A new operation for genitourinary prolapse

From anatomy to patient experience in pelvic floor surgery: Mindlines, evidence, responsibility, and transvaginal mesh

Beginning in the late 1990s, surgeons around the world widely adopted the transvaginal placement of permanent synthetic mesh for the treatment of several common pelvic floor disorders in women. By 2012 it had become the subject of extensive litigation, including one of the biggest mass-tort cases in U.S. history, with litigants reporting debilitating and unexpected complications. Based on qualitative research that includes interviews with surgeons, observations of medical conferences, and analysis of archival materials, we argue the adoption of transvaginal mesh cannot be fully explained without recognizing the role of mindlines, or collective moral-epistemological ways of knowing and acting responsibly. The adoption of mesh was anchored in a mindline focused on repairing anatomy. The harms that resulted from transvaginal mesh necessitated a shift to a focus on patient experience. We analyze the role of evidence-based medicine (EBM) in the re-organization of these surgeons' mindlines, showing that mindlines are not reducible to evidence as defined by EBM and that evidence thus defined facilitated the adoption of transvaginal mesh.

Long-term experience with a novel uterine-sparing transvaginal mesh procedure for uterovaginal prolapse

OBJECTIVES

To evaluate outcomes and quality of life in patients operated transvaginally with an original mesh shape for uterus-sparing prolapse surgery and to demonstrate the safety and efficacy of the technique.

STUDY DESIGN

We prospectively evaluated 66 postmenopausal patients (POP-Q Stage III: 32, IV: 34) operated between May 2008 and December 2013. We used wide weave polypropylene monofilament mesh that functions as a hammock anchored posteriorly to sacrospinous ligaments, its anterior wings exit the pelvis through the obturatory membrane. Follow-up was scheduled at 3-, 12- months and in May 2016. Prolapse-Quality of Life Questionnaire (P-QoL) was administered preoperatively, at 12 months and in May 2016. The chi square and Wilcoxon test were used for statistical analysis.

RESULTS

Mean follow-up was 5.6 (SD: 1.6, Range: 1.1-8.1) years. The overall success rate (POP-Q ≤ 2) was 92.5% at 12 months and 84.4% at May 2016, these data remained stable over time (p > 0.05). Early complications occurred in 2 (3%) patients, late in 5 (7.8%) of which mesh extrusion in 4 (6.3%). Data from P-QoL showed significant improvement between preoperative and postoperative data (P < 0.01 for all domains) and they remained stable with time (p > 0.05). De-novo dyspareunia was 17.6% at 12 months and 10.3% at May 2016.

CONCLUSIONS

The low rate and grade of complications demonstrates the safety of the procedure, which offers stable anatomical correction with significant improvement in QoL.

Current trends and future perspectives in pelvic reconstructive surgery

Pelvic organ prolapse is a prevalent disorder with a high lifetime incidence of surgical repair. Pelvic organ prolapse surgery has greatly evolved over the past years, and pelvic floor reconstructive surgeons are faced with a vast array of treatment options for their patients. Our review article illustrates the current trends and future perspectives for the surgical treatment of pelvic organ prolapse.

Reasons for and Against Use of Non-absorbable, Synthetic Mesh During Pelvic Organ Prolapse Repair, According to the Prolapsed Compartment

Awareness and reporting of mesh-related complications of pelvic organ prolapse repairs have increased in recent years. As a result, deciding whether to use a mesh or not has become a difficult task for urogynecologists. Our aim was to summarize reasons for and against the use of mesh in prolapse repair based on a review of relevant literature. Scopus and PubMed databases were searched for papers reporting on the efficacy and safety of native tissue versus non-absorbable, synthetic mesh prolapse repairs. Randomized controlled trials, systematic reviews, and meta-analyses were included. Evidence is presented for each vaginal compartment separately. In the anterior compartment, mesh repairs seem to offer clearly superior efficacy and durability of results compared to native tissue repairs, but with an equally clear increase in complication rates. In the isolated posterior compartment prolapse, high-quality evidence is sparse. As far as the apical compartment is concerned, sacrocolpopexy is the most efficacious, yet the most invasive procedure. Data on the comparison of transvaginal mesh versus native tissue repairs of the apical compartment are somewhat ambiguous. Given the inevitable coexistence of advantages and disadvantages of mesh use in each of the prolapsed vaginal compartments, an individualized treatment decision, based on weighing risks against benefits for each patient, seems to be the most rational approach.

Transvaginal mesh surgery for pelvic organ prolapse: one-year outcome analysis

OBJECTIVE

The aim of the study was to assess the role of Prolift + M (PP-PG) vaginal mesh surgery to correct uterovaginal prolapse not only from an anatomic but also a subjective (patient's) standpoint.

METHODS

A prospective cohort of subjects treated with transvaginal mesh for prolapse between April 2009 and November 2010 was analyzed. A composite score that included subjective criteria of absence of a bothersome bulge and objective criteria based on Pelvic Organ Prolapse Quantification lower than stage II was used to assess treatment success.

