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Ács J, Szabó A, Fehérvári P, Harnos A, Skribek B, Tenke M, Szarvas T, Nyirády P, Ács N, Hegyi P, Majoros A. Safety and Efficacy of Vaginal Implants in Pelvic Organ Prolapse Surgery: A Meta-analysis of 161 536 Patients. Eur Urol Focus 2023:S2405-4569(23)00243-2. [PMID: 37968187 DOI: 10.1016/j.euf.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 11/02/2023] [Indexed: 11/17/2023]
Abstract
CONTEXT Among the many surgical treatments for pelvic organ prolapse (POP), better results can be achieved with the use of vaginal implants. However, owing to perceived complications, vaginal implant surgeries have been restricted or banned in many countries. OBJECTIVE To assess the real value of vaginal implants in POP surgery and compare the safety and efficacy of operations with and without implants. EVIDENCE ACQUISITION A systematic search was performed in three medical databases. Randomised controlled trials and observational studies comparing the safety and efficacy of vaginal POP surgery with implants versus native tissue were included. Safety outcomes were defined as different types of complications (functional and non-functional) and reoperations for complications. Efficacy outcomes were parameters of anatomical success and the rate of reoperations due to recurrence. A multivariate meta-analysis framework was used to estimate pooled odds ratios (ORs) with confidence intervals (CIs) with simultaneous control for study correlations and estimation of multiple correlated outcomes. EVIDENCE SYNTHESIS We included 50 comparative studies in the analysis. Rates of reoperation for complications (OR 2.15, 95% CI 1.20-3.87), vaginal erosion (OR 14.05, 95% CI 9.07-21.77), vaginal bleeding (OR 1.67, 95% CI 1.25-2.23), and de novo stress urinary incontinence (OR 1.44, 95% CI 1.18-1.75) were significantly higher in the implant group. Rates of anatomical success (OR 3.22, 95% CI 2.06-5.0) and reoperation for recurrence (OR 0.55, 95% CI 0.36-0.85) were superior in the implant group. CONCLUSIONS POP surgeries with vaginal implants are more effective than surgeries without implants, with acceptable complication rates. Therefore, the complete prohibition of implants for POP surgeries should be reconsidered. PATIENT SUMMARY We compared vaginal surgery with and without implants for repair of pelvic organ prolapse. Despite higher complication rates, vaginal implants provide better long-term results overall than surgery without implants.
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Affiliation(s)
- Júlia Ács
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary; Department of Urology, Semmelweis University, Budapest, Hungary
| | - Anett Szabó
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary; Department of Urology, Semmelweis University, Budapest, Hungary
| | - Péter Fehérvári
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary; Department of Biostatistics, University of Veterinary Medicine Budapest, Budapest, Hungary
| | - Andrea Harnos
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary; Department of Biostatistics, University of Veterinary Medicine Budapest, Budapest, Hungary
| | - Benjamin Skribek
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
| | - Martin Tenke
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary; Department of Urology, Semmelweis University, Budapest, Hungary
| | - Tibor Szarvas
- Department of Urology, Semmelweis University, Budapest, Hungary; Department of Urology, University of Duisburg-Essen and German Cancer Consortium, Essen, Germany
| | - Péter Nyirády
- Department of Urology, Semmelweis University, Budapest, Hungary
| | - Nándor Ács
- Department of Obstetrics and Gynecology, Semmelweis University, Budapest, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary; Institute of Pancreatic Diseases, Semmelweis University, Budapest, Hungary; Institute for Translational Medicine, University of Pécs Medical School, Pécs, Hungary
| | - Attila Majoros
- Department of Urology, Semmelweis University, Budapest, Hungary.
