial surface. This paper proposes a simple and versatile strategy to produce non-leaching antibacterial polylactide (PLA) surfaces without any degradation of the polyester chains. The method is based on a one-pot procedure that provides a "clickable" PLA surface via anionic activation which is then functionalized with an antibacterial quaternized poly(2-(dimethylamino)ethyl methacrylate) (QPDMAEMA) by covalent immobilization on the surface. The anti-adherence and antibiofilm activities of modified PLA surfaces are assessed for different QPDMAEMA molecular weights and different quaternization agents. Antibacterial PLA surfaces are shown to be very active against Gram-negative and Gram-positive strains, with adherence reduction factors superior to 99.999% and a marked reduction in biofilm on the most potent surfaces. In addition to this substantial antibacterial activity, the proposed PLA surfaces are also cytocompatible, as demonstrated through the proliferation of L929 fibroblasts.

How to deal with complications after laparoscopic ventral mesh rectopexy: lessons learnt from a tertiary referral centre

AIM

Laparoscopic ventral mesh rectopexy (LVMR) is increasingly recognized as having utility in rectal prolapse, obstructive defaecation syndrome (ODS), faecal incontinence (FI) and multicompartment pelvic floor dysfunction (PFD). This study aimed to highlight gaps in service provision and areas for improvement by examining a cohort of patients with complications referred to a tertiary centre.

METHOD

Examination was carried out of a password-protected electronic database of all LVMRs operated on in one institution.

RESULTS

Fifty patients (45 women), median age 54 (range, 24-71) years, were referred with early symptomatic failure (n = 27) following an inadequate LVMR or major mesh complications (erosion into another organ, fistulation or stricturing) (n = 23). All were amenable to remedial laparoscopic surgery. Functional improvements were found in pre- and postoperative ODS, Wexner (FI) scores (two-tailed t-test; P < 0.0001) and quality of life (Birmingham Bowel and Urinary Symptoms Questionnaire-22) scores at 3 months (two-tailed t-test; P < 0.001) and normalization at 1 year (P < 0.015). This was mirrored by improved linear bowel symptom severity visual analogue scale scores (two-tailed t-test; P < 0.0001 at 3 months and P = 0.015 at 1 year) .

CONCLUSION

LVMR can be associated with technical complications arising from inadequate technique or from operation-specific complications that are amenable to complex revisional laparoscopic surgery with significant improvement in quality of life and function.

The use of synthetic mesh and the management of mesh extrusion in vaginal surgery

The authors present a review of the literature regarding the management of mesh extrusion in vaginal surgery. As used in traditional surgical techniques, the use of mesh theoretically allows for a broader base of support and eliminates the need to rely on pre-existing weakened fascia. In this article, the different physical properties and types of synthetic mesh used, and their respective advantages and disadvantages in terms of mesh extrusion, are reviewed.

Magnetic resonance imaging of abdominal versus vaginal prolapse surgery with mesh

INTRODUCTION AND HYPOTHESIS

We compared two surgical approaches in patients with symptomatic prolapse of the vaginal apex with normal controls by analyzing pelvic landmark relationships measured using magnetic resonance imaging (MRI) before and after surgery.

METHODS

In this prospective multicenter pilot study involving 16 participants, nulliparous controls (n = 6) were compared with ten parous (3.0 ± 1.0) women with uterine apical prolapse equal to or greater than stage 2. Group A (n = 5) underwent abdominal sacral colpopexy with monofilament polypropylene mesh and group B (n = 5) with vaginal mesh kit repair (Total ProLift). Subtotal hysterectomy was performed in all group A and no group B women. All patients underwent preoperative and 3-month postoperative Pelvic Organ Prolapse Quantification (POP-Q) and dynamic MRI. Comparison of MRI pelvic angles and distances was performed and analyzed by Mann-Whitney rank sum test and chi-square test.

RESULTS

Vaginal apical support is similar at 3 months for abdominal sacral colpopexy (ASCP) and ProLift by POP-Q examination and MRI analysis. In both treatment groups, the postoperative POP-Q point C and MRI parameters were similar to nulliparous controls at 3 months.

CONCLUSIONS

Anatomic outcomes for ASCP compared with ProLift were similar at 3 months in terms of vaginal apical support by POP-Q and MRI analysis. Continued comparative analysis of postoperative support with objective imaging seems warranted.

