Functional failure of fascia lata allografts

Sacrocolpopexy using autologous rectus fascia: Cohort study of long-term outcomes and complications

OBJECTIVE

To evaluate objective and subjective outcomes of patients who underwent sacrocolpopexy using autologous rectus fascia to provide more data regarding non-mesh alternatives in pelvic organ prolapse surgery.

DESIGN

Ambispective cohort study with retrospective and prospective data.

SETTING

A single academic medical centre.

POPULATION

Women who underwent abdominal sacrocolpopexy using autologous rectus fascia between January 2010 and December 2019.

METHODS

Patients were recruited for a follow-up visit, including completing the Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Organ Prolapse Quantification (POP-Q) examination. Demographic and clinical characteristics were collected.

MAIN OUTCOME MEASURES

Composite failure, anatomic failure, symptomatic failure and retreatment.

RESULTS

During the study period, 132 women underwent sacrocolpopexy using autologous rectus fascia. The median follow-up time was 2.2 years. Survival analysis showed that composite failure was 0.8% (95% CI 0.1%-5.9%) at 12 months, 3.5% (95% CI 1.1%-10.7%) at 2 years, 13.2% (95% CI 7.0%-24.3%) at 3 years and 28.3% (95% CI 17.0%-44.8%) at 5 years. The anatomic failure rate was 0% at 12 months, 1.4% (95% CI 0.2%-9.2%) at 2 years, 3.1% (95% CI 0.8%-12.0%) at 3 years and 6.8% (95% CI 2.0%-22.0%) at 5 years. The symptomatic failure rate was 0% at 12 months, 1.3% (95% CI 0.2%-9.0%) at 2 years, 2.9% (95% CI 0.7%-11.3%) at 3 years and 13.1% (95% CI 5.3%-30.3%) at 5 years. The retreatment rate was 0.8% (95% CI 0.1%-5.9%) at 12 months and 2 years, 9.4% (95% CI 4.2%-20.3%) at 3 years and 13.0% (95% CI 6.0%-27.2%) at 5 years.

CONCLUSION

Autologous rectus fascia sacrocolpopexy may be considered a safe and effective alternative for patients who wish to avoid synthetic mesh.

Biocompatibility of allogenic canine fascia lata: In vitro evaluation and small case series

OBJECTIVE

To evaluate the biocompatibility of canine fascia lata (FL) in vitro and after FL allograft implantation in dogs with clinical disease.

STUDY DESIGN

In vitro experiment and small case series.

SAMPLE POPULATION

Six dogs treated with allogenic freeze-dried FL.

METHODS

Fibroblasts were cultured on disks of FL, polypropylene mesh (PM; negative control), and porcine small intestinal submucosa (SIS; positive control). Constructs were compared at 3, 7, and 14 days for water content, DNA amounts, scanning electron microscopy, and histology. Records of dogs treated with FL allografts with follow-up examination were reviewed for signalment, indication for surgery, surgical procedure, and outcomes. All owners were invited to complete a standardized questionnaire for long-term follow-up.

RESULTS

Water content was greater in FL and SIS than in PM (P = .03). Fascia lata constructs contained more DNA compared with PM constructs at days 7 and 14 (P < .05), whereas SIS constructs did not differ from FL or PM. Fibroblasts appeared spherical and distributed throughout FL constructs, whereas they appeared stellate and remained on the surface of SIS and PM. Fascia lata allografts were implanted in six dogs with surgical conditions. No incisional complications were noted. All dogs had good to excellent long-term outcomes, except one that experienced recurrence of a perineal hernia 2 years after repair.

CONCLUSION

In vitro, canine FL allowed attachment and proliferation of fibroblasts throughout layers of the graft. Canine allogenic FL was clinically well tolerated in this small population of dogs.

CLINICAL SIGNIFICANCE

Allogenic FL is biocompatible and can be considered an alternative to SIS for soft tissue augmentation in dogs.

Managing female pelvic floor disorders: a medical device review and appraisal

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.

Scaffolds for Pelvic Floor Prolapse: Logical Pathways

Pelvic organ prolapse (POP) has borrowed principles of treatment from hernia repair and in the last two decades we saw reinforcement materials to treat POP with good outcomes in terms of anatomy but with alarming complication rates. Polypropylene meshes to specifically treat POP have been withdrawn from market by manufactures and a blank space was left to be filled with new materials. Macroporous monofilament meshes are ideal candidates and electrospinning emerged as a reliable method capable of delivering production reproducibility and customization. In this review, we point out some pathways that seem logical to be followed but have been only researched in last couple of years.

Pubovaginal sling materials and their outcomes

Stress urinary incontinence (SUI) is the most common type of urinary incontinence, and approximately 200 different methods have been described for its surgical management. A better understanding of the pathophysiology of SUI has led to the development of surgical therapies focused on creating a strong suburethral supportive layer and urethral resistance. The most important advantage of the pubovaginal sling (PVS) procedure is that it restores urethral resistance during stress maneuvers to prevent incontinence, while improving urethral coaptation at rest and allowing for spontaneous micturition. Various autologous, allograft, xenograft and synthetic materials have been used for the PVS. The autologous PVS procedure for the treatment of SUI offers the highest success rate and is the most commonly used PVS surgical method. Unlike xenograft and allograft materials, the autologous procedure does not result in a tissue reaction and is associated with a low rate of material-related complications.

Apical prolapse

INTRODUCTION AND HYPOTHESIS

The aim was to review the safety and efficacy of pelvic organ prolapse surgery for vaginal apical prolapse.