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Sferra R, Pompili S, D'Alfonso A, Sabetta G, Gaudio E, Carta G, Festuccia C, Colapietro A, Vetuschi A. Neurovascular alterations of muscularis propria in the human anterior vaginal wall in pelvic organ prolapse. J Anat 2019; 235:281-288. [PMID: 31148163 PMCID: PMC6637706 DOI: 10.1111/joa.13014] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/15/2019] [Indexed: 01/03/2023] Open
Abstract
In the pathophysiology and progression of pelvic organ prolapse (POP), it has been demonstrated that there is a reorganisation of the muscularis propria of the anterior vaginal wall due to a phenotypic smooth muscle cell to myofibroblast switch. An abnormal deposition of collagen type III seems to be influenced by the involvement of advanced glycation end-products. The aim of the present study was to evaluate the hypothesis that this connective tissue remodelling could also be associated with neurovascular alterations of the muscularis in women with POP compared with control patients. We examined 30 women with POP and 10 control patients treated for uterine fibromatosis. Immunohistochemical analysis, using glial fibrillary acidic protein, S-100 protein, receptor tyrosine kinase, neurofilament and α-smooth muscle actin antibodies, was performed. S-100, receptor tyrosine kinase and neurofilament were also evaluated using Western blot analysis. We observed a decrease in all neurovascular-tested markers in nerve bundles, ganglia and interstitial cells of Cajal from POP samples as compared with controls. Even if the processes responsible for these morphological alterations are still not known, it is conceivable that collagen III deposition in the anterior vaginal wall affects not only the architecture of the muscle layer but could also modify the intramuscular neurovascularisation and account for an alteration of the neuromuscular plasticity of the layer.
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Affiliation(s)
- R Sferra
- Department of Biotechnological and Applied Clinical SciencesUniversity of L'AquilaL'AquilaItaly
| | - S Pompili
- Department of Biotechnological and Applied Clinical SciencesUniversity of L'AquilaL'AquilaItaly
| | - A D'Alfonso
- Department of Life, Health and Environmental Sciences, Gynecology and Obstetrics UnitUniversity of L'AquilaL'AquilaItaly
| | - G Sabetta
- Department of Biotechnological and Applied Clinical SciencesUniversity of L'AquilaL'AquilaItaly
| | - E Gaudio
- Department of Anatomical, Histological, Forensic Medicine and Orthopedic SciencesSapienza University of RomeRomeItaly
| | - G Carta
- Department of Life, Health and Environmental Sciences, Gynecology and Obstetrics UnitUniversity of L'AquilaL'AquilaItaly
| | - C Festuccia
- Department of Biotechnological and Applied Clinical SciencesUniversity of L'AquilaL'AquilaItaly
| | - A Colapietro
- Department of Biotechnological and Applied Clinical SciencesUniversity of L'AquilaL'AquilaItaly
| | - Antonella Vetuschi
- Department of Biotechnological and Applied Clinical SciencesUniversity of L'AquilaL'AquilaItaly
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Vetuschi A, Pompili S, Gallone A, D'Alfonso A, Carbone MG, Carta G, Festuccia C, Gaudio E, Colapietro A, Sferra R. Immunolocalization of Advanced Glycation End Products, Mitogen Activated Protein Kinases, and Transforming Growth Factor-β/Smads in Pelvic Organ Prolapse. J Histochem Cytochem 2018; 66:673-686. [PMID: 29737911 DOI: 10.1369/0022155418772798] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Collagen and matrix metalloproteinases (MMP) play a pivotal role in the pathophysiology of Pelvic Organ Prolapse (POP) as a switch between type I and III collagen together with a simultaneous activation of MMPs have been observed in the vaginal wall. The aim of this study was to evaluate the Advanced Glycation End (AGE) products, ERK1/2 and transforming growth factor (TGF)-β/Smad pathway expression in muscularis propria in women with POP compared with control patients. We examined 20 patients with POP and 10 control patients treated for uterine fibromatosis. Immunohistochemical analysis using AGE, RAGE, ERK1/2, Smads-2/3, Smad-7, MMP-3, and collagen I-III, TIMP, and α-SMA were performed. Smad-2/3, Smad-7, AGE, ERK1/2, p-ERK, and p-Smad3 were also evaluated using Western-blot analysis. POP samples from the anterior vaginal wall showed disorganization of the normal muscularis architecture. In POP samples, AGE, ERK1/2, Smad-2/3, MMP-3, and collagen III were upregulated in muscularis whereas in controls, Smad-7 and collagen I were increased. The receptor for AGEs (RAGE) was mild or absent both in controls and prolapse. We demonstrated the involvement of these markers in women with POP but further studies are required to elucidate if the overexpression of these molecules could play a crucial role in the pathophysiology of POP disease.