Percutaneously assisted cystoscopic removal of intravesical mesh erosion

This describes a novel approach to cystoscopic removal of a mesh erosion occurring 3 months after anterior vaginal repair with mesh augmentation.

New antibiotic-eluting mesh used for soft tissue reinforcement

The surgical implantation of prostheses for soft tissue repair may be followed by post-operative mesh-related infection, a significant and dramatic complication, that is treated by mesh removal. A new antibiotic-eluting mesh has been manufactured on pre-existing polypropylene prostheses using an airbrush spraying technology. Among the degradable polymers tested as coating agents and drug reservoirs, poly(ε-caprolactone) (PCL), which is deposited after heating, provides a homogeneous, regular and smooth shell around the polypropylene filaments of the mesh without dramatically altering the biomechanical properties of the new modified mesh. An anti-infective drug (e.g. ofloxacin) is incorporated into this polymeric coating giving a limited burst effect followed by sustained drug diffusion for several days. An ofloxacin-eluting mesh has demonstrated excellent antibacterial activity in vitro on Escherichia coli adherence, biofilm formation and inhibitory diameter, even with low drug loads. Although further in vivo investigations are required to draw conclusions on the anti-infective effectiveness of the coated mesh, the airbrush coating of ofloxacin-PCL on existing prostheses is already potentially appealing in an effort to decrease post-operative infection.

Necrotizing fasciitis following transobturator tape procedure: a case report and literature review

A 51-year-old diabetic woman was referred to our unit with a history of increasing pain in her right thigh and gait disturbance, 10 days following surgery for treatment of stress urinary incontinence with a transobturator tape. Examination elicited a tender right thigh associated with swelling and erythema. Inspection of the vagina revealed an exposed mesh through the vaginal erosion. Plain radiographs and magnetic resonance imaging revealed large thigh abscesses suggestive of gas gangrene from the pelvis to the calf. The mesh was completely removed; extensile incisions, as well as aggressive debridement of all necrotic tissue in the thigh and calf, were performed. A diagnosis of necrotizing fasciitis with gas extending to the lower leg level was confirmed. After mesh removal, abscess drainage and debridement, the patient recovered with antibiotics and daily wound care. Three months after the operation, the patient showed no recurrence of the infection.

Inflammatory cytokine and matrix metalloproteinase expression induced by collagen-coated and uncoated polypropylene meshes in a rat model

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.

Urogenital complaints and female sexual dysfunction. Part 2

INTRODUCTION

Female sexual dysfunction (FSD) is common in women with urogenital disorders that occur as a result of pelvic floor muscle and fascial laxity.

AIM

Provide a comprehensive review of FSD as it relates to common urogenital disorders including pelvic organ prolapse (POP) and stress urinary incontinence (SUI) and to discuss the impact of the surgical repair of these disorders on sexual function.

METHODS

Systematic search of the medical literature using a number of related terms including FSD, POP, SUI, surgical repair, graft augmentation, complications, and dyspareunia.

MAIN OUTCOME MEASURES

Review of the medical literature to identify the relation between FSD and common urogenital disorders in women and to describe appropriate treatment strategies to improve quality of life (QOL) and sexual function.

RESULTS

FSD is common in women with POP and SUI. Treatment options for POP and SUI include behavioral, pharmacological, and surgical methods which can also affect sexual function.

CONCLUSIONS

Sexual dysfunction is a common, underestimated complaint in women with POP and SUI. Treatment should be tailored toward improving sexual function and QOL. Surgical correction is generally beneficial but occasionally can result in negative alterations in sexual function. Patient selection and methods used for surgical repair are important factors in determining anatomical and functional success.

A multicenter prospective trial evaluating fetal bovine dermal graft (Xenform® Matrix) for pelvic reconstructive surgery

Background

A prospective multicenter clinical study was performed to evaluate the safety and efficacy of a bovine dermal graft (Xenform^® Matrix, Boston Scientific, Natick, MA, USA) during vaginal reconstructive surgery.