METHODS

Every 4 years and as part of the Fifth International Collaboration on Incontinence we reviewed the English-language scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials (RCT) or systematic reviews), level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies) and level 4 case reports. The highest level of evidence was utilised by the committee to make evidence-based recommendations based upon the Oxford grading system. Grade A recommendation usually depends on consistent level 1 evidence. Grade B recommendation usually depends on consistent level 2 and or 3 studies, or "majority evidence" from RCTs. Grade C recommendation usually depends on level 4 studies or "majority evidence from level 2/3 studies or Delphi processed expert opinion. Grade D "no recommendation possible" would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi.

RESULTS

Abdominal sacral colpopexy (ASC) has a higher success rate than sacrospinous colpopexy with less SUI and postoperative dyspareunia for vault prolapse. ASC had greater morbidity including operating time, inpatient stay, slower return to activities of daily living and higher cost (grade A). ASC has the lowest inpatient costs compared with laparoscopic sacral colpopexy (LSC) and robotic sacral colpopexy (RSC). LSC has lower inpatient costs than RSC (grade B).In single RCTs the RSC had longer operating time than both ASC and LSC (grade B). In small trials objective outcomes appear similar although postoperative pain was greater in RSC. LSC is as effective as ASC with reduced blood loss and admission time (grade C). The data relating to operating time are conflicting. ASC performed with polypropylene mesh has superior outcomes to fascia lata (level I), porcine dermis and small intestine submucosa (level 3; grade B). In a single RCT, LSC had a superior objective and subjective success rate and lower reoperation rate compared with polypropylene transvaginal mesh for vault prolapse (grade B).Level 3 evidence suggests that vaginal uterosacral ligament suspension, McCall culdoplasty, iliococcygeus fixation and colpocleisis are relatively safe and effective interventions (grade C).

CONCLUSION

Sacral colpopexy is an effective procedure for vault prolapse and further data are required on the route of performance and efficacy of this surgery for uterine prolapse. Polypropylene mesh is the preferred graft at ASC. Vaginal procedures for vault prolapse are well described and are suitable alternatives for those not suitable for sacral colpopexy.

Anatomical Position of Four Different Transobturator Mesh Implants for Female Anterior Prolapse Repair

Purpose: Polypropylene mesh implants are frequently used for pelvic floor reconstruction in women. Yet they vary in size and fixation. The purpose of this study is to compare four mesh products with regard to their anatomical positioning and functionality within the pelvic floor, to determine whether each mesh fits equally well in a female cadaver. Methods: One female pelvis was dissected, opening the retropubic space exposing the endopelvic fascia and demonstrating the arcus tendineus fasciae pelvis (ATFP). Anatomical parameters were measured before and after implanting four meshes via the transobturator approach. Results: The anterior fixation of the ATFP was found to be 5 mm lateral to the symphysis in this cadaver. The endopelvic fascia covered 54.6 cm². The obturator nerve was located 35 mm from the white line. The distance of the proximal and lateral points of mesh fixation from the ischial spine or ATFP varied from 0 to 25 mm. The meshes varied in size and anatomical positioning. Conclusion: These observations demonstrate the necessity of developing optimally sized meshes and appropriate introducer techniques that can provide sufficient vaginal support. Surgeons, furthermore, need profound knowledge of anatomy, the patient's pelvic floor defect and the meshes available on the market.

The use of biological materials in urogynecologic reconstruction: a systematic review

There are numerous randomized controlled trials examining biological materials in urogynecologic surgery. For prolapse surgery, the addition of a biological graft adds no benefit compared with native tissue repairs for rectocele repair. Conflicting data exist regarding cystocele repair. Synthetic mesh repairs provide superior anatomical support for sacral colpopexy and cystocele repair compared with biologic grafts. However, biological and synthetic mesh slings have equivalent success rates for the treatment of stress urinary incontinence. Contrary to prior assumptions that biologic grafts add tissue strength without graft-related complications, there appears to be no benefit to the use of biological materials for prolapse and incontinence surgery.

Meta-analysis of the efficacy and safety of the application of adjuvant material in the repair of anterior vaginal wall prolapsed

INTRODUCTION

This study is a meta-analysis of the efficacy and safety of the application of adjuvant material in the repair of anterior vaginal wall prolapse and a sub-category analysis of the use of nonabsorbable synthetic mesh, biological graft and absorbable synthetic mesh.

METHOD

Pubmed, Embase and Ovid databases were searched for published randomized controlled trials from 1980 to February 2012 on the treatment of anterior vaginal wall prolapse with adjuvant materials. A comprehensive meta-analysis applying Revman5.1 analysis software was performed.

RESULTS

A total of 20 randomized controlled trials including 2,313 participants were recognized. The result showed that repair with adjuvant materials was better and more effective; nevertheless, use of adjuvant materials resulted in longer duration of surgery and more peri-operative bleeding when compared with the control group, but no significant differences were observed between the two groups regarding visceral injury, postoperative pain, urinary tract infection rate, new stress incontinence and new dyspareunia.

CONCLUSION

Adjuvant material is worthy of clinical popularization, especially the biological graft type because of its lower anatomy failure rate and no difference in safety compared with the control group. However, exposure to adjuvant materials and erosion rate are high, which are the most important aspects to be improved.

Biomaterials in urinary incontinence and treatment of their complications

Biomaterials integrate with the anatomy and provide support to the weakened area. They are generally synthetic, but natural substances are also used. These substances are being increasingly used in stress urinary incontinence. This article discusses the various biomaterials, minimally invasive techniques, and recent advances for the treatment of female stress urinary incontinence. In addition, their complications and subsequent management are explored.