RESULTS

Transvaginal mesh was performed in 157 subjects (age, 64.7 ± 11.6 years; body mass index, 28.5 ± 4.8 kg/m) for pelvic organ prolapse. Five anterior mesh surgeries (3.2%), 48 posterior mesh surgeries (30.6%), and 104 total mesh surgeries (66.2%) were performed in subjects with stage II or greater degrees of prolapse. Stage II prolapse was noted in 44 subjects (28.0%), 91 subjects (58.0%) had stage III prolapse, and 22 subjects (14.0%) had stage IV prolapse. The mean follow-up was 13 months. Our composite success score was 88.1%. Pure anatomic success based on Pelvic Organ Prolapse Quantification lower than stage II was 94%. The mean operative time was 117.8 ± 42.4 minutes. The mean intraoperative blood loss was 106.1 ± 116.4 mL. There were 3 cases (2.2%) of mesh exposure in the vagina. There were no visceral injuries. The incidence of de novo dyspareunia was 6%.

CONCLUSION

Transvaginal PP-PG mesh surgery is safe and effective with few postoperative morbidities.

Incidence of extrusion following type I polypropylene mesh "kit" repairs in the correction of pelvic organ prolapse

Introduction and Hypothesis. We sought to determine the mesh extrusion (vaginal exposure) rates and subject outcomes following IntePro (Type I polypropylene) mesh “kit” repairs for vaginal prolapse. Methods. Data were pooled from two prospective multicenter studies evaluating the safety and efficacy of the Perigee and Apogee (American Medical Systems, Minnetonka, Minn, USA) to treat anterior and posterior/apical prolapses, respectively. Extrusions involving the anterior compartment (AC) or posterior compartment/apex (PC/A) were recorded. Results. Two hundred sixty women underwent mesh placement, with a total of 368 mesh units inserted (173 in the AC and 195 in the PC/A). Extrusions were noted in 13 (7.5%) of AC implants and 27 (13.8%) of PC/A implants through 12 months. No difference was seen between those with and without extrusion in regard to anatomic cure, postoperative painor quality of life at 1 year. Conclusions. Extrusion had no apparent effect on short-term outcomes. Given the unknown long-term sequellae of vaginal mesh exposure, a thorough assessment of risks and benefits of transvaginal mesh placement should be considered at the time of preoperative planning.

Transvaginal mesh surgery for pelvic organ prolapse--Prolift+M: a prospective clinical trial

INTRODUCTION AND HYPOTHESIS

This study deals with assessment of safety, efficacy, and potential complications of Prolift+M system to correct uterovaginal prolapse.

METHODS

We analyzed a prospective cohort treated with the Gynecare PROLIFT+M mesh system between October 2008 and March 2010. A composite score that included subjective/objective cure and lack of complications was used to assess treatment success.

RESULTS

One hundred sixty-seven women (age 65.1 ± 11.2 years, BMI 29.2 ± 5.8 kg/m(2)) were treated for pelvic organ prolapse using the PROLIFT+M system. Seven anterior Prolift+M, 42 posterior Prolift+M, and 118 total Prolift+M mesh surgeries were performed in patients with stage II or greater degrees of prolapse. Mean operative time was 122.7 ± 43.9 min. Mean intraoperative blood loss was 119.4 ± 125.3 ml. Our composite success score was 72.5% (treatment failures per POP-Q stage 1.4%, perception of bulge 4.4%, erosions 3.6%, pain/dyspareunia 3.7%, incontinence 0.7%, de novo urge urinary incontinence 8.7%, voiding dysfunction 0.6%, recurrent urinary tract infection 2.2%, and anal incontinence 2.2%).

CONCLUSIONS

Prolift+M surgery is safe and effective with minimal postoperative morbidities.

Pelvic reconstruction with mesh for advanced pelvic organ prolapse: a new economic surgical method

OBJECTIVE

The aim of this study was to introduce a new pelvic reconstructive surgical operation with use of specially designed puncture needles and precut mesh. In addition, the anatomic results and the safety of this reconstructive approach were evaluated.

METHODS

Ninety-nine women who were older than 60 years with stage III or IV prolapse according to pelvic organ prolapse quantification (POP-Q) underwent the modified pelvic reconstructive surgical operation. Follow-up was more than 1 year. The objective and subjective results were measured by POP-Q and quality-of-life questionnaires, respectively. Complications were also observed both in the surgical operation and in the follow-up examination.

RESULTS

No severe intraoperative complications were observed. POP-Q measurements of Ba, Bp, and C taken 1 year postoperatively were significantly improved compared with those at baseline (P < 0.001), but eight women (8.1%) showed recurrence. A significant improvement in quality-of-life scores was observed (P < 0.001). The incidence rate of mesh exposure and the de novo urgent incontinence rates were 2% and 12%, respectively.

CONCLUSIONS

This new pelvic reconstructive surgical operation is a cost-effective and safe method and is easy to perform.