Methods

Forty-five women with ICS stage 2 or higher pelvic organ prolapse (POP) were enrolled at 4 centers. POP-Q, pelvic floor function (PFDI-20), sexual function (PISQ-12), and patient satisfaction tools were used to assess subjects at baseline, and at 2 and 6 weeks, and 3, 6 and 12 months post surgery. The significance of symptom score changes at 6 months and 1 year were determined by the t-test for paired data. Forty-three of the 45 patients completed the 12 month study.

Results

The majority of the subjects had cystocele (98%) and/or rectocele (84%) defects at study entry. At 12 months, 74% of the defects had improved to a stage 0 or 1. Mean PFDI-20 scores improved by 72% (p < 0.001) at 12 months, and PISQ-12 scores were maintained during the follow-up period indicating no decline in sexual function. Three subjects experienced one serious adverse event each; one of the adverse events (constipation) was deemed by the study physician to be unrelated to Xenform^®. One subject had severe pyelonephritis resulting in dialysis. This subject had a previous history of pyelonephritis, sepsis and acute renal failure. The third subject had a reported recurrent cystocele of moderate severity, possibly related to the device. No graft related erosions or pain lasting more than 30 days were reported. No subjects withdrew due to an adverse event.

Conclusion

This study is the first to investigate the use of Xenform^® Matrix in vaginal reconstructive surgery among patients with POP. Significant improvement was maintained at 12 months utilizing both objective and subjective assessment tools, confirming the safety and efficacy of this material in vaginal surgery.

Trial Registration

ClinicalTrials.gov NCT01244165

Use of Surgisis mesh in the management of polypropylene mesh erosion into the vagina

INTRODUCTION AND HYPOTHESIS

mesh in pelvic reconstructive surgery is being used increasingly in clinical practice. Complications such as mesh erosion and dyspareunia can cause significant patient morbidity. In cases where vaginal mesh erosions are large or multifocal resulting in inadequate healthy epithelium for repair, this may lead to recurrent mesh erosion or vaginal stenosis.

METHOD

nine patients with synthetic mesh erosion who failed to respond to conservative measures were managed surgically with Surgisis.

RESULTS

the median time at which patients presented with mesh erosion was 12 weeks. The size of erosion ranged from 1 to 4 cm in diameter. At follow-up, five patients were cured, three still had evidence of mesh erosion although the overall defects were smaller, and one patient required further surgery.

CONCLUSION

with mesh erosion being a troublesome reality following insertion of synthetic mesh repairs, Surgisis may prove to be a useful option in the treatment of large vaginal mesh defects.

Bacterial colonisation of collagen-coated polypropylene vaginal mesh: are additional intraoperative sterility procedures useful?

Introduction and hypothesis

The use of vaginally implanted polypropylene meshes in the treatment of prolapse is becoming increasingly popular. We set out to detect how often bacterial colonisation of the mesh occurs and if the intraoperative sterility procedures that are applied matter.

Methods

In 64 consecutive women, bacterial colonisation was compared between two intraoperative sterility procedures. Culture swabs of the core mesh were taken during surgery, and the mesh arms removed at the end of surgery were cultured separately.

Results

Sixty-seven implants were cultured. In 56 (83.6%) implants, a positive culture with vaginal bacteria was found with very low bacterial density (<10³ colony-forming units). No significant differences in bacterial species, density, clinical infection and erosion (two anterior and one posterior) were found between the two intraoperative sterility methods.

Conclusions

Colonisation of vaginally implanted mesh occurs frequently but in low bacterial densities, irrespective of the intraoperative sterility procedure used.

Laparoscopic removal of mesh used in pelvic floor surgery

Various meshes are being used widely in clinical practice for pelvic reconstructive surgery despite the lack of evidence of their long-term safety and efficacy. Management of complications such as mesh erosion and dyspareunia can be challenging. Most mesh-related complications can probably be managed successfully via the transvaginal route; however, this may be impossible if surgical access is poor. This case report demonstrates the successful laparoscopic removal of mesh after several failed attempts via the vaginal route.