Update of AUA guideline on the surgical management of female stress urinary incontinence

PURPOSE

We updated the 1997 American Urological Association guideline on female stress incontinence.

MATERIALS AND METHODS

MEDLINE searches of English language publications from 1994 and new searches of the literature published between December 2002 and June 2005 were performed using identified MeSH terms. Articles were selected for the index patient defined as the otherwise healthy woman who elected to undergo surgery to correct stress urinary incontinence or the otherwise healthy woman with incontinence and prolapse who elected to undergo treatment for both conditions.

RESULTS

A total of 436 articles were identified as suitable for inclusion in the meta-analysis, and an additional 155 articles were suitable for complications data only due to insufficient followup of efficacy outcomes in the latter reports. Surgical efficacy was defined using outcomes pre-specified in the primary evidence articles. Urgency (resolution and de novo) was included as an efficacy outcome due to its significant impact on quality of life. The primary efficacy outcome was resolution of stress incontinence measured as completely dry (cured/dry) or improved (cured/improved). Complications were analyzed similarly to the efficacy outcomes. Subjective complications (pain, sexual dysfunction and voiding dysfunction) were also included as a separate category.

CONCLUSIONS

The surgical management of stress urinary incontinence with or without combined prolapse treatment continues to evolve. New technologies have emerged which have impacted surgical treatment algorithms. Cystoscopy has been added as a standard component of the procedure during surgical implantation of slings.

Abdominal vault suspension with rectus sheath strips: a case series

This is a retrospective case series conducted in Worthing General Hospital to evaluate the clinical outcome of abdominal vault suspension (AVS) using rectus sheath strips to treat vaginal vault prolapse. Thirty-four patients had suspension of the vaginal vault using this procedure. Patients were followed up at 3-6 months and by questionnaire for up to 90 months. Incidence of intraoperative and postoperative complications, improvement of prolapsed symptoms and recurrence of vault prolapsed were the main outcome measures. There were no serious intraoperative complications. Ninety four percent of patients had subjective resolution of their prolapsed symptoms whereas 6% had further symptoms. Hospital stay ranged from 2 to 8 days. There were no cases of bowel problems in the postoperative period or in the long term. Hospital stay ranged from 2 to 8 days. AVS using rectus sheath strips appears to be a safer and easier alternative to other abdominal suspension procedures. The use of patients' own tissue eliminates the risk of mesh erosion.

Histologic comparison of pubovaginal sling graft materials: a comparative study

OBJECTIVES

Little is known about the host response to the various biologic and synthetic graft materials used as substitutes for autologous fascia. We investigated the host response to sling graft materials in humans.

METHODS

A total of 24 women undergoing sling revision had a portion of the graft material removed for comparative analysis. At exploration, the degree of graft preservation (integrity), encapsulation, infection, and fibrosis was quantified. A histopathologic analysis was performed by systematically examining each specimen for the inflammatory response, neovascularity, and host fibroblast infiltration.

RESULTS

A total of 24 grafts were explanted at 2-34 months after implantation. The indications for removal were a lack of sling efficacy in 2, urinary retention in 9, and sling obstruction in 13. The types of graft material were polypropylene mesh (PPM) in 10, autologous fascia in 5, porcine dermis in 4, cadaveric dermis in 3, and cadaveric fascia in 2. No graft degradation had occurred in PPM material. Autologous and cadaveric fascia had the most demonstrable graft degradation. No encapsulation had occurred with autologous fascia or PPM. The porcine dermis was the most encapsulated. No host infiltration had occurred with the encapsulated porcine grafts, and only peripheral infiltration of fibroblasts had occurred in the cadaveric grafts. The PPM grafts had the greatest number of fibroblasts throughout the entire graft. Neovascularity was the most prevalent in mesh and was also present in the autologous fascia. Giant cells were seen in two mesh and two porcine grafts.

CONCLUSIONS

The results of our study have shown that porcine dermis has the potential to encapsulate. The degree of host tissue infiltration was greatest with PPM, and no degradation of the mesh material had occurred with time.

Regional variability, processing methods, and biophysical properties of human fascia lata extracellular matrix

This study aims to assess the regional variability, processing methods, mechanical, biochemical, and cellular properties of human fascia lata as a scaffold for soft tissue repair and tissue engineering applications. Ten pairs of fascia lata (donor age 18-55) were used. One fascia patch from each pair was used to assess the geometric and biomechanical variability of fresh fascia. The other from each pair was subjected to 1 of 2 allograft processing methods: antibiotic soak alone or acellularization plus antibiotic soak. Stiffness, modulus, hydroxyproline, chondroitin/dermatan sulfate glycosaminoglycan (CSDS GAG), and DNA content were quantified in fascia from fresh and treated groups. The effect of location was not significant for thickness or stiffness within a 6 x 12 cm2 region of the iliotibial tract of fresh human fascia lata. Processing did not significantly change the stiffness, modulus, or CSDS GAG content of fascia ECM. However, hydroxyproline (collagen) content is significantly reduced in acellularized fascia, probably reflecting a removal of soluble collagen during the treatment (p < 0.02). Processing reduced the DNA content of fresh fascia approximately 10-fold (p < 0.001). The mechanical, chemical and ultrastructural similarities between fascia lata and tendon may make fresh or processed fascia an attractive ECM scaffold for soft tissue, particularly tendon, repair.

Update on the utilization of grafts in pelvic reconstruction surgeries

PURPOSE OF REVIEW

Implanted grafts are increasingly used by pelvic reconstructive surgeons and gynecologists. In addition, the marketing of a variety of grafts has been aggressively expanded without scientific evidence to support their use. This review aims to provide an update of the current status and role of grafts in reconstructive pelvic surgery and to review the current knowledge of the biology of currently marketed synthetic and biologic grafts.

