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

Meta-analysis of the efficacy of laparoscopic uterosacral ligament suspension in patients with pelvic organ prolapse

OBJECTIVE

This study aimed to evaluate the efficacy of laparoscopic uterosacral ligament suspension (LUSLS) for pelvic organ prolapse (POP) using a meta-analysis method.

METHODS

All articles about LUSLS published in English from Jan. 2010 to Jan. 2020 were retrieved using a computer from search engines, including PubMed, EMbase, Cochrane Library, CNKI, Wanfang, VIP, and Chinese Medical Journals. Meta-analysis was performed by two evaluators using RevMan 5.3 software according to the inclusion criteria.

RESULTS

A total of five studies were finally included, with 361 LUSLS cases and 361 control cases. LUSLS group showed a shorter operation duration (SMD-1.96; 95% CI = -3.90- -0.03; P = 0.05), more POP-quantification system (Q) (I) (SMD1.64; 95% CI = 1.05-2.56; P = 0.03), than the control group, with significant differences. There was no difference in the complication incidence, hospital stay, POP-Q>=II between the 2 groups (P > 0.05).

CONCLUSION

LUSLS was a safe and effective treatment for POP. Patients had higher postoperative satisfaction, shorter operation duration and satisfactory outcome. More high-quality randomized controlled trials are required in the future to make the results of the meta-analysis more accurate.

[Vaginal mesh exposure after prolapse surgery. A descriptive study of 43 cases: Epidemiology and therapeutic management]

OBJECTIVE

To describe the prevalence and time of occurrence of vaginal mesh exposure based on the initial surgical approach of prolaps. To describe their therapeutic management.

MATERIAL

Descriptive retrospective study of 43 women followed for vaginal mesh exposure diagnosed during a follow-up visit or motivated by symptoms. The initial surgery was performed abdominally (promontofixation) or vaginally. The therapeutic management was carried out by medical and/or surgical (prosthetic resection partial or complete).

RESULTS

The prevalence of vaginal exposure was 7.3% in case of vaginal initial surgery and 2.8% in case of promontofixation initial (P=0.02). Mesh exposure have appeared earlier in case of vaginal initial surgery compared to promontofixation (14.9 months vs. 45.2 months). After vaginal initial surgery, vaginal mesh exposure appeared to third within 6 months postoperatively (9/29). The success rate of medical treatment was 21.4%. In total, 31% of women initially made vaginally and 64.9% of women initially made abdominally required at least two surgeries to get a cure.

CONCLUSION

Vaginal mesh exposure may be away from the initial surgery, especially when the first initial surgery was abdominal. The medical treatment of vaginal mesh exposure led to poor results. The overall rate of healing in our experience was good but at the cost of considerable morbidity as a significant proportion of patients required two or more surgical interventions.

Vaginal prolapse repair using the Prolift kit: a registry of 100 successive cases

OBJECTIVES

To evaluate anatomical, functional outcomes and complications inherent to the treatment of pelvic organ prolapse by implantation of polypropylene mesh, using the Prolift kit.

MATERIALS AND METHODS

Single-center observational study of 100 successive patients enrolled in a registry, who underwent Prolift prolapse repair. Data on prior treatments, associated procedures and per- and post-operative complications were collected and the patients were seen after 2, 6 and 12 months. Anatomical outcomes were assessed using the International Continence Society Pelvic Organ Prolapse Quantification (ICS POP-Q) system. Function was assessed in terms of urinary and digestive problems, and impact on sex life. Failure was defined as relapse of POP-Q Grade 2 or more.

RESULTS

Of the 100 patients, 32 had an anterior, 14 a posterior, 54 a total Prolift; 53 had concomitant urinary incontinence surgery. At 6 and 12 months respectively, 8% and 12% of the patients were lost to follow-up. Mean operating time was 39.8 min. With respect to peri-operative complications, there was no bladder or rectal damage but three patients experienced bleeding (≥ 300 ml) without needing transfusion. POP-Q Grades before surgery were: Grades III-IV cystocele in 65.7% of the anterior Prolift patients; Grades II-III rectocele in the posterior; and 77.8% of total were Grade III and 11.1% Grade IV. The incidence of recurrence was 3.6% at Month 6 and 10.2% at Month 12. Significant (p<0.05) improvements were seen in median scores for the various POP-Q items. With respect to functional problems, stress urinary incontinence was cured in 92% of the patients but 7.7% reported new-onset urinary incontinence after one year. One case of vaginal exposure after one year was observed and major or symptomatic mesh retraction was observed in 8%. New-onset dyspareunia was reported by 11.1% of the patients.

CONCLUSIONS

These results confirm the feasibility of using the Prolift kit in the repair of prolapse via a vaginal approach and the low per- and post-operative morbidity associated with that technique. Nevertheless, longer-term evaluation is required to confirm the results.