Tela de polipropileno versus correção sítio-especifica no tratamento do prolapso de parede vaginal anterior: resultados preliminares de ensaio clínico randômico

OBJETIVO: Comparar o uso de tela de polipropileno e correção sitio-específica no tratamento cirúrgico do prolapso vaginal anterior. MÉTODOS: Estudo prospectivo randômico comparativo em que foram operadas 32 pacientes com idades entre 50 e 75 anos, que apresentavam prolapso vaginal anterior estádio III ou IV, ou recidivado. A estática pélvica foi avaliada segundo as recomendações da International Continence Society (ICS), o sistema POP-Q e pelo Índice de Quantificação de Prolapso (POP-Q-I) Absoluto e Relativo. Para o rastreamento da incontinência urinária de esforço oculta todas as pacientes, sintomáticas ou não, foram submetidas a estudo urodinâmico em posição semi-ginecológica e semi-sentada, com redução do prolapso com pinça de Cheron. Registrou-se o tempo cirúrgico, o volume de sangramento intra-operatório e as complicações intra e pós-operatórias. O tempo de seguimento médio do estudo foi de 8,5 meses. RESULTADOS: Em relação aos resultados anatômicos ocorreu melhores resultados com a utilização de tela de polipropileno sobre o reparo sitio-específico. Em relação à morbidade cirúrgica, observou-se menor tempo cirúrgico no grupo em que utilizou-se tela. CONCLUSÃO: Houve superioridade dos resultados anatômicos obtidos com a utilização de tela de polipropileno sobre o reparo sitio-específico.

Long-term histologic response to synthetic and biologic graft materials implanted in the vagina and abdomen of a rabbit model

OBJECTIVE

We sought to evaluate the effects of graft type, site of implantation, and ovariectomy on the long-term histologic response to graft materials used in pelvic reconstructive surgery.

STUDY DESIGN

In all, 45 rabbits underwent ovariectomy or sham laparotomy and were implanted with polypropylene (PP) mesh (n = 23) or cross-linked porcine dermis (PS) (n = 22) in the vagina and abdomen. Grafts were harvested 9 months later and were processed for histology to evaluate the host inflammatory response and degree of tissue incorporation within the grafts.

RESULTS

Polypropylene induced a milder (P < .007), more uniform response than PS, whereas PS elicited a more variable response and degraded by 9 months. Vaginal grafts had higher scores for inflammation (P = .005) and neovascularization (P < .001), and had lower scores for fibroblastic proliferation (P < .001) than abdominal grafts. Ovariectomy had no effect (P > .05).

CONCLUSION

Synthetic and biologic grafts evoke different foreign body responses, which may have implications for surgical outcomes in women.

Biomechanical properties of synthetic and biologic graft materials following long-term implantation in the rabbit abdomen and vagina

OBJECTIVE

We sought to evaluate the effects of anatomic location and ovariectomy on biomechanical properties of synthetic and biologic graft materials after long-term implantation.

STUDY DESIGN

A total of 35 rabbits underwent ovariectomy or sham laparotomy and were implanted with polypropylene (PP) mesh (n = 17) or cross-linked porcine dermis (PS) (n = 18) in the vagina and abdomen. Grafts were harvested 9 months later and underwent mechanical properties testing.

RESULTS

After implantation, PS was similar in strength (P = .52) but was twice as stiff as PP (P = .04) and had a maximal elongation only half that of PP (P < .001). Degradation of PS was associated with decreased ultimate tensile strength (P = .03) and elastic modulus (P = .046). Vaginal PP grafts shrunk more (P < .001) and were less stiff than abdominal PP grafts (P = .049) but were not different in strength (P = .19). Ovariectomy had no effect (P > .05).

CONCLUSION

Cross-linked PS undergoes long-term degradation resulting in compromised biomechanical properties and thus is likely inferior to lightweight PP meshes for pelvic organ prolapse and incontinence procedures.

[Effectiveness evaluation of polypropylene mesh in the repair of urogenital prolapse in 106 patients]

OBJECTIVE

To evaluate the efficacy and security of polypropylene meshes in the repair of urogenital prolapse.

MATERIAL AND METHOD

Retrospective and non-randomized study in 106 patients which had different kinds of urogenital prolapse repaired using polypropylene meshes between April 2005 and January 2007. The follow-up was carried out by two visits to the hospital, 2 and 6 months after surgery. The variables analyzed were age, parity, menopause presence, kind of surgical technique, surgical time, time at hospital and complications. Afterwards, the information was analyzed descriptively.