RECENT FINDINGS

Xenografts are preferable to human tissue-banked grafts due to more predictable integrity. How these biomaterials compare to synthetics in terms of surgical outcomes has not been well studied, however. Absorbable materials that mimic some behaviors of synthetic and biological materials have been developed. Furthermore, several new techniques have been advocated with limited studies.

SUMMARY

While the reduction of surgical failure rates in vaginal surgery is desirable, the addition of graft materials must demonstrate improvement in anatomical, functional, and quality of life outcomes over time. Furthermore, future complications due to improper placement or movement of a graft and the possible shrinkage of the graft are of concern. Therefore, significant research is necessary for the preclinical testing of materials, and expertise needs to be developed for the management of complications.

Evolution of biological and synthetic grafts in reconstructive pelvic surgery

Surgery is an evolving science in the attempt to make surgical procedures more effective, safer, and less invasive. Recurrence and subsequent re-operation for stress incontinence and prolapse has been reported to be necessary in one of three patients, so there is a need for improvement [1]. In reconstructive pelvic surgery (RPS), the use of biological and synthetic grafts for the transabdominal and transvaginal treatment of pelvic organ prolapse (POP) or stress urinary incontinence (SI) has improved long-term support and function after surgery. However, the potential benefits of using grafts need to be carefully balanced against the risks of using materials foreign to the patient's body. Pelvic organ prolapse develops secondary to defective endopelvic fascial and muscular support. The levator ani provides resting tonic muscular support for all three pelvic compartments. Once neuromuscular damage occurs, extra strain is placed on the connective tissue supports, which may also subsequently fail. To date, there is no surgery that adequately addresses the issue of neuromuscular damage of the pelvic floor musculature. In conventional POP surgery, defective support is repaired by suturing of the patient's own connective tissue, fascia, or ligaments. The rationale for the use of grafts is to reinforce and strengthen pelvic organ repairs similar to the use of grafts to strengthen abdominal hernia repair.

The biology behind fascial defects and the use of implants in pelvic organ prolapse repair

Implant materials are increasingly being used in an effort to reduce recurrence after prolapse repair with native tissues. Surgeons should be aware of the biology behind both the disease as well as the host response to various implants. We will discuss insights into the biology behind hernia and abdominal fascial defects. Those lessons from "herniology" will, wherever possible, be applied to pelvic organ prolapse (POP) problems. Then we will deal with available animal models, for both the underlying disease and surgical repair. Then we will go over the features of implants and describe how the host responds to implantation. Methodology of such experiments will be briefly explained for the clinician not involved in experimentation. As we discuss the different materials available on the market, we will summarize some results of recent experiments by our group.

Synthetic slings: which material, which approach

PURPOSE OF REVIEW

The success in the use of the tension-free midurethral sling procedures (tension-free vaginal tape, suprapubic arch, transobturator tape) has dramatically altered the approach to the surgical management of stress urinary incontinence in women and marked a resurgence in the use of mesh. We will analyze the characteristics of synthetic meshes and explain the rationale for using monofilament materials with larger pore sizes. Thus, the purpose of this review is to introduce the surgeon to a variety of commercially available mesh materials and the characteristics that make mesh suitable for use as sling grafts.

RECENT FINDINGS

Type I macroporous mesh materials appear most suitable for transvaginal implantation. Utilization of these materials in a minimally invasive retropubic or transobturator approach, promising early and intermediate follow-up data has been achieved. The outcome of these procedures in women with urethral hypermobility and genuine stress incontinence seems clear. No controlled data, however, exist to define the role of these procedures in difficult cases of stress incontinence. Newer generations of minimally invasive slings may offer treatment alternatives in these difficult cases.

SUMMARY

Minimally invasive slings using Type I mesh materials are safe and effective. 'Hybrid' type slings may offer alternatives in difficult cases of stress urinary incontinence.

Comparison of autologous rectus fascia and cadaveric fascia in pubovaginal sling continence outcomes

OBJECTIVE

The purpose of this study was to compare autologous versus cadaveric grafts in pubovaginal slings.

STUDY DESIGN

Women who had pubovaginal slings from 1994 to 2003 completed history, questionnaires, prolapse staging, and cough stress testing. Failure was defined by recurrent urinary incontinence symptoms and reoperation for stress incontinence. Group differences were evaluated using Student t test or chi-square test. The log-rank test was used to evaluate time to failure between the groups.

RESULTS

Of 303 women enrolled, 153 had autologous and 150 had cadaveric grafts. Regular urine leakage (39.6% vs 28.3%, P = .04) and reoperation for stress incontinence (12.7% vs 3.3%, P = .003) occurred more in the cadaveric versus autologous group, respectively. Adjusting for differing follow-up times, the cadaveric versus autologous group experienced higher rates of urinary incontinence (16 vs 5 per 100 women-years, P < .0001) and higher rates of reoperation (4 vs 1 per 100 women-years, P < .0003).

CONCLUSION

Autologous grafts used in pubovaginal slings have superior continence outcomes compared with cadaveric fascia.