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Affiliation(s)
- Antonella Vetuschi
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Simona Pompili
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Anna Gallone
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Angela D'Alfonso
- Department of Life, Health and Environmental Sciences, Gynecology and Obstetrics Unit, University of L'Aquila, L'Aquila, Italy
| | - Maria Gabriella Carbone
- Department of Life, Health and Environmental Sciences, Gynecology and Obstetrics Unit, University of L'Aquila, L'Aquila, Italy
| | - Gaspare Carta
- Department of Life, Health and Environmental Sciences, Gynecology and Obstetrics Unit, University of L'Aquila, L'Aquila, Italy
| | - Claudio Festuccia
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Eugenio Gaudio
- Department of Anatomical, Histological, Forensic Medicine and Orthopedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Alessandro Colapietro
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Roberta Sferra
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
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Wu PY, Chang CH, Shen MR, Chou CY, Yang YC, Huang YF. Seeking new surgical predictors of mesh exposure after transvaginal mesh repair. Int Urogynecol J 2016; 27:1547-55. [PMID: 26992722 DOI: 10.1007/s00192-016-2996-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 02/29/2016] [Indexed: 12/26/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The purpose of this study was to explore new preventable risk factors for mesh exposure. METHODS A retrospective review of 92 consecutive patients treated with transvaginal mesh (TVM) in the urogynecological unit of our university hospital. An analysis of perioperative predictors was conducted in patients after vaginal repairs using a type 1 mesh. Mesh complications were recorded according to International Urogynecological Association (IUGA) definitions. Mesh-exposure-free durations were calculated by using the Kaplan-Meier method and compared between different closure techniques using log-rank test. Hazard ratios (HR) of predictors for mesh exposure were estimated by univariate and multivariate analyses using Cox proportional hazards regression models. RESULTS The median surveillance interval was 24.1 months. Two late occurrences were found beyond 1 year post operation. No statistically significant correlation was observed between mesh exposure and concomitant hysterectomy. Exposure risks were significantly higher in patients with interrupted whole-layer closure in univariate analysis. In the multivariate analysis, hematoma [HR 5.42, 95 % confidence interval (CI) 1.26-23.35, P = 0.024), Prolift mesh (HR 5.52, 95 % CI 1.15-26.53, P = 0.033), and interrupted whole-layer closure (HR 7.02, 95 % CI 1.62-30.53, P = 0.009) were the strongest predictors of mesh exposure. CONCLUSION Findings indicate the risks of mesh exposure and reoperation may be prevented by avoiding hematoma, large amount of mesh, or interrupted whole-layer closure in TVM surgeries. If these risk factors are prevented, hysterectomy may not be a relative contraindication for TVM use. We also provide evidence regarding mesh exposure and the necessity for more than 1 year of follow-up and preoperative counselling.
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Affiliation(s)
- Pei-Ying Wu
- Department of Obstetrics & Gynecology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 70403, Taiwan
| | - Chih-Hung Chang
- Department of Urology, St. Joseph Hospital, Kaohsiung, Taiwan
| | - Meng-Ru Shen
- Department of Obstetrics & Gynecology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 70403, Taiwan
| | - Cheng-Yang Chou
- Department of Obstetrics & Gynecology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 70403, Taiwan
| | - Yi-Ching Yang
- Department of Family Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Fang Huang
- Department of Obstetrics & Gynecology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, 70403, Taiwan.
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Pelvic organ prolapse in women: how is it diagnosed and treated currently? MENOPAUSE REVIEW 2015; 14:155-60. [PMID: 26528102 PMCID: PMC4612550 DOI: 10.5114/pm.2015.54338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 09/03/2015] [Accepted: 09/10/2015] [Indexed: 11/17/2022]
Abstract
The aim of the paper was to summarize the current opinions about the management of pelvic organ prolapse in women. Food and Drug Administration safety announcements from 2008 and 2011 triggered the discussion about the methods of treatment of pelvic organ prolapse and the used materials and a partial return to the methods which had been totally criticized before the implementation of meshes. The decrease in mesh usage is also observed. The studies did not demonstrate the prevalence of any particular surgical procedure. The amount of studies concerning the evaluation and the treatment of pelvic organ prolapse ensures that the quality of care provided to women with urogynecological problems is continuously increasing.