RESULTS

Average age was 64.4 years. The rate of multiparity and menopause women was 91.51% and 92.45% respectively. The most used surgical technique was the anterior mesh with tension-free band (34.90%), to repair the associated urinary incontinence. The rate of intraoperatory complications was 2.83%, immediate complications was 37.73% and late complications was 21.69%. The success rate after 6 months was 80-100% depending on the technique.

CONCLUSIONS

There is a low rate of intraoperatory and 6 months after the repair in the reconstructive surgery of pelvic floor for the urogenital prolapses using polypropylene meshes, which makes this technique a secure and effective option for the treatment of this problem.

Histologic response of porcine collagen-coated and uncoated polypropylene grafts in a rabbit vagina model

OBJECTIVE

The purpose of this study was to determine whether the host tissue response in the rabbit vagina differs for 2 synthetic graft materials that are used in pelvic reconstructive surgery.

STUDY DESIGN

One strip of porcine collagen-coated or uncoated polypropylene mesh was implanted adjacent to a sham operative site into the posterior vagina of 10 New Zealand white rabbits and harvested 12 weeks later. Rabbits were assigned randomly to group 1 (coated; n = 5), group 2 (uncoated; n = 5), or group 3 (unoperated; n = 4). Full-thickness sagittal sections of posterior vaginal wall and rectum were scored for inflammation, neovascularization, and fibroblastic proliferation.

RESULTS

Erosion of grafts did not occur in any animal. Coated and uncoated meshes induced a mild inflammatory response with minimal fibrosis and good host tissue incorporation within the grafts. Few apoptotic and proliferating cells were seen for both graft types.

CONCLUSION

Both coated and uncoated polypropylene meshes elicit a mild foreign body reaction and minimal fibrotic response without evidence of vaginal epithelial erosion.

Laparoscopic management of uterine prolapse with cystocele and rectocele using "Gynemesh PS"

OBJECTIVE

Our department performed laparoscopic correction of uterine or vault prolapse with cystocele and rectocele using the "Gynemesh PS." The aim of this study was to evaluate the surgical outcomes and perioperative morbidity after a laparoscopic operation.

MATERIALS AND METHODS

From August 2004 to September 2005, we performed laparoscopic pelvic floor repairs in 6 cases of vault prolapse and 15 cases of uterine prolapse at the Department of Obstetrics and Gynecology at the Kyungpook National University Hospital (Daegu, Korea). Uterine and vault prolapse were repaired by laparoscopic rectocele and cystocele repair using the Gynemesh PS, uterosacral ligament suspension, paravaginal repair, and Burch colposuspension. In uterine prolapse, we also carried out a subtotal hysterectomy. The stage of prolapse was classified by means of the pelvic organ prolapse quantification (POPQ) system.

RESULTS

The mean age, Q-index, and parity were 64 years (range, 47-79), 24.6 (range, 18.7 approximately 27.8), and 5 (range, 3 approximately 10), respectively. Mean operation time was 141 minutes (range, 90 approximately 211). Mean estimated blood loss was 53 mL (range, 20 approximately 80). Mean hospital stay was 5 days (range, 3 approximately 9 days). There were no major complications, but postoperative voiding difficulty developed in 1 case. Mean preoperative POPQ stage was 3 and immediate, 6-week, 3-month, 6-month, and 1-year postoperative POPQ score was 0. Mean follow-up period was 7.5 months (range, 3 approximately 13). The objective success rate was 100%.

CONCLUSIONS

Laparoscopic pelvic floor repair is an effective procedure and enables us to combine the advantages of laparotomy with the low morbidity of the vaginal route. In Europe, the sacrocolpopexy was more popular, but uterosacral ligament suspension is the most natural anatomic repair of defects and, hence, the least likely to be predisposed to future defects in the anterior or posterior vaginal wall or to compromise vaginal function. However, further studies are required on the long-term efficiency and reliability in order to evaluate the value of this technique.

[The prosthetic kits in the prolapse surgery: is it a gadget?]

OBJECTIVE

To search if the prosthetic kits bring an interest, other that financier.