Incidence and management of graft erosion, wound granulation, and dyspareunia following vaginal prolapse repair with graft materials: a systematic review

INTRODUCTION AND HYPOTHESIS

This study describes the incidence, risk factors, and treatments of graft erosion, wound granulation, and dyspareunia as adverse events following vaginal repair of pelvic organ prolapse with non-absorbable synthetic and biologic graft materials.

METHODS

A systematic review in Medline of reports published between 1950 and November 2010 on adverse events after vaginal prolapse repairs using graft materials was carried out.

RESULTS

One hundred ten studies reported on erosions with an overall rate, by meta-analysis, of 10.3%, (95% CI, 9.7 - 10.9%; range, 0 - 29.7%; synthetic, 10.3%; biological, 10.1%). Sixteen studies reported on wound granulation for a rate of 7.8%, (95% CI, 6.4 - 9.5%; range, 0 - 19.1%; synthetic, 6.8%; biological, 9.1%). Dyspareunia was described in 70 studies for a rate of 9.1%, (95% CI, 8.2 - 10.0%; range, 0 - 66.7%; synthetic, 8.9%; biological, 9.6%).

CONCLUSIONS

Erosions, wound granulation, and dyspareunia may occur after vaginal prolapse repair with graft materials, though rates vary widely across studies.

Vaginal repair of cystocele with anterior wall mesh via transobturator route: efficacy and complications with up to 3-year followup

Study Objective. The objective of this study was to report on the safety and efficacy of cystocele repair with anterior wall mesh placed via a transobturator route (Perigee system, AMS, Minnetonka, MN). Design. Single center retrospective study. Setting. Single center hospital setting and Urogynecology practice in the United States. Patients. 77 women presenting with symptomatic anterior wall prolapse. Intervention. Repair of cystocele with an anterior wall Type I soft-polypropylene mesh placed via a transobturator approach. Concomitant procedures in other compartment were also completed as indicated. Measurements and Main Results. 77 women underwent the Perigee procedure at our institution over a 2-year period. The mesh was attached to the pelvic sidewalls at the level of the bladder neck and near the ischial spine apically with needles passed through the groins and obturator space. Mean follow-up was 18.2 months (range 3–36 months). Objective cure rate was 93%. Subjectively only two patients have had recurrent symptoms of prolapse, and only 1 of these has required repeat surgery for cystocele. Mesh exposure vaginally occurred in 5 patients (6.5%); however all were treated with estrogen and/or local excision of exposed mesh and had no further sequelae. There were no incidences of chronic pain, infection, or abscess, and no patient required complete mesh removal for infection, pain, or extrusion. Conclusion. In select patients with anterior wall prolapse, repair with mesh augmentation via the transobturator route is a safe and effective procedure with up to 3 years of follow-up.

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

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

Tensile properties of commonly used prolapse meshes

INTRODUCTION AND HYPOTHESIS

To improve our understanding of the differences in commonly used synthetic prolapse meshes, we compared four newer generation meshes to Gynecare PS using a tensile testing protocol. We hypothesize that the newer meshes have inferior biomechanical properties.

METHODS

Meshes were loaded to failure (n = 5 per group) generating load-elongation curves from which the stiffness, the load at failure, and the relative elongation were determined. Additional mesh samples (n = 3) underwent a cyclic loading protocol to measure permanent elongation in response to subfailure loading.

RESULTS

With the exception of Popmesh, which displayed uniform stiffness, other meshes were characterized by a bilinear behavior. Newer meshes were 70-90% less stiff than Gynecare (p < 0.05) and more readily deformed in response to uniaxial and cyclical loading (p < 0.001).

CONCLUSION

Relative to Gynecare, the newer generation of prolapse meshes were significantly less stiff, with irreversible deformation at significantly lower loads.

Colpopexie infracoccygéale translévatorienne postérieure (IVS): faisabilité et premiers résultats d'une série continue de 108 cas

OBJECTIVE

We present a continuous series of 108 patients operated for genital prolapse by vaginal route using the Posterior Intravaginal Slingplasty (PIVS) technique (IVS 02 Tyco Healthcare, polypropylene multifilament band), associated to prosthetic repair of cystocele and/or rectocele if present by interposition of a mesh (Surgipro Mesh Tyco Healthcare).

PATIENTS AND METHODS

Inclusion criteria were C and/or D point superior to -1 cm. The main criterion is the assessment of feasibility, morbidity and anatomical results obtained for the treatment of level 1 genital prolapse with an average follow-up of 19 months. The secondary criterion is to assess the same elements for the treatment of associated cystocele and rectocele.

RESULTS

Seventy-three patients presented with a cystocele (Ba>-1 cm) and eighty-seven with a rectocele (Bp>-1 cm). Nineteen patients had a hysterectomy, twenty had amputation of the cervix and forty-nine were treated for stress urinary incontinence by anterior IVS. Perioperative complications consisted of seven bladder injuries, one injury to the lower rectum during dissection. Postoperative complications were: a loss more than 2 g haemoglobin for seven patients, two haematomas in the cave of Retzius, one haematoma of the pararectal fossa with secondary superinfection requiring mesh removal. Three erosions occurred: two in front of the vesicovaginal prosthesis and one in front of the recto-vaginal prosthesis. The latter became secondarily super infected and had to be removed. With regard to the anatomical result, one failure was noted for the Posterior IVS excluding the two patients in whom the prosthetic material had to be removed. For the anterior compartment, eight failures occurred. From a functional perspective, we noted one case of dyspareunia due to fibrous retraction and seven patients complained of de novo stress urinary incontinence and eight of moderate voiding obstruction.