Transvaginal mesh repair of anterior and posterior vaginal wall prolapse: a clinical and ultrasonographic study

OBJECTIVES

To investigate whether ultrasonography coupled with clinical examination can help in understanding the mechanism of recurrence after transvaginal mesh repair of anterior and posterior vaginal wall prolapse.

METHODS

Ninety-one patients who had undergone surgery for anterior and/or posterior vaginal wall prolapse with the Prolift system had a clinical examination and introital/endovaginal two-dimensional ultrasonography a minimum of 1 year later. The retraction of anterior and posterior meshes was estimated relative to the original length of the mesh by transvaginal palpation. Patients with no, moderate (< 50%) or severe (> or = 50%) mesh retraction were compared. Anterior recurrence of prolapse was defined according to the International Continence Society by a Ba value > or = -1 and posterior recurrence by a Bp value > or = -1 (where Ba represents the most distal position of the anterior vaginal wall and Bp the most distal position of the posterior vaginal wall). On ultrasonography, two distances were measured in the midsagittal plane: Distance 1, from the distal margin of the anterior mesh to the bladder neck, and Distance 2, from the distal margin of the posterior mesh to the rectoanal junction.

RESULTS

Seventy-five anterior and 62 posterior meshes were studied at a mean follow-up of 17.9 months. Patients with anterior recurrence presented significantly more often with severe anterior mesh retraction compared with patients without anterior recurrence (5/8 vs. 2/67, P < 0.001) and also had an increased Distance 1 (P < 0.001). Patients with posterior recurrence presented significantly more often with severe posterior mesh retraction compared with patients without posterior recurrence (3/4 vs. 3/58, P < 0.01) and also had an increased Distance 2 (P < 0.01).

CONCLUSIONS

Recurrence of prolapse after transvaginal mesh repair appears to be associated with severe mesh retraction and loss of mesh support on the distal part of the vaginal walls.

Anatomic outcomes of vaginal mesh procedure (Prolift) compared with uterosacral ligament suspension and abdominal sacrocolpopexy for pelvic organ prolapse: a Fellows' Pelvic Research Network study

OBJECTIVE

The objective of the study was to compare apical support anatomic outcomes following vaginal mesh procedure (VMP) (Prolift) to uterosacral ligament suspension (USLS) and abdominal sacrocolpopexy (ASC).

STUDY DESIGN

This multicenter, retrospective chart review compared apical anatomic success (stage 0 or 1 based on point C or D of the Pelvic Organ Prolapse Quantification), level of vaginal apex (point C or D) 3-6 months after prolapse repair at 10 US centers between 2004 and 2007.

RESULTS

VMP, USLS, and ASC were performed for 206, 231, and 305 subjects respectively. There was no difference in apical success after VMP (98.8%) compared with USLS (99.1%) or ASC (99.3%) (both P = 1.00) 3-6 months after surgery. The average elevation of the vaginal apex was lower after VMP (-6.9 cm) than USLS (-8.05 cm) and ASC (-8.5 cm) (both P < .001)

CONCLUSION

Patients undergoing VMP have similar apical success compared with USLS and ASC despite lower vaginal apex 3-6 month after surgery.

[Surprising vaginal polyps]

We present herein a particular case of surprising vaginal polyps, associated with nodular lesions (epidermal cysts). Fibroepithelial polyps are rare and benign but pathological aspect may be similar to malignant lesions. Vaginal polyps usually appear after genito-urinary surgery, during pregnancy, or with hormonal treatment. These lesions are effectively treated by local resection, with rare recurrence.

[Mid-term results of the grade 3-4 genital prolapse cure by vaginal route using a total hammock of porcine skin implant associated with bilateral sacro-spinofixation]

OBJECTIVE

To evaluate the feasibility, morbidity and mid-term results of genital prolapse cure by vaginal route using a total hammock of porcine skin implant (Pelvicol) and bilateral sacro-spinofixation.

PATIENTS AND METHODS

From May 2001 to June 2006, 101 patients with grade 3-4 genital prolapse, using the POPQ classification, were treated by vaginal route. One patient refused the use of porcine skin implant for religious reasons. Anterior fixation of the total hammock was performed by transobturator route and the posterior fixation was done on sacrospinous ligaments associated with a bilateral Richter operation. Intra- and postoperative complications, anatomical results, as well as global satisfaction, have been evaluated.