The use of prosthetics in pelvic reconstructive surgery

With an ageing population, increasing numbers of women are presenting with pelvic floor disorders. The lifetime risk of undergoing prolapse or incontinence surgery in the USA is 1 in 11. With a recognized reoperation rate exceeding 30% for prolapse surgery, attempts are being made to improve our primary surgical outcomes. The introduction of synthetic and biological prostheses have been proposed to reduce recurrence rates whilst maintaining vaginal capacity and coital function. The role of synthetic prostheses is well established for use in continence surgery in the form of midurethral slings and for abdominal sacrocolpopexy to correct vault prolapse. However, postoperative morbidity-specifically the risk of mesh erosion-has limited their use for vaginal prolapse surgery. Biological prostheses have been introduced to offer an alternative for use in these repairs. While these grafts largely obviate the problem of erosion there are concerns regarding longevity, and only short-term outcome data are currently available. The role of prosthetics in pelvic floor surgery is an evolving and controversial field. Current and future research should be directed at evaluating the safety and efficacy of specific products and comparison of subjective and objective outcome parameters to standard surgical techniques for pelvic organ prolapse.

Suburethral sling materials: best outcome with autologous tissue

OBJECTIVE

This study was undertaken to assess the outcome of suburethral slings by type of sling material.

STUDY DESIGN

A retrospective review of women who underwent a suburethral sling between January 1997 and January 2003 with autograft, allograft or xenograft materials. Objective failure was defined as urinary leakage with cough stress testing at any time after 3 months, postoperatively. Objective cure was defined as no leakage with a standing cough stress test with at least 200 mL bladder volume at a minimum of 12 months postoperatively. Data were analyzed using Student t, Wilcoxon rank sum, and Kaplan-Meier survival tests.

RESULTS

A total of 241 women were included in this study: 78 received autograft, 80 received allograft, and 83 received xenograft. Objective failure was 36% and 46% for allograft and xenograft, respectively compared with 13% for autograft (P < .001).

CONCLUSION

Autograft has a significantly higher cure rate when used for suburethral slings.

Bladder neck pubovaginal slings

Over the past 30 years, the pubovaginal sling has surpassed retropubic and transvaginal suspensions as the most common surgical operation for correcting stress urinary incontinence. This resurgence has been due in part to innovative technological advances that have shortened operative times and expedited postoperative recovery. The introduction of novel allografts, xenografts and synthetic materials has also been accompanied by unique complications, previously not encountered with autologous materials. The aim of this review is to compare the available sling materials in the context of biocompatibility and efficacy.

A Randomized Controlled Trial Comparing Fascia Lata and Synthetic Mesh for Sacral Colpopexy

OBJECTIVE

To compare the objective anatomic outcomes after sacral colpopexy performed with cadaveric fascia lata and polypropylene mesh.

METHODS

Patients undergoing a sacral colpopexy were randomized to receive either fascia lata or polypropylene mesh in a double-blinded fashion. Data were collected at 6 weeks, 3 months, 6 months, and 1 year postoperatively. The main outcome measures were pelvic organ prolapse quantification (POP-Q) system stage and individual POP-Q points over time. Objective anatomic failure was defined as POP-Q stage 2 or more at any point during the follow-up period. Proportions of patients with objective anatomic failure at 1 year in each group were compared using the chi(2) test. Mean POP-Q points and stage at 1 year were compared by using the independent samples t test.

RESULTS

One hundred patients were randomized to receive either fascia (n = 46) or mesh (n = 54). Of the 89 patients returning for 1-year follow-up, 91% (41/45) of the mesh group and 68% (30/44) of the fascia group were classified as objectively cured (P = .007). We found significant differences between the mesh and fascia groups with respect to the 1-year postoperative comparisons of points Aa, C, and POP-Q stage. There were no differences between the 2 groups with respect to points TVL (total vaginal length), GH (genital hiatus), PB (perineal body), Ap or Bp (2 points along the posterior vaginal wall).

CONCLUSIONS

Polypropylene mesh was superior to fascia lata in terms of POP-Q points, POP-Q stage, and objective anatomic failure rates.

LEVEL OF EVIDENCE

I.

Histologic evaluation of human cadaveric fascia lata in a rabbit vagina model

The purpose of this study was to evaluate the histologic response of human cadaveric fascia lata after vaginal implantation. Freeze-dried, gamma-irradiated cadaveric fascia lata from three lots was implanted between the rectovaginal membrane and vaginal epithelium in New Zealand white rabbits. Rabbits were killed at 2, 4, 8, and 12 weeks after implantation. At necropsy, gross findings were described and specimens for routine cultures were taken. Histologic evaluation determined graft integrity, neovascularization, inflammatory response, and host tissue incorporation. Nine rabbits were available for histologic analysis and 14 for gross and microbiologic analysis. Vaginal erosions occurred with three grafts. The remainder were adherent to the surrounding tissues. Erosion was associated with bacterial colonization of the graft. Autolysis of one graft occurred at 4 weeks. Over time, the inflammatory response decreased and neovascularization increased; by 12 weeks, the graft collagen was replaced by host collagen. Cadaveric fascia lata serves as scaffolding for host tissue incorporation with replacement by host collagen.

Functional and anatomic outcome after transvaginal rectocele repair using collagen mesh: a prospective study

PURPOSE

This study was designed to evaluate rectocele repair using collagen mesh.

METHODS

32 female patients underwent surgical repair using collagen mesh. Outcome was assessed in 29 patients and preoperative assessment included standardized questionnaire, clinical examination, and defecography. At the six-month follow-up, patients answered a standardized questionnaire and underwent clinical examination. At the 12-month follow-up, patients answered a standardized questionnaire, underwent clinical examination, and defecography.