DISCUSSION AND CONCLUSIONS

The technical feasibility is excellent. Feasibility of level 2 repair, anterior or posterior, but results on cystocele are insufficient in case of lateral defect.

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.

Biologic grafts and synthetic meshes in pelvic reconstructive surgery

Despite the lack of evidence, augmenting pelvic organ prolapse surgery with biologic graft or synthetic mesh is increasing. The objective of this review is to examine the available grafts and meshes and discuss the current data addressing the use of these implants in correction of apical, anterior, and posterior prolapse. Most of the studies are retrospective with few randomized controlled trials. There is level I evidence suggesting that repair of apical prolapse with abdominal sacral colpopexy using synthetic mesh results in improved outcomes. However, most of the data concerning graft or mesh incorporation in anterior or posterior repairs do not support augmentation with prosthesis.

Results of Cystocele Repair: A Comparison of Traditional Anterior Colporrhaphy, Polypropylene Mesh and Porcine Dermis

PURPOSE

Because traditional anterior colporrhaphy can have a high recurrence rate, we assessed the recurrence rate of 3 methods of cystocele repair, including 1) traditional anterior colporrhaphy, 2) repair using porcine dermis interposition graft and 3) repair using polypropylene mesh. Additionally, we compared the rate of erosion of porcine dermal graft with that of polypropylene mesh.

MATERIALS AND METHODS

The records of patients who underwent cystocele repair by the same urologist using porcine dermal graft, polypropylene mesh or traditional repair from January 1999 to August 2005 were reviewed. Data were collected on history, physical examination, outcomes and complications. Using the Baden-Walker system a cystocele of grade 2 or higher on followup examination was considered recurrence.

RESULTS

A total of 119 patients underwent cystocele repair from January 1999 to August 2005. Followup was available on 99 patients and it averaged 13.5 months (range 2 to 46). Of the patients 56 (57%) underwent cystocele repair using porcine dermal graft, 25 (25%) received polypropylene mesh and 18 (18%) underwent traditional repair. Of the 99 patients 22 (22%) had cystocele recurrence. Based on the type of repair 36% of patients (20 of 56) with porcine dermal grafts had recurrence compared to 4% (1 of 25) and 6% (1 of 18) using polypropylene and traditional repair, respectively. Mean time to cystocele recurrence was 4.9 months (range 0.5 to 20). A total of 12 patients (21%) had extrusion of porcine grafts through the anterior vaginal wall incision compared to 1 (4%) with polypropylene mesh.

CONCLUSIONS

In our patient population the short-term failure rate for anterior vaginal wall prolapse using porcine dermis interposition graft was higher than that for traditional anterior colporrhaphy or polypropylene mesh. In addition, the incidence of vaginal extrusion of porcine graft was unacceptably high. Porcine dermis is a less suitable material for cystocele repair than polypropylene mesh or traditional anterior colporrhaphy. Prospective, randomized trials are necessary to determine the true efficacy and complication rates of these graft materials for anterior vaginal wall prolapse repair.

Comparaison de différents biomatériaux destinés à la chirurgie vaginale dans un modèle in vivo d'infection de prothèse chez le rat

OBJECTIVES

The purpose of this study was to develop an animal model of prosthetic infection and compare in vivo bacterial infectiosity of different biomaterials used in vaginal surgery.

MATERIALS AND METHODS

We implanted 36 prostheses of poly(lactic acid) with 94% L forms (PLA94), in a model of incisional abdominal hernia in Wistar rats. Bacterial inoculation was done just after implantation with three strains of Escherichia coli of variable virulence, two different concentrations and two different times of inoculation (during surgery or 48 hours after). All meshes were explanted and animals sacrificed on day 30 after intervention. Bacteriology and histology were then performed. In the same way, three materials used in vaginal surgery (knitted light-weight polypropylene [PP], thermoformed PP [Uratape] and polyurethane coated poly[ethylene terephtalate] [PTFE]) were tested and compared to the PLA94 using the same protocol.

RESULTS

All inoculated prostheses were still infected at day 30 after implantation with the same E. coli strain. There was a significant difference in bacterial infectiosity linked to virulence of the inoculated strain (p=.005) and the amount injected (P<0.001). Infectiosity was significantly lower for PLA94 when compared to the three other prostheses (P=0.008). The most important infectiosity was seen with PTFE and thermoformed PP. For histologists, PLA94 also gave the weakest inflammatory reaction.