RESULTS

The technique was always feasible. With a mean follow-up of 29 months, anatomical results were optimal in 73.3% while 16.8% of recurrences were observed. Mean operating time was 112+/-39 min (range: 40-310). Intraoperative complication rate was 4.9% (three bladder injuries, one rectal injury, one unfundibulo pelvic ligament injury during hysterectomy). Postoperative complication rate was 11.9% (four cases of urinary retention, one urethral plication and five pararectal haematomas including two cases requiring a second surgery complicated by an urethrovaginal fistula in one case and one urinary infection). With a mean follow-up of 29+/-12 months (74-12), optimal anatomical results and recurrence rate were 73.3 and 16.8%, respectively. Global satisfaction rate was 87.7%. This rate decreased to 60% for patients with a 4- to 6-year follow-up.

CONCLUSION

Our results confirmed the feasibility of genital prolapse cure using a total hammock of porcine skin and bilateral sacro-spinofixation with a similar rate of complications to vaginal surgery without implant. However, anatomical results at mid-term raise the issue on the permanence of biological meshes.

Complications from vaginally placed mesh in pelvic reconstructive surgery

INTRODUCTION AND HYPOTHESIS

We describe complications associated with the use of transvaginal mesh for treatment of pelvic organ prolapse.

METHODS

We retrospectively identified patients referred to our institution from January 2003 through September 2007 who had complications after vaginal placement of mesh.

RESULTS

We identified 21 patients with a mean (SD) age of 61 (11) years. Types of mesh used included mesh kits (n = 9, 43%), nontrocar mesh augmentation (n = 5, 24%), IVS Tunneller (n = 4, 19%), and unspecified (n = 3, 14%). Eleven patients (52%) underwent more than one procedure before referral. Only three patients were referred by the original treating surgeon. Complications included mesh erosions in 12 women, dyspareunia in ten, and recurrent prolapse in nine. Sixteen patients (76%) were managed surgically. Follow-up survey among sexually active patients showed 50% with persistent dyspareunia.

CONCLUSIONS

Use of vaginal mesh for pelvic reconstruction can produce complications. Multiple interventions may be necessary, and bothersome symptoms may persist.

Does the Prolift system cause dyspareunia?

OBJECTIVE

The purpose of this study was to determine the de novo dyspareunia rate with the Prolift procedure.

STUDY DESIGN

All Prolift cases performed between August 2005 and August 2007 were evaluated. The rate of de novo dyspareunia was calculated by chart review. Type and degree of dyspareunia were assessed by self-administered questionnaire. Demographics, use of hormone therapy, failure rate, and willingness to have the surgery again were summarized using descriptive statistics.

RESULTS

The rate of de novo dyspareunia was 16.7%. Over 75% of patients with de novo dyspareunia described the pain as mild or moderate. Most described dyspareunia with insertion. Eighty-three percent of respondents with de novo dyspareunia would have the procedure done again.

CONCLUSION

The Prolift is associated with a 17% de novo dyspareunia rate. Despite this, most would have the surgery done again.

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.

Mesh-related infections after pelvic organ prolapse repair surgery

The use of vaginal meshes has been an advance in the surgical management of women with pelvic organ prolapse. We reviewed the literature to synthesize the evidence regarding the infectious complications related to this new type of foreign body. We searched PubMed, current contents, and references of initially identified relevant articles and extracted data regarding the incidence, clinical manifestation, and management of vaginal mesh-related infections. The incidence of mesh-related infections and erosion ranged from 0 to 8%, and 0 to 33%, respectively, in the published studies. Various factors influence the development of vaginal mesh-related infectious complications such as the kind of biomedical material (e.g. filament structure, pore size) of the mesh, the type of procedure, the preventive measures taken, and the age and underlying comorbidity of the treated women. Non-specific pelvic pain, persistent vaginal discharge or bleeding, dyspareunia, and urinary or faecal incontinence are the most common manifestation of vaginal mesh-related infection. Clinical examination may reveal induration of the vaginal incision, vaginal granulation tissue, draining sinus tracts, and prosthesis erosion or rejection. Various pathogens have been implicated, including Gram-positive and Gram-negative aerobic and anaerobic bacteria. The management of mesh-related infections in women who underwent pelvic organ reconstruction is combined surgical and medical treatment. Although the use of vaginal meshes has become a new effective method of pelvic organ prolapse surgery clinicians should be aware of the various post-operative complications, including mesh-related infections.

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

OBJECTIVE

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

MATERIALS AND METHOD

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

[Bladder erosion few years after TVT procedure]

The surgical treatment of the stress urinary incontinence mainly use tension free vaginal tape done through the Retzius space: a case of bladder erosion occurring 5 years after a TVT (Gynecare-Ethicon, USA) procedure is reported. First clinical signs occur 2 years after the operation and the removal of the tape (included in the muscle of the bladder) by vaginal and sus-pubic route was necessary 5 years later because the quality of life was dramatically altered. This complication could be related to the patient (past hysterectomy, history of fibrosis surrounding a mammary implant, Gougerot-Sjögren disease) or to the surgeon with a technical defect during the TVT procedure. The late complications of TVT procedure should be recorded in a national register.