RESULTS

Preoperatively, 26 patients had a Stage II and 3 patients had a Stage III rectocele. At the 6-month follow-up, five patients had rectocele > or = Stage II (P < 0.001) and at the 12-month follow-up, seven patients had rectocele > or = Stage II (P < 0.001) at clinical examination. At the preoperative defecography, all patients presented a rectocele. At the 12-month defecography, 14 patients had no rectocele (P < 0.001) and 15 had a rectocele. At the six-month follow-up, there was a significant decrease in rectal emptying difficulties, need of digital support of the posterior vaginal wall at defecation, and defecation frequency. At the 12-month follow-up, symptom improvement remained, but was less pronounced.

CONCLUSIONS

Rectocele repair using collagen mesh improved anatomic support, but there is a substantial risk for recurrence with unsatisfactory anatomic and functional outcome one year after surgery. Rectocele repair using mesh was not associated with an increased risk of dyspareunia. Rectocele repair using biomaterial mesh reinforcement needs further evaluation before adopted into clinical practice.

Abdominal sacrocolpopexy for vault prolapse without burial of mesh: a case series

OBJECTIVES

To audit the clinical outcome of abdominal vault suspension (sacrocolpopexy, hysteropexy or cervicopexy) using non-absorbable mesh, without burial by closure of the peritoneum.

DESIGN

A case series.

SETTING

Urogynaecology units of four hospitals.

POPULATION

One hundred and twenty-eight women having open or laparoscopic sacrocolpopexy (121), hysteropexy (6) or cervicopexy (1) using non-absorbable mesh for vault prolapse.

METHODS

Patients had suspension of the vault, uterus or cervix from the sacral promontory using a monofilament polypropylene mesh. The pelvic peritoneum was not closed over the mesh. Patients were followed up every six months.

MAIN OUTCOME MEASURES

Incidence of bowel complications as a consequence of the mesh; cure rate of prolapse and incidence of other post-operative complications; rate of re-operation for prolapse or incontinence.

RESULT

After a median follow up of 19 months (1.5-62), there were no bowel complications as a result of non-burial of mesh. Three patients had asymptomatic vaginal mesh erosion, which required minor surgical intervention. Ninety percent of patients had good resolution of their prolapse symptoms while 10% of patients required further surgery.

CONCLUSION

Leaving the mesh uncovered by the pelvic peritoneum was not associated with complications. It appears safe to perform vault suspension without closing the peritoneum.

Histopathologic changes of porcine dermis xenografts for transvaginal suburethral slings

OBJECTIVE

The purpose of this study was to examine the histopathologic changes of HMDI (Hexamethylene di-isocyanate) cross-linked porcine dermis grafts used for suburethral sling surgery.

STUDY DESIGN

Twelve patients underwent reoperation with graft removal for urinary retention or recurrent stress urinary incontinence after transvaginal sling surgery. Tissue specimens were available for pathologic evaluation in 7 patients. Graft specimens underwent histologic preparation including hematoxylin and eosin staining. A single pathologist reviewed the slides blinded to clinical outcomes.

RESULTS

Histopathologic analyses revealed only limited collagen remodeling, and evidence of a foreign body type reaction was present in some specimens. In cases of recurrent stress incontinence, implants appeared to be completely replaced by dense fibroconnective tissue and moderate neovascularization without evidence of inflammation or graft remnants.

CONCLUSION

HMDI cross-linked porcine dermal collagen implants result in variable tissue reactions that may have unpredictable clinical outcomes in different patients, raising questions about the overall tolerability and efficacy of these grafts in pelvic reconstructive surgery.

Comparison of long-term outcomes of autologous fascia lata slings with Suspend Tutoplast fascia lata allograft slings for stress incontinence

OBJECTIVE

This study was undertaken to compare the objective and subjective long-term surgical outcomes in patients receiving Tutoplast fascia lata allograft slings with those receiving autograft slings for the treatment of stress urinary incontinence (SUI).

STUDY DESIGN

We reviewed all patients (n = 71) undergoing suburethral sling with either autologous fascia lata (n = 39) or Tutoplast fascia lata (n = 32) for urodynamic stress incontinence (USI) from October 1, 1998, to August 1, 2001.

RESULTS

Of the original 71 patients, 47 were evaluated by objective and/or subjective means at a minimum of 2 years after surgery. Subjective quality of life measures, subjective continence, maximum urethral closure pressure, and bladder neck mobility were not different between the 2 groups. USI was demonstrated in 41.7% of allograft patients compared with no autograft patients (P = .007).

CONCLUSION

Although patient reported cure of SUI is high for both sling types, USI recurs at a significantly higher rate in Tutoplast slings compared with autologous slings.

Abdominal sacral colpopexy with allograft fascia lata: one-year outcomes

OBJECTIVE

The purpose of this study was to assess 1-year outcomes of sacral colpopexy with the use of allograft fascia lata.

STUDY DESIGN

Records of all subjects who underwent sacral colpopexy with allograft fascia lata from May 1, 2001, to April 30, 2003, were reviewed. Subjects underwent pre- and postoperative evaluation of prolapse with the pelvic organ prolapse quantification system. The Fisher's exact test was used to analyze the results.

RESULTS

Allograft fascia lata was used for 24 colpopexies during this period. No significant intraoperative or postoperative complications or graft erosions occurred. Five subjects were lost to follow-up after 3 months. Analysis was performed on the remaining 19 subjects. Prolapse of stage 2 or more in compartments Aa, Ba, Ap, Bp, and C was preoperatively 50%, 74%, 78%, 84%, and 68% and postoperatively 11%, 16%, 21%, 26%, and 5%, respectively.

CONCLUSION

Allograft fascia lata may be a suitable alternative to permanent mesh for sacral colpopexy, but longer-term outcomes and larger studies are needed.

