Two years follow up of 270 patients treated by transvaginal mesh for anterior and/or apical prolapse

Comparing Patient-Reported Outcome Measures for Pain in Women With Pelvic Floor Disorders: A Scoping Review

Women with pelvic floor disorders (PFDs) typically undergo surgery involving transvaginal mesh implants; however, transvaginal mesh surgery is associated with many adverse events including post-surgical pain. Assessment of pain as a symptom is necessary using patient-reported outcome measures (PROMs). This scoping review aimed to describe and compare existing PROMs previously used to measure pain in women with PFDs. A scoping search of Ovid MEDLINE, EMBASE, CINAHL Plus, Ovid PsycInfo, and grey literature was conducted. Studies published in English describing the development, implementation, and application of PFD-associated pain PROMs among adult women before and after pelvic floor surgery were included. From each article, a descriptive summary organised by study first author, publication year, country, setting, aim, study characteristics, and results were extracted. From 2,604 articles identified, 54 studies were included, describing 44 PROMs. Most studies described at least 2 to 3 instruments. The Pelvic Floor Distress Inventory-20 was most commonly described by 12 studies followed by the Patient Global Impression of Improvement scale. Of the 44 PROMs, 27 were condition-specific, of which 9 included items on pain; 17 generic PROMs, 4 of which contained items on pain; and 6 pain-specific PROMs. PROMs identified in our review measured pain not related to PFDs or pelvic floor surgery and quantified the pain experienced. These PROMs did not measure all areas of pain including region, sensation, impact, and triggers. The findings of this review will assist with developing a new pain-specific PROM in this population. PERSPECTIVE: Women with pelvic floor disorders often undergo surgery involving transvaginal mesh, from which they experience debilitating pain. Pain is a major issue impacting women's lives. Patient-reported outcome measures can be used to assess the pain; however, it is unclear whether existing instruments are relevant.

Induction of a different immune response in non-titanized compared to titanized polypropylene meshes

It is well known that pelvic organ prolapse (POP) significantly reduces the quality of life of affected women and in many cases requires corrective surgery. Aim of the study was to compare the immune response against titanized versus non-titanized meshes, especially macrophage polarization and immune checkpoint association. For this, we analyzed 644 POP surgeries, which were performed between 2017 and 2022, in our department. Four of them needed revision surgery caused by erosion. We analyzed the influx of CD68 & CD163 positive macrophages and the expression of immune checkpoint molecules PD-L1 and PD1 in these 4 patients. We identified a large number of CD68 and CD163 positive macrophages and additionally a PD-L1 expression of these cells. Based on the in-vivo results, we isolated monocytes and co-cultivated monocytes with different mesh material covered with or without fibroblasts. We identified a significantly enhanced macrophage activation and PD-L1 expression in macrophages surrounding non-titanized polypropylene mesh material. Encapsulation of the material by fibroblasts was crucial for that. Specifically, CD68-positive macrophages are upregulated (p < 0.001), co-expressing PD-L1 (p < 0.001) in monocytes co-cultivated with non-titanized polypropylene meshes. Monocytes co-cultivated with titanized polypropylene meshes showed significantly lower expression of CD163 (p = 0.027) and PD-L1 (p = 0.022). In conclusion, our in vitro data suggest that the titanium coating leads to a decreased polarization of macrophages and to a decreased immune response compared to non-titanized meshes. This could be an indication for the increased incidence of erosion of the non-titanized meshes, which is a severe complication of this procedure and requires revision surgery. STATEMENT OF SIGNIFICANCE: Pelvic organ prolapse is a well-known problem for women and often requires corrective surgery. Polypropylene meshes are often used, which differ in their coating (titanized vs. non-titanized). A severe side effect of these surgeries is mesh erosion, due to onset of inflammation, which requires revision surgery. We examined all erosion cases (4 of 644 patients) with implanted nontitanium-coated meshes by immunohistochemistry and found upregulation of macrophage polarization (as markers CD68 and CD163) and increased expression of the immune checkpoint molecules PD-L1 and PD1. This suggests inflammatory processes and an enhanced immune response. In addition, we set up an in vitro experiment to investigate whether coating plays a role. Here, we demonstrated that the non-titanized meshes elicited a significantly higher immune response in comparison to titanized meshes, which could lead to the higher erosion rate of the non-titanized meshes. Our results highlight the benefit of titanized meshes, which should lead to a lower revision surgery rate and thus improved patient outcome.