MATERIALS AND METHOD

Authors have counted 5 firms presenting the varied kits. The Prolift kit with synthetic pre- cut mesh made of polypropylene, standardized needle, cannulas and protective devices of recovery of mesh arms in 3 versions, anterior, posterior and total. Perigee and Apogee systems in a synthetic version (IntePro) and a biological version (InteXen ++LP) matched of specific needles for the different obturator passages and infra coccygeus. The Avaulta kit declines in a biosynthetic version and a hybrid version with a specific needle for its anterior kit and an other for its posterior kit. The Biomesh Soft system presents a polypropylène mesh posed on a multi pattern sheet to carve following dots with a share of 3 needles according to the type of arm passage ended by a recuperator thread. The Nazca POP Repair System, in its anterior version claims to be able to correct in the same time a urinary incontinence by pre-pubic arms. The polypropylene mesh is perforated and is had with the help a needle for its anterior and posterior kit. Authors have been interested in the research of studies on prosthesis with and without kit.

RESULTS

The Prolift kit contains the alone prosthesis having been evaluated without (TVM) and with kit. Authors remind results of two studies, understanding 684 cases without kit and 110 cases with kit. The rate of early per and postoperative complications has been decreased half, the rate of mesh exposure decreased from 11,3 to 4,7%. Studies on Perigee and Apogee IntePro kits, whose meshe and the procedure are similar to the Prolift seem to obtain from results equal. The Biological version has not made the object of study. For the Avauta kit, alone the mesh in plate not pre-cut has been well studied as for its tolerance for the biosynthetic version. Nothing on the hybrid version. No study is found for the Biomesh Soft kit and Nazca POP repair system.

DISCUSSION

The cost of these kits, varying 1 to 4, is to take in consideration and to put in scale with the returned service. Alone TVM/Prolift allows to advance in a reply. The utilization of needles, presents in all the kits, but especially devices facilitating the passage and the recovery of prosthesis arms, presents solely in the Prolift kit, reduce the utilization of valves and the risk of tear tissues during their job. The improvement of techniques by elements of the kit make that the surgical procedure become mini invasive.

CONCLUSION

The full kits allow a best security of procedures, facilitate the surgical gesture and limit complications. It is necessary to remain vigilant in the evaluation of these new materials "ready to wear" and to require pre clinic and clinic studies before their distribution.

Adductor brevis myositis following transobturator tape procedure: a case report and review of the literature

The tension-free vaginal tape (TVT) procedure has long been considered the gold standard for female stress incontinence. Since its introduction in 1995, several other tapes and other minimally invasive treatments have arisen. The transobturator tape (TOT) procedure reproduces the natural suspension of the urethra through the obturator and puborectalis muscles. The TOT procedure was reportedly developed in an effort to prevent bladder perforation associated with the TVT and is generally considered to be a procedure with low morbidity. At our institution, we report the first case of infected mesh with subsequent myositis of adductor muscles after a TOT procedure. To our knowledge, this is the first case reporting this complication, citing specifically that the anatomical structures traversed by the tape, including both muscle and fascia, can be at risk for infection and ultimately require removal of the sling material. We performed a MEDLINE literature search using key words such as "transobturator tape," "tension free vaginal tape," and "adductor and obturator complications" to ascertain any reported adductor or obturator muscle complications after placement of TOT. Further, we reviewed the literature to elucidate the consequences of using different mesh materials, specifically their effects on erosion. We reported our case of a 43-year-old woman who presented with right-leg cellulitis and vaginal discharge after having a TOT placed for stress incontinence. Inflammation of the adductor muscles was demonstrated on computed tomography (CT) scan and ultrasound. On physical exam, the mesh had visibly eroded through the vaginal wall. Our patient underwent excision of the mesh material. She ultimately had an uneventful postoperative course and was discharged home in good condition on the postoperative day 2. The mesh material removed was ObTape. We believe our study is the first case report to discuss the complication of infected adductor muscles and erosion of the tape during post-TOT procedure. After a careful review of the literature, there is no mention of myositis of adductor muscles as a possible complication after the TOT procedure. In fact, the literature has deemed this minimally invasive treatment as a safe and effective procedure with minimal complications including only de novo urgency or urinary retention. The site of infection is of particular interest and can be explained by the course through the anatomical structures that are unique to this particular procedure. Ultimately, the treatment for this procedure was the removal of the mesh along with broad-spectrum antibiotics. In conclusion, the burden falls upon the surgeons to report in a timely fashion both successes and complication for the TOT procedure given their relatively limited experience. This is paramount in determining patients' risks.