Anatomical outcome and quality of life following posterior vaginal wall prolapse repair using collagen xenograft

The aim of this study was to evaluate quality of life, sexual function, and anatomical outcome after posterior vaginal wall prolapse repair using a collagen xenograft. Thirty-three patients were evaluated preoperatively and at 6 and 12 months follow-up (FU). Quality of life and sexual function were assessed using a self-reported questionnaire. Prolapse staging was performed using the pelvic organ prolapse quantification system (POPQ). Preoperatively 3 patients had stage I, 26 patients stage II, and 4 patients stage III prolapse of the posterior vaginal wall. Prolapse of the posterior vaginal wall > or = stage II was observed in 7 patients (21%) at the 6-month FU and in 13 patients (39%) at the 12-month FU. Mean point Bp was reduced from -1.1 preoperatively to -2.5 at 6 months FU (p < 0.01) and -1.8 at 12 months FU (p < 0.01). Previous abdominal surgery was associated with a less favorable anatomical outcome (odds ratio: 2.0, 95% confidence interval: 1.5-3.8). There were no significant changes in sexual function or dyspareunia during the 1-year FU. Preoperatively 76% of the patients reported a negative impact on quality of life as a result of genital prolapse. There was a significant improvement in several variables associated with quality of life at 6 and 12 months FU. Posterior vaginal wall prolapse repair using a collagen xenograft was associated with an unsatisfying anatomical outcome at 1-year FU although several quality of life-associated variables affecting psychosocial function were improved. Improvement was not restricted to postoperative restoration of vaginal topography, and previous surgery had a negative effect on anatomical outcome.

Synthetic sling options for stress urinary incontinence

In the past decade, sling surgery has become the preferred technique for the management of female stress urinary incontinence. A greater understanding of the pathogenesis of stress urinary incontinence and a greater durability and effectiveness for sling surgery has allowed this technique to become the benchmark for treatment of female stress urinary incontinence. As a consequence, a multitude of products have been developed using various techniques and materials to perform sling surgery. This article reviews the materials and techniques available and the complications associated with each. Most importantly, the outcomes are discussed so that the readers can best understand the impact of these surgeries on our patients.

Absorbable versus nonabsorbable graft: outcome of bone anchored male sling for post-radical prostatectomy incontinence

PURPOSE

We determined the outcome of the bone anchored male sling procedure for stress urinary incontinence in men regarding the graft material used.

MATERIALS AND METHODS

A total of 39 men with post-radical prostatectomy incontinence received a perineal bone anchored male sling. Patients with previous salvage external beam radiotherapy and high serum prostate specific antigen, incontinence due to neurogenic or posttraumatic etiology, or previous benign prostatectomy were excluded. Urodynamic evaluation was performed preoperatively. The number of pads daily used by patients was recorded preoperatively and during postoperative visits. To compress the urethra 2 types of materials were used. Absorbable biomaterials were used in the first 12 patients and nonabsorbable material was used in the following 27.

RESULTS

Mean patient age +/- SD was 67.3 years (range 50 to 79). The mean duration between radical prostatectomy and male sling surgery was 57.9 +/- 40.4 months (range 5 to 135). The procedure was successful in 26 patients (96.2%) in the nonabsorbable group and in 1 (8.3%) in the absorbable group at a mean followup of 18.9 and 28.8 months, respectively.

CONCLUSIONS

The absorbable sling materials that were used for the bone anchored male sling demonstrated disintegration of the material. Autolysis of these absorbable materials removed active compression forces on the urethra after a short period. Nonabsorbable graft is associated with the best outcome following the perineal bone anchored male sling procedure.

Surgical outcome of abdominal sacrocolpopexy with synthetic mesh versus abdominal sacrocolpopexy with cadaveric fascia lata

Nineteen women who had an abdominal sacrocolpopexy (ASC) with synthetic mesh and 18 women who had an ASC with freeze-dried, irradiated cadaveric fascia lata returned for blinded pelvic organ prolapse quantification (POPQ) examinations. The mean relative vaginal descent (delta) from perfect total vaginal length in the mesh group was 1.1 (0.3) cm, and the delta in the fascia group was 2.8 (0.8) cm (p=0.02, Mann-Whitney U). The proportion of women with "optimal" surgical outcome in the mesh group was 89% and 61% in the fascia group (p=0.06, Fischer's exact test). This study suggests that cadaveric fascia lata may not be a good choice for ASC.

Medium-term follow-up on use of freeze-dried, irradiated donor fascia for sacrocolpopexy and sling procedures

The aim of this study was to document longer-term follow-up of patients in a previously reported series who underwent either sacrocolpopexy (SCP) or suburethral sling procedures utilizing freeze-dried, irradiated donor fascia. Subjects from the initial series of 67 SCPs and 35 slings were included in this retrospective chart review of postoperative follow-up where surgical follow-up longer than 3 months from the procedure was available. Subjects undergoing SCP were examined at the time of any clinical visit and their pelvic organ support evaluated utilizing the POP-Q system. The SCP procedure was considered to be unsuccessful if any anterior vaginal wall point (Aa or Ba) was at the hymen or beyond, or if the vaginal apical point (C or D) descended to a point at least halfway to the hymen from a position of perfect apical support. Subjects who did not return for clinical examination after their 3-month postoperative visit but who had been in telephone contact with the clinic stating that they had experienced symptomatic recurrence of their POP were also included as having unsuccessful SCP procedures. Those similarly in contact with the office by telephone, but not clinically examined, who indicated no subjective return of their POP, were coded as successful. The outcome of the sling procedure was primarily evaluated subjectively, with the patient indicating that stress incontinence symptoms were present or absent. Follow-up was available for 75 patients, who had undergone 54 SCP and 27 sling procedures (6 patients had undergone both SCP and sling procedures). When failure was defined according to any of the criteria listed in the methods section, 45 (83%) patients experienced SCP failure at a median of 12 months after surgery. A total of 14 (52%) sling procedures were failures, with recurrent SUI symptoms experienced from 2 weeks to 24 months (median 3 months) after the procedure. One year after surgery, 23 (43%) SCPs were known to be failures, and 11 (41%) slings were known to be failures. The remaining 13 (48%) slings were subjectively successful when last seen 7-51 months after surgery. We reoperated on 21 (40%) patients. At the time of repeat SCP (chosen by 16 patients) we found graft between the sacrum and vagina in just 3 patients (19%). The use of freeze-dried, irradiated donor fascia for both SCP and sling procedures was associated with an unacceptably high failure rate in our series.