DISCUSSION AND CONCLUSION

An original animal model of prosthetic infection allowed us to compare in vivo bacterial infectiosity of different biomaterials used in vaginal surgery and to demonstrate that the PLA94 mesh induces a milder risk of infection than polypropylene.

Use of grafts in pelvic reconstructive surgery

There has been growing interest in the use of grafts in pelvic reconstructive surgery. This article will address available graft materials and assess their clinical efficacy and safety. We conducted a Pubmed MEDLINE literature search for full-length English text studies with follow-up periods of at least one year. There are many reports on synthetic and biological graft materials; the majority are not well-designed, have short-term follow-up, small sample sizes, and poor outcome assessment. The use of non-absorbable synthetic grafts may offer excellent anatomical cure rates. However, it is associated with a high incidence of graft-related complications, including healing abnormalities and adverse bladder, bowel, and sexual function effects. These complications can be decreased with absorbable synthetic meshes, but efficacy is lower compared to non-absorbable ones. There is insufficient evidence in favor of biological grafts. In conclusion, based on current knowledge, routine application of grafts in pelvic reconstruction is not recommended. It is preferred that graft utilization be individualized, with close monitoring for complications.

Dyspareunia and chronic pelvic pain after polypropylene mesh augmentation for transvaginal repair of anterior vaginal wall prolapse

Synthetic mesh augmentations for pelvic floor reconstructive surgeries are increasing in usage and popularity. Many studies are focusing on the anatomical success rates of transvaginal anterior compartment repairs with synthetic mesh, with minimal attention on its postoperative complications. We present a case report on a 59-year-old postmenopausal woman who underwent an anterior repair with 6x4-cm polypropylene mesh. Postoperatively, she developed severe dyspareunia and debilitating chronic pelvic pain. The patient failed conservative medical therapy and now requests complete removal of the synthetic mesh.

Les prothèses synthétiques dans la cure de prolapsus génitaux par la voie vaginale : bilan en 2005

Since 1996, prosthetic meshes have become increasingly popular for transvaginal surgical cure of genital prolapse. In light of the growing number of proposed techniques and materials we reviewed the experience of the pioneers in order to provide surgeons with the most objective information available. We reviewed the literature indexed in Meline/PubMed and Current Contents retaining all work concerning resorbable and non-resorbable meshes. For the larger class of non-resorbable meshes we also reviewed articles by category of material, each type of mesh being carefully defined: different compositions of polypropylene, polyester, composite meshes and also insertion kits. Resorbable meshes were evaluated in two randomized studies which did not demonstrate better results than with simple folding known to have a high rate of recurrence. For polypropylene meshes, Marlex was studied in six trials which demonstrated a high rate of cure at one year but also a high rate of erosion which reached 25%. Use of Atrium was mentioned in three studies with a 6 to 12% recurrence rate and an erosion rate nearly reaching 20%. The majority of studies used Prolene and Gynemesh. Seventeen authors reported their experience, generally reviewing retrospective series, with recurrence rates of less than 10% for follow-up periods rarely greater than two years. A large variety of forms and sizes have been used, hindering comparisons. The rate of erosion was also quite variable, as high as 45%, demonstrating the need for a precise definition of erosion. Only recently have authors shown interest in the impact of prosthetic meshes on quality of life and sexual activity. An improvement is generally noted for defecation but the rate of dyspareunia has reached as high as 60%. Here again grades of prosthetic retraction should be better defined. Proposed to improve these phenomena, soft Prolene recently used by several authors does not appear to fulfil expectations. Since 2005, several precut polypropylene meshes have been proposed with an insertion kit. The Prolift kit has been followed prospectively in 100 patients undergoing regular surveillance. Surgipro has been used sporadically in small series but follow-up is still too short for proper assessment. Polyester meshes (Mersilene and Paritex) have been presented by three authors who have found them useful but reports have been vague concerning results and complications. Polytetrafluoroethylene has not been evaluated for transvaginal surgery, probably because of the poor tolerance of suburetral bands. For composite meshes, Vypro has been used by four authors who noted about 10% erosion but with a short follow-up insufficient to draw conclusions about the functional and anatomic outcome. Surfaced meshes, advocated for transvaginal treatments, have been studied in only two reports. Plevitex is a polypropylene mesh coated with collagen; another polyester composite with polyglactin 910. The rate of dyspareunia varied from 14 to 24%. Other composites with antiadherents or antiseptics are also proposed for transvaginal insertion but have not been studied. This work demonstrated the lack of sufficient evidence from prospective randomized trials and the lack of standardized techniques to draw any definite conclusions. While evidence is being accumulated on the lower rate of recurrence for anterior compartment prolapse, the lack of data on the rate of complications and patient quality of life is unacceptable for this functional surgery. We still have reservations about widespread use of synthetic meshes. A special chapter is detailed in appendix on post-operative complications. These new specific complications call to a new semiology, with a classification in 4 types and under-types, proposed by authors. Type 1: defects of healing. Type 2: the infection of the graft. Type 3: the shrinkage of the mesh. Type 4: erosions. Authors detail the symptoms of these 4 types as well as the prevention and the treatment of these complications.