Update in Transvaginal Grafts: The Role of Lightweight Meshes, Biologics, and Hybrid Grafts in Pelvic Organ Prolapse Surgery

Transvaginal mesh/grafts have been popularized over the past 20 years in an attempt to improve the longevity of traditional vaginal pelvic organ prolapse (POP) surgery. Several national bodies have concluded that the proposed benefits of mesh/graft implantation are outweighed by the significant increase in surgery complications related to these products. As a consequence mesh products for vaginal POP surgery have been withdrawn from use in many countries. This article is a narrative review of newer mesh and graft products including lightweight polypropylene mesh products, biological grafts, hybrid grafts, and tissue engineered grafts.

International Urogynecology Consultation Chapter 1 Committee 5: relationship of pelvic organ prolapse to associated pelvic floor dysfunction symptoms: lower urinary tract, bowel, sexual dysfunction and abdominopelvic pain

INTRODUCTION AND HYPOTHESIS

This article from Chapter 1 of the International Urogynecology Consultation (IUC) on Pelvic Organ Prolapse (POP) establishes the prevalence of lower urinary tract disorders, bowel symptoms, vulvo-vaginal/lower abdominal/back pain and sexual dysfunction in women with POP.

METHODS

An international group of nine urogynecologists/urologists and one medical student performed a search of the literature using pre-specified search terms in Ovid, MEDLINE, Embase and CINAHL from January 2000 to March 2019. Publications were eliminated if not relevant or they did not include clear definitions of POP or the symptoms associated with POP. Definitions of POP needed to include both a physical examination finding using a validated examination technique and the complaint of a bothersome vaginal bulge. Symptoms were categorized into symptom groups for ease of evaluation. The Specialist Unit for Review Evidence (SURE) was used to evaluate for quality of the included articles. The resulting list of articles was used to determine the prevalence of various symptoms in women with POP. Cohort studies were used to evaluate for possible causation of POP as either causing or worsening the symptom category.

RESULTS

The original search yielded over 12,000 references, of which 50 were used. More than 50% of women with POP report lower urinary tract symptoms. Cohort studies suggest that women with POP have more obstructive lower urinary tract symptoms than women without POP. Pain described in various ways is frequently reported in women with POP, with low back pain being the most common pain symptom reported in 45% of women with POP. In cohort studies those with POP had more pain complaints than those without POP. Sexual dysfunction is reported by over half of women with POP and obstructed intercourse in 37-100% of women with POP. Approximately 40% of women have complaints of bowel symptoms. There was no difference in the median prevalence of bowel symptoms in those with and without POP in cohort studies.

CONCLUSIONS

The prevalence of lower urinary tract disorders, bowel symptoms, vulvo-vaginal/lower abdominal/back pain and sexual dysfunction in women with POP are common but inconsistently reported. There are few data on incidence of associated symptoms with POP, and cohort studies evaluating causality are rare or inconsistent. Obstructive voiding, lower abdominal and pelvic pain, and sexual dysfunction are most frequently associated with POP.

Outpatient vaginal surgery for pelvic organ prolapse: a prospective feasibility study

BACKGROUND

In the light of recent progress in pelvic organ prolapse surgery, the modalities of hospital admission need reconsidering. This work aims to assess success rate of outpatient (ambulatory) vaginal mesh surgery for genital prolapse.

METHODS

A prospective observational study was conducted between January 2015 and July 2017, including all patients presenting with POP-Q stage ≥3 anterior and/or apical prolapse.

RESULTS

Sixty-nine of the 89 eligible patients were treated on an ambulatory basis (group A); 20 required overnight admission (group B): i.e., ambulatory success rate, 77.5%. Mean operative time was 44.9±2.5 min in group A and 62±6.5 min in group B. Reasons for ineligibility for ambulatory management comprised organizational issues at home (10.5%) and excessive home-to-hospital distance (5.7%). The postoperative urinary retention rate was 4.5%. Rates for successful cystocele correction (POP-Q <2) at 2 months were similar in the two groups: 94.2% in group A and 94.4% in group B (P=ns). Mean satisfaction score was 8.6±0.3/10.

CONCLUSIONS

Outpatient anterior vaginal mesh surgery for prolapse is safe and effective. The current medical-economic context favors ambulatory management. Patient selection, prior information and continuity of care seem primordial.

Changes in Sexual Function Following Uphold Transvaginal mesh Surgery for the Treatment of Urogenital Prolapse

Uphold transvaginal mesh implantation is an option for treating pelvic organ prolapse (POP). This prospective cohort study aims to evaluate the effect of Uphold transvaginal mesh implantation on female sexual function. 205 women with symptomatic POP were recruited and evaluated pre-operatively and re- evaluated six months post-operatively in terms of anatomical restoration, quality of life influenced by urinary incontinence and female sexual function. 30 women eventually completed the assessments and been statistically evaluated. The main outcome focused on sexual function. In our study, we found that Uphold transvaginal mesh surgery could achieve effective anatomical restoration of POP and better sexual function regardless of concomitant sling surgery.