Clinical and histological safety assessment of rectocele repair using collagen mesh

AIM

To clinically and histologically evaluate inflammatory response following rectocele repair using porcine collagen mesh.

METHODS

Seventeen patients underwent rectocele repair using porcine collagen mesh. Inflammatory response was assessed by clinical and histological inflammatory grading pre- and postoperatively. Postoperative body temperature, complications and hospital stay was compared with 15 patients undergoing posterior colporraphy.

RESULTS

Postoperative clinical examination did not demonstrate any inflammatory reaction. There were no significant changes in fibroblast count (P = 0.43), connective tissue density grading (P = 0.54), macrophage count (P = 0.20), inflammatory cell count (P = 0.48), total cell count (P = 0.51), or inflammatory grading (P = 0.87) postoperatively compared with preoperative values. Body temperature was significantly elevated for both the study and control group, although higher for the study group, postoperatively day 1 (P < 0.001). There were no significant differences in hospital stay and postoperative complications.

CONCLUSION

Porcine collagen mesh was not associated with an adverse inflammatory response at clinical or histological evaluation and appears to be a safe material when used for rectocele repair.

High rate of vaginal extrusion of silicone-coated polyester sling

OBJECTIVES

To report the results of a pilot study evaluating the suitability of silicone-coated polyester as a suburethral sling material for female stress incontinence surgery.

METHODS

Ten women with stress or mixed urinary incontinence were prospectively evaluated with history and physical examination, pad test, urodynamic studies, and the Incontinence-Quality of Life questionnaire. The 2 x 7-cm sling was secured with transvaginal bone anchors placed through an anterior vaginal wall incision. Patients were evaluated at 1, 6, and 12 months by history and physical examination, pad test, and the Incontinence-Quality of Life and Success Rate and Overall Patient Satisfaction questionnaires.

RESULTS

Ten patients (mean age 62.3 years) underwent successful placement of the suburethral sling. The Incontinence-Quality of Life scores improved from a mean total score of 43.3 +/- 14.6 preoperatively to 97.7 +/- 14.4 at 1 year postoperatively (P <0.001). The Success Rate and Overall Patient Satisfaction questionnaires completed at 1 year demonstrated a mean satisfaction rating of 8.9 +/- 1.7 (scale 1 to 10), and the mean reported improvement in incontinence was 90% +/- 16.3%. The mean pad weight decreased from 103.1 +/- 33.2 g preoperatively to 1.6 +/- 1.01 g at 1 year (P <0.007). Two patients (20%) developed vaginal extrusion of the suburethral sling at 6 and 10 months. The slings were removed surgically. Both women healed without incident and reported continued continence at 1 year without additional surgical intervention.

CONCLUSIONS

Placement of a suburethral sling using transvaginal bone anchors and silicone-coated polyester is an effective surgical treatment for stress urinary incontinence at 1 year. The high rate of vaginal extrusion in our series limits its utility.

Time Dependent Variations in Biomechanical Properties of Cadaveric Fascia, Porcine Dermis, Porcine Small Intestine Submucosa, Polypropylene Mesh and Autologous Fascia in the Rabbit Model: Implications for Sling Surgery

PURPOSE

We investigated time dependent variations in tensile strength, stiffness, shrinkage and distortion in 6 materials commonly used for transvaginal anti-incontinence surgery.

MATERIALS AND METHODS

A total of 15 rabbits were randomized into 3 survival groups (2, 6 and 12 weeks, respectively). Each rabbit had human cadaveric fascia, porcine dermis, porcine small intestine submucosa, polypropylene mesh and autologous fascia implanted on the anterior rectus fascia. At harvest tensiometry and image analysis were performed on each sling. Results were compared to baseline for each sling type and the percent decrease from baseline was compared among sling types.

RESULTS

Each type of human cadaveric fascia and porcine allografts showed a marked decrease (60% to 89%) in tensile strength and stiffness from baseline. Polypropylene mesh and autologous fascia did not differ in tensile strength from baseline. Polypropylene mesh increased in stiffness from baseline. Autologous fascia and small intestinal submucosa demonstrated a 41% and 50% decrease in surface area, respectively, at 12 weeks.

CONCLUSIONS

To our knowledge the relative contribution of biomechanical properties of sling material to the success of anti-incontinence surgery is unknown. However, rapid loss of tensile strength and stiffness in porcine and cadaveric materials may contribute to the early re-emergence of symptoms following successful sling surgery. The results of this study add scientific validity to the increasing use of synthetics in anti-incontinence surgery. Urologists selecting a sling material should be aware of its time dependent biomechanical fate relative to other sling materials.