Prolapse repair by vaginal route using a new protected low-weight polypropylene mesh: 1-year functional and anatomical outcome in a prospective multicentre study

The aim of this study was to evaluate the anatomical and functional results of a low-weight polypropylene mesh coated with an absorbable film in prolapse surgery by vaginal route. We have conducted a prospective multicentre study in 13 gynaecological and urological units. There were 230 patients requiring repair for anterior or posterior vaginal prolapse included. The present report is based on the analysis of the first 143 patients evaluated after at least 10 months follow-up. All patients were operated by the vaginal route using a specially designed mesh (Ugytex, Sofradim, France). Prolapse severity were evaluated using the Pelvic Organ Prolapse staging system. Symptoms and quality of life were evaluated preoperatively and during follow-up using the validated Pelvic Floor Distress Inventory (PFDI) and Pelvic Floor Impact Questionnaire (PFIQ) self-questionnaires. Mean age was 63 years (37-91). Anterior, posterior and anterior-posterior repair with the mesh were performed in 67 (46.9%), 11 (7.7%) and 65 (45.4%) patients, respectively. With a mean follow-up of 13 months (10-19), 132 patients were considered anatomically cured (92.3%) with a recurrence rate of 9 of 132 for cystocele (6.8%) and 2 of 76 for rectocele (2.6%). Nine vaginal erosions occurred (6.3%), six of them necessitated another procedure by simple excision. The rate of de novo dyspareunia was 12.8%. At follow-up, improvement of PFDI and PFIQ scores were highly significant (p<0.0001). The use of low-weight polypropylene mesh coated with a hydrophilic absorbable film for vaginal repair of genital prolapse seems to decrease local morbidity while maintaining low recurrence rates.

Traitement du prolapsus génital avec mise en place d’une prothèse de polypropylène par voie vaginale

OBJECTIVES

We evaluated the results of surgical insertion of a polypropylene mesh via the vaginal route in young women presenting genital prolapse.

MATERIAL AND METHODS

Retrospective study concerning 20 women under age 50 who underwent between July 2000 and December 2003 surgical insertion of an anterior (n=14), posterior (n=3) or double (anterior and posterior) (n=3) polypropylene mesh via the vaginal route. A minimum follow-up of 6 months was required for inclusion in the study. Anatomical results were assessed using the Pelvic Organ Prolapse Quantification (POP-Q) according to ICS (International Continence Society) recommendations. To document the functional results, the patients answered 3 validated self-assessment questionnaires related to pelvic symptoms, sexual behaviors and quality of life.

RESULTS

Mean follow-up was 21 months (6 to 52 months). A vaginal erosion of the mesh occurred in 2 women (10%). Cystocele recurred in one woman among the 17 patients who had an anterior polypropylene mesh (Gynemesh, Gynecare, Ethicon). Seventeen women were sexually active before the surgical procedure and 19 post-operatively. Among these women, 5 (26%) reported alteration of sexual activity after surgery (with dyspareunia in 4 cases (21%)), and 14 women (74%) reported no changes or improvement in sexual activity.

CONCLUSION

Surgical management of genital prolapse using a polypropylene mesh inserted via the vaginal route has proven its anatomical efficacy in young women. The potential adverse consequences on sexual life would require clinical research concerning the surgical approach (abdominal or vaginal route) and synthetic materials used in prolapse surgery for young women.

Scientific basis for use of grafts during vaginal reconstructive procedures

PURPOSE OF REVIEW

The use of graft material and mesh in the setting of pelvic organ prolapse surgery has gained increasing popularity and attention in spite of lack of scientific evidence to support their use. The objective of this review is to discuss available synthetic and biologic graft materials, review operative techniques, and evaluate the anatomic and functional results of published data on graft augmented prolapse repairs and antiincontinence procedures.

RECENT FINDINGS

Natural biologic graft materials (such as fascia lata) have been used to augment prolapse surgery and have a theoretical advantage of causing less erosions; however, a renewed interest in the employment of synthetic mesh in the anterior and posterior segments has increased, partly due to the need to find improved materials with less inconsistent material strength. The insertion of 'tension-free' meshes for anterior and posterior vaginal wall prolapse may be promising, but studies with longer follow-up are necessary to determine their true efficacy and safety profile.

SUMMARY

The recent introduction of newer graft materials and minimally invasive surgical techniques for pelvic organ prolapse repair and stress incontinence has rapidly grown, despite the relative lack of evidence-based information to document their long-term efficacy and safety. Their current use must take into account the risk-benefit profile and be individualized for each surgical candidate. The ultimate goal is to correct both the anatomic and functional derangements seen in this patient population, while improving quality of life.