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Manonai J, Rostaminia G, Denson L, Shobeiri SA. Clinical and ultrasonographic study of patients presenting with transvaginal mesh complications. Neurourol Urodyn 2015; 35:407-11. [PMID: 25620321 DOI: 10.1002/nau.22725] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 11/24/2014] [Indexed: 01/26/2023]
Abstract
AIM The objective of this study was to investigate the clinical and ultrasonographic findings of women who had three-dimensional endovaginal ultrasound (EVUS) for the management of vaginal mesh complications. METHODS This was a retrospective study of patients that had EVUS due to mesh complications at a tertiary care center. The clinical charts were reviewed. The stored 3D volumes were reviewed regarding mesh information by two examiners independently. The predictive value of physical examination for detection of vaginal mesh was calculated. Patient outcomes were reviewed. RESULTS Seventy-nine patients presented to our center because of their, or their physicians' concern regarding mesh complications. Forty-one (51.9%) had vaginal/pelvic pain, and 51/62 (82.2%) of sexually active women experienced dyspareunia. According to ultrasonographic findings, mesh or sling was not demonstrated in six patients who believed they have had mesh/sling implantation. The positive predictive value for vaginal examination was 94.5% (95% CI: 84.9%-98.8%), negative predictive value was 12.5% (95% CI: 2.8%-32.4%), sensitivity was 72.2% (95% CI: 59.4%-81.2%), and specificity was 50.0% (95% CI: 12.4%-87.6%). Fifty-four patients were indicated for surgical treatment. Median postoperative review was 12 (range, 3-18) months and 38/53 (71.7%) patients were satisfied. CONCLUSIONS The most common complaints of vaginal mesh complications were pain and dyspareunia. EVUS appeared to be helpful for assessing mesh presence, location, and extent including planning for surgical intervention.
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Affiliation(s)
- Jittima Manonai
- Department of Obstetrics & Gynaecology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Ghazaleh Rostaminia
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Lindsay Denson
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - S Abbas Shobeiri
- Department of Obstetrics and Gynecology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
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Kdous M, Zhioua F. 3-year results of transvaginal cystocele repair with transobturator four-arm mesh: A prospective study of 105 patients. Arab J Urol 2014; 12:275-84. [PMID: 26019962 PMCID: PMC4435760 DOI: 10.1016/j.aju.2014.09.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 05/01/2014] [Accepted: 09/24/2014] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVES To evaluate the long-term efficacy and safety of transobturator four-arm mesh for treating cystoceles. PATIENTS AND METHODS In this prospective study, 105 patients had a cystocele corrected between January 2004 and December 2008. All patients had a symptomatic cystocele of stage ⩾2 according to the Baden-Walker halfway stratification. We used only the transobturator four-arm mesh kit (Surgimesh®, Aspide Medical, France). All surgical procedures were carried out by the same experienced surgeon. The patients' characteristics and surgical variables were recorded prospectively. The anatomical outcome, as measured by a physical examination and postoperative stratification of prolapse, and functional outcome, as assessed by a questionnaire derived from the French equivalents of the Pelvic Floor Distress Inventory, Pelvic Floor Impact Questionnaire and the Pelvic Organ Prolapse-Urinary Incontinence-Sexual Questionnaire, were considered as the primary outcome measures. Peri- and postoperative complications constituted the secondary outcome measures. RESULTS At 36 months after surgery the anatomical success rate (stage 0 or 1) was 93%. On a functional level, all the scores of quality of life and sexuality were improved. The overall satisfaction score (visual analogue scale) was 71.4%. There were no perioperative adverse events. Mesh erosion was reported in 7.6% and mesh retraction in 5.7% of the patients. CONCLUSIONS If the guidelines and precautions are followed, vaginal prosthetic surgery for genitourinary prolapse has shown long-term benefits. It provides excellent results both anatomically and functionally. However, complications are not negligible and some are specific to prosthetic surgery.
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Affiliation(s)
- Moez Kdous
- Department of Obstetrics and Gynecology, Aziza Othmana Hospital, Tunis, Tunisia
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Martius Graft for Management of Exposed Vaginal Prolapse Mesh. J Minim Invasive Gynecol 2013; 20:227-9. [DOI: 10.1016/j.jmig.2012.10.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2012] [Revised: 10/02/2012] [Accepted: 10/18/2012] [Indexed: 11/23/2022]
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9
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Current world literature. Curr Opin Urol 2012; 22:336-45. [PMID: 22677776 DOI: 10.1097/mou.0b013e3283551cbf] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Angioli R, Montera R, Plotti F, Terranova C, Aloisi A, Zullo MA. Suburethral sling in autoimmune patients: complications, quality of life, and success rate. Int Urogynecol J 2011; 23:453-7. [DOI: 10.1007/s00192-011-1595-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 10/18/2011] [Indexed: 11/24/2022]
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