Pelvic organ prolapse repair with a trocarless mesh system: two-year results

INTRODUCTION AND HYPOTHESIS

Our aim was to investigate the efficacy of the EndoFast Reliant™ system, which is a novel trocarless mesh technology for the treatment of pelvic organ prolapse (POP).

METHODS

This was a retrospective cohort study including 31 female patients with POP who underwent vaginal repair. Total follow-up duration was 24 months. All patients were evaluated with a clinical history, POP-Q measures, pelvic ultrasound, body mass index (BMI), questionnaires on symptoms, and quality of life scoring system.

RESULTS

The mean age was 53 ± 9.7 years, and the mean BMI was 28.5 ± 3.9 kg/m². The BMI of 20 patients was < 30 kg/m². No intraoperative complications occurred. Prolapse was anatomically resolved in 87.1% of patients at 2-year follow-up. Four patients presented stage 1 non-symptomatic prolapse recurrence. De novo stress urinary incontinence developed in four (12.9%) cases and de novo urgency developed in two (6.4%) cases; all were diagnosed and treated easily with oral medication. One case of mesh exposure was found and treated conservatively. There was no migration of fasteners or mesh. Urinary retention, postoperative groin pain, and dyspareunia were not observed.

CONCLUSIONS

The EndoFast Reliant™ system was found successful with high success rates, short learning time and very low complication rates in our study. However, further prospective studies with higher patient numbers and longer follow-up durations are needed to reach definitive conclusions.

Long-term results of genital prolapse surgery with polypropylene mesh

INTRODUCTION AND OBJECTIVE

The risk of intervention due to urogenital prolapse in a woman's life is 11.1%. Recurrences after classic surgery reach up to 38%. With the aim of improving these results, transvaginal mesh kits are used. The purpose of the study is to describe the results of efficacy and long-term safety of vaginal prolapse surgery with polypropylene mesh, assess subjective symptoms before and after surgery and the level of satisfaction.

PATIENTS AND METHODS

A descriptive, retrospective study of 58 women with symptomatic genital prolapses operated with polypropylene mesh between September / 2011-November / 2016. Mean age: 66.53 years, 98.27% menopausal women, 77.59% overweight/obesity, 29.31% with previous gynaecological surgery and 55.17% with combined prolapse. 46 Elevate anterior and 12 posterior were inserted. The mean follow-up period was 34.02 months. The PFDI questionnaire was used pre and post-surgery, as well as the satisfaction questionnaire.

RESULTS

Healing rate of 91.38%. Recurrences were associated with a higher BMI and with background of recurrence of previous surgery. Mean length of stay: 2.5 days. 70.69% did not need analgesia at discharge. Clavien-Dindo complications: 1 type I (urinary retention), 5 type II (urinary tract infection) and 1 type IIIa (erosion). De novo stress urinary incontinence occurred in 3.44%, while de novo dyspareunia 14.28%. 89.36% patients improved subjective symptoms, and 95.92% were satisfied.

CONCLUSION

This surgery achieves high healing rates, with few complications, improvement of subjective symptoms and high level of satisfaction of the patients.

Deep Dyspareunia: Review of Pathophysiology and Proposed Future Research Priorities

INTRODUCTION

Dyspareunia has been traditionally divided into superficial (introital) dyspareunia and deep dyspareunia (pain with deep penetration). While deep dyspareunia can coexist with a variety of conditions, recent work in endometriosis has demonstrated that coexistence does not necessarily imply causation. Therefore, a reconsideration of the literature is required to clarify the pathophysiology of deep dyspareunia.

AIMS

To review the pathophysiology of deep dyspareunia, and to propose future research priorities.

METHODS

A narrative review after appraisal of published frameworks and literature search with the terms (dyspareunia AND endometriosis), (dyspareunia AND deep), (dyspareunia AND (pathophysiology OR etiology)).

MAIN OUTCOME VARIABLE

Deep dyspareunia (present/absent or along a pain severity scale).

RESULTS

The narrative review demonstrates potential etiologies for deep dyspareunia, including gynecologic-, urologic-, gastrointestinal-, nervous system-, psychological-, and musculoskeletal system-related disorders. These etiologies can be classified according to anatomic mechanism, such as contact with a tender pouch of Douglas, uterus-cervix, bladder, or pelvic floor, with deep penetration. Etiologies of deep dyspareunia can also be stratified into 4 categories, as previously proposed for endometriosis specifically, to personalize management: type I (primarily gynecologic), type II (nongynecologic comorbid conditions), type III (central sensitization and genito-pelvic pain/penetration disorder), and type IV (mixed). We also identified gaps in the literature, such as lack of a validated patient-reported questionnaire or an objective measurement tool for deep dyspareunia and clinical trials not powered for sexual outcomes.