Vaginal mesh erosion after transvaginal repair of cystocele using Gynemesh or Gynemesh-Soft in 138 women: a comparative study

The objective of this study was to compare mesh erosion after transvaginal repair of cystocele using Gynemesh or Gynemesh-Soft mesh. We retrospectively analyzed 138 consecutive cases of transvaginal repair of cystocele using synthetic mesh. The study endpoint was the pathological evidence of vaginal erosion. Multiple logistic regression was used to determine independent predictors of vaginal erosion. One hundred and thirty eight women (ages 30-83 years) with cystocele between October 1999 and October 2004, from a French University Hospital, participated in this study. Cystocele repair was performed in all patients according to the technique of tension-free polypropylene mesh. The median follow-up was 32.1 months (range 7.5-59.9) in the Gynemesh group and 7.1 months (range 1-21.9) in the Gynemesh-Soft group. Vaginal erosion was reported in 27 (20%) of the patients. Anatomically, the success rate was 95% (131/138). There was no statistically significant difference between the Gynemesh and the Gynemesh-Soft meshes [the rate of vaginal erosion of the mesh was 16% (15/89) vs 24% (12/49), respectively, p=0.39]. Univariate analysis only identified age class as factor significantly associated with the probability of vaginal erosion. Multivariate analysis revealed that age class is an independent predictive factor of vaginal erosion (age > 70 years, odds ratio (OR) 3.6, 95% confidence interval (CI) 1.3-9.7, p=0.010). Furthermore cystocele stage > 2 (Baden and Walker classification) is a protective factor against vaginal erosion (OR 0.3, 95% CI 0.1-0.8, p=0.016). Thirteen symptomatic patients (13/27, 48%) necessitated a partial excision of the mesh, associated with a vaginal mucosal closure. Two patients (2/27, 7%) underwent a complete excision of the mesh. The incidence of de novo dyspareunia was 9% in patients with vaginal erosion and 11% in patient without mesh erosion (p=0.85). There was no occurrence of bladder or urethral erosion and no vaginal or pelvic infection. Isolated vaginal erosion of the mesh did not prove to be problematic. Gynemesh-Soft mesh does not decrease the incidence of vaginal erosion. Age > 70 years is an independent predictive factor of vaginal erosion. We recommend that mesh placement by vaginal route should be avoided by women with moderate cystocele. Where possible, total hysterectomy and vertical incision should also be avoided. Management of vaginal erosion is simple and is associated with a low rate of morbidity. However, patients should be informed that vaginal erosion of the mesh can occur. A multivariate analysis reveals that the incidence of vaginal erosion is not significantly different between Gynemesh and Gynemesh-Soft meshes. Other factors of erosion are analyzed.

Long-term anatomical and functional assessment of trans-vaginal cystocele repair using a tension-free polypropylene mesh

We report a case series of 63 women with cystocele who underwent the same trans-vaginal procedure between October 1999 and October 2002. The polypropylene mesh (GyneMesh, Gynecare, Ethicon, France) was placed from the retropubic space to the inferior part of the bladder in a tension-free fashion. Patients were followed up for 24 to 60 months, with a mean follow-up of 37 months. Fifty-five patients returned for follow-up (87.3%). At follow-up, 49 women were anatomically cured (89.1%), five women had stage 2 anterior vaginal wall prolapse (9.1%), and one had a recurrent stage 3 (1.8%). Functional results and sexual function were also investigated. Fifty-three women had significant improvement in their quality of life (96.4%). There were a total of three cases of local pain around a mesh shrinkage (5.5%) and five vaginal erosions of the mesh (9.1%). Four out of 24 patients had dyspareunia (16.7%). In conclusion, the vaginal repair of anterior vaginal wall prolapse reinforced with a polypropylene mesh was efficient at 2 to 5 years follow-up. However, the first generation of polypropylene mesh we used was responsible for high rates of local complications and dyspareunia. Therefore, the polypropylene mesh has to be improved (lower weight) and the technique has to be documented by a randomized controlled trial before we could recommend its use in clinical practice.

Uterus-Sparing Vaginal Surgery of Genitourinary Prolapse Employing Biocompatible Material

OBJECTIVE

The study presents an original uterus sparing technique for transvaginal repair of total genitourinary prolapse. The technique employs a synthetic mesh of mixed polypropylene and 910 polyglactin fibers.

METHODS

The prosthesis creates a support for the cystocele, the cervix and the enterocele. It has four anchoring sites: two at the rear in the sacrospinous ligaments and two at the front in the arcus tendineous of the levator ani muscle. Between February 2001 and December 2004, 24 patients (mean age 66.9 years), presenting symptoms of uterine prolapse, cystocele and enterocele (POP-Q stage III-IV Aa associated to II-III-IV C), were treated with our procedure. Pre- and postoperative parameters were evaluated statistically.

RESULTS

No patient had any serious complications. The mean follow-up was 31.1 months (range 6-52). 19 patients (79.1%) have shown excellent results and have been completely cured. In 5 other cases (20.8%), the cystocele was completely cured and there was a significant improvement in the hysterocele and the enterocele. One patient required surgical treatment for postoperative stress incontinence. Statistical analysis of data regarding the pre- and postoperative prolapse stage demonstrated a high degree of objective cure rates (p < 0.0001).

CONCLUSIONS

While hysterectomy remains the habitual treatment for severe uterine prolapse, our technique provides a promising alternative solution. It is also significant that there were no complications of erosion or infection associated with the prosthesis.

Outcomes of vaginal reconstructive surgery with and without graft material

OBJECTIVE

This study was undertaken to evaluate the outcomes of vaginal surgery for pelvic organ prolapse, comparing cases implementing graft augmentation to those without graft augmentation.

STUDY DESIGN

This was a retrospective cohort study of 312 patients who underwent vaginal surgery for prolapse from February 1998 to January 2004.

RESULTS

Of the 312 patients, 98 (31.4%) had graft augmentation. The median follow-up was 9 months (3-67 months). Graft use was not associated with reduction in recurrent prolapse, recurrent stage 3 prolapse, recurrent incontinence, or additional surgery for prolapse. After controlling for confounders, there was still no difference in surgical outcomes. Complications such as vaginal/graft infection (18.4% vs 4.7%; P < .001) and granulation tissue (38.8% vs 17.3%; P < .001) were more common after cases in which graft was used.

CONCLUSION

In the early postoperative period, there was no benefit in using graft for prolapse repair. Graft use leads to a higher rate of postoperative complications.

Laparoscopic sacral colpopexy approach for genito-urinary prolapse: experience with 363 cases

OBJECTIVE

To evaluate the surgical outcome, complications and benefits of laparoscopic double promonto-fixation for patients with pelvic prolapse.

METHODS

Women with genito-urinary prolapse underwent a transperitoneal placement of a 100% polyester mesh on the anterior vaginal wall and a posterior mesh on the levator ani muscle. Both of these were anchored to the sacral promontory. A TVT was placed simultaneously in patients who had concurrent stress urinary incontinence.

RESULTS

A total of 363 patients were operated upon between 1996 and 2002. Their mean age was 63 (range 35-78), average follow-up was 14.6 months, the mean operating time was 97 minutes. There were 8 conversions due to anesthetic or surgical difficulties. Follow up was done by a postal questionnaire and physical examination at 6 months and then yearly. 96% were satisfied with the results of their operation and no patients complained of sexual dysfunction. There was a 4% recurrence rate of prolapse, 3 vaginal erosions, 2 urinary retentions that required TVT section, 1 bowel incarcerations, 1 spondylitis and 2 mesh infection.

CONCLUSIONS

Laparoscopic promonto-fixation is feasible and highly effective technique that offers good long-term results with complication rates similar to open surgery, with the added benefits of minimally invasive surgery.

Surgical management of anterior vaginal wall prolapse: an evidencebased literature review

The aim of this review is to summarize the available literature on surgical management of anterior vaginal wall prolapse. A Medline search from 1966 to 2004 and a hand-search of conference proceedings of the International Continence Society and International Urogynecological Association from 2001 to 2004 were performed. The success rates for the anterior colporrhaphy vary widely between 37 and 100%. Augmentation with absorbable mesh (polyglactin) significantly increases the success rate for anterior vaginal wall prolapse. Abdominal sacrocolpopexy combined with paravaginal repair significantly reduced the risk for further cystocele surgery compared to anterior colporrhaphy and sacrospinous colpopexy. The abdominal and vaginal paravaginal repair have success rates between 76 and 100%, however, no randomized trials have been performed. There is currently no evidence to recommend the routine use of any graft in primary repairs, and possible improved anatomical out-comes have to be tempered againstcomplications including mesh erosions, infections and dyspareunia.

Pelvic floor reconstruction: state-of-the-art and beyond

Reconstructive surgery for pelvic-floor dysfunction is challenging and complex. It requires an extensive familiarity with pelvic anatomy and a wide armamentarium of surgical procedures to offer patients with various structural defects. Not every patient is suited for every procedure and the surgeon must be able to individualize the approach. Each technique has indications and benefits: vaginal repairs are relatively simple and cause less morbidity than abdominal repairs, which are generally more durable. Laparoscopic repairs provide excellent visualization with decreased morbidity, but operative times are longer, there is greater cost, and learning curves are steep. Techniques and principles described for vaginal and abdominal approaches can be applied to laparoscopic and robotic surgery, but comparative outcomes are not available. Robotic assistance with the laparoscopic approach may bring this method to the mainstream by helping surgeons who are not trained formally in laparoscopy to perform advanced skills. Advances in technology and surgical skills will support the application of laparoscopic and robotic approaches, and the development of better synthetic and biologic materials likely will improve vaginal repairs. Future studies will determine the utility of the approach.

The use of graft materials in anterior compartment pelvic reconstruction

Since 1996, the number of reports in the urologic and gynecologic literature using synthetic and allograph prosthetics to enhance the durability of anterior compartment repairs have increased significantly. Central to the use of these prosthetics is long-term follow-up to demonstrate that their use actually confers a benefit to patients and surgeons alike. This review attempts to catalog those reports and the outcomes, with an emphasis on the cadaveric prolapse repair with sling, which is used by the authors for repair of anterior compartment prolapse with overt or occult genuine stress urinary incontinence.