CONCLUSION

We propose the following research priorities for deep dyspareunia: deep dyspareunia measurement tools, inclusion of the population avoiding intercourse due to deep dyspareunia, nongynecologic conditions in the generation of deep dyspareunia, exploration of sociocultural factors, clinical trials with adequate power for deep dyspareunia outcomes, partner variables, female sexual response, pathways between psychological factors and deep dyspareunia, and personalized approaches to deep dyspareunia. Orr N, Wahl K, Joannou A, et al. Deep Dyspareunia: Review of Pathophysiology and Proposed Future Research Priorities. Sex Med Rev 2020;8:3-17.

Long-term follow-up of patients treated by transvaginal mesh repair for anterior prolapse

OBJECTIVE

The aim of the study was to assess 5 years outcome of transvaginal single incision mesh surgery (SIMS) for anterior pelvic organ prolapse (POP).

STUDY DESIGN

This was a prospective study including all patients from January 2009 to December 2012 who underwent SIMS for symptomatic anterior prolapse stage ≥2, according to POP Quantification (POP-Q). Symptoms and quality of life were assessed using validated questionnaires: Pelvic Floor Distress Inventory (PFDI-20), Pelvic Floor Impact questionnaire (PFIQ-7), and Prolapse/ Incontinence Sexual Questionnaire (PISQ-12). Main outcome was subjective success (question 3 of PFDI-20 score = 0). Mesh-related complications, objective and functional outcomes were used as the secondary outcomes.

RESULTS

270 patients were included in the study. Median follow-up was 5,7 years [4,5-8,2]. Subjective success rate was 86,6% at 5 years. Objective success rate was 53,1% at 5 years. At 5 years, composite failure (subjective + objective) occurred for 17 patients (12%), 7 patients with direct recurrence and 10 with indirect recurrence. Re-treatment was performed in six patients (2,8%; 3 hysterectomies for apical recurrence and 3 posterior repairs for posterior recurrence). One case (0,4%) of asymptomatic mesh exposure occurred. The reoperation rate for mesh-related complications was 3,4%. At 5 years, de novo dyspareunia rate was 11,7%, 3,9% considered as mesh-related. A significant improvement was noted for symptoms and quality of life.

CONCLUSION

Five-year results demonstrate that vaginal mesh surgery provides a durable and safe repair of anterior compartment prolapse with a low rate of mesh-related complications and reoperations. Between the 2- and 5-year follow-up, patient satisfaction and associated improvements in prolapse-specific symptoms were sustained and minimal new morbidity occurred.

Self-retaining support implant: an anchorless system for the treatment of pelvic organ prolapse-2-year follow-up

INTRODUCTION AND HYPOTHESIS

The search for an improved vaginal mesh prompted the development of a new anchorless implant. The objective was to report on outcome after 2 years of a technique using a self-retaining support (SRS) implant.

METHODS

Patients with anterior vaginal wall prolapse, with/without apical prolapse, were recruited. Participants underwent surgical repair using the SRS device. Demographic data, pre-surgical Pelvic Organ Prolapse Quantification (POP-Q) scoring, quality of life (QoL) questionnaires (Pelvic Floor Distress Inventory Short Form 20 [PFDI-20], Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire 12 [PISQ-12]), and surgical data were collected. Patients were followed at 2 weeks, 2, 6, 12, and 24 months after surgery. Objective anatomical success was defined using the NIH criteria.

RESULTS

Twenty women were recruited for the study with an average age of 62.1 years and an average parity of 4.0 deliveries. Average BMI was 28. Pre-operative mean POP-Q measurements were Aa =1.40 (-1 to 3) cm, Ba = 2.3 (-1 to 6) cm and C = 0.4 (-7 to 6) cm. Surgical time averaged 31.2 min. Estimated blood loss averaged 165 ml. No intra-operative complications were observed. One case (5%) of frame erosion was documented 8 months after surgery. At 2 years' follow-up, mean POP-Q measurements were: Aa = -2.95 (-3 to -2) cm, Ba = -2.85 (-3 to -2) cm, and C point -6.90 (-10 to -3) cm. Seventeen (85%) patients had stage 0 and 3 patients (15%) had stage 1. No mesh erosions or chronic pelvic pain were documented at follow-up. The total PFDI score at follow-up was decreased by 92.8 points (p < 0.0001).

CONCLUSIONS

At 2 years' follow-up, the SRS implant was found to be safe, showing no intra-operative or immediate post-operative complications. All women presented with POP-Q measurements of the anterior and apical compartment at normal value (Ba ≤ -2 cm) and statistically significant subjective improvement.