The role of synthetic and biologic materials in the treatment of pelvic organ prolapse

Early safety and efficiency outcomes of a novel interdisciplinary laparoscopic resection rectopexy combined with sacrocolpopexy for women with obstructive defecation syndrome and pelvic organ prolapse: a single center study

BACKGROUND

Obstructive defecation syndrome (ODS) defines a disturbed defecation process frequently associated with pelvic organ prolapse (POP) in women that substantially compromises quality of life. Conservative management offers limited relief and a surgical intervention may be required. This is characterized by individual approaches. AIM OF THE STUDY: This retrospective single center study evaluated the surgical and clinical short-term outcome of a novel interdisciplinary laparoscopic resection rectopexy (L-RRP) with mesh- sacrocolpopexy (L-SCP) for women suffering from ODS and POP.

METHODS

The study participants underwent surgery in an interdisciplinary laparoscopic approach. Safety was the primary endpoint, assessed via postoperative morbidity classified by Clavien-Dindo scale. Secondary outcomes included evaluation of bowel function, fecal and urinary incontinence and pelvic organ prolapse status at 12 months follow-up. Additionally, a biological mesh (BM) was offered to women, who asked for an alternative to synthetic mesh material (SM).

RESULTS

Of the 44 consecutive patients requiring surgery for ODS and POP, 36 patients underwent the interdisciplinary surgical approach; 28 patients with SM and 8 patients with BM. In total 5 complications occurred, four of them were classified as minor. One minor complication was observed in the BM group. One anastomotic leakage occurred in the SM group. The two ODS scores, the bowel dysfunction score, and the incontinence score improved significantly (p = 0.006, p = 0.003, p < 0.001, and p = 0.0035, respectively). Pelvic floor anatomy was fully restored (POP-Q 0) for 29 (80%) patients after surgery. 17 patients (47%) suffered from urinary incontinence before surgery, which was restored in 13 patients (76.5%).

CONCLUSIONS

The interdisciplinary approach with L-RRP and L-SCP and the use of a BM in a small subgroup were technically feasible, safe, and effective in this single center setting. The study's retrospective design, the small sample size and the lack of comparators limit the generalizability of the findings requiring future randomized trials.

TRIAL REGISTRATION

Retrospectively registered at clinicaltrials.gov, trial number NCT05910021, date of registration 06/10/2023.

Comprehensive anatomy of the superior hypogastric plexus and its relationship with pelvic surgery landmarks: defining the safe zone around the promontory

BACKGROUND

Pelvic surgery carries an inherent risk of autonomic nerve injury leading to genitourinary and bowel dysfunction due to the close proximity of the superior hypogastric plexus (SHP). The aim of this study was to define the detailed anatomy of SHP and identify its relationship with the vascular landmarks and ureters for pelvic autonomic nerve-preserving surgery.

METHODS

A cadaveric study on the detailed anatomy of the SHP was conducted in our surgical anatomy research unit. Between 02/2019 and 10/2019, macroscopic anatomical dissections were performed on 45 fresh adult cadavers (39 male, 6 female). Distances between the SHP, major vascular structures, and other anatomical landmarks were measured.

RESULTS

Three types of SHP morphology were observed: mesh (64.8%), single nerve (24.4%), and fiber (10.8%). SHP bifurcation was located inferior to the aortic bifurcation in all cases; however, it was observed cranial to the promontory in 80% of the cases, whereas 18% were caudally and 2% were over the promontory. The closest vessels to the left and right of the SHP bifurcation were the left common iliac vein (LCIV) (86.2%, the mean distance was 8.49 ± 7.97 mm) and the right internal iliac artery (RIIA) (48.2%, mean distance was 13.4 ± 9.79 mm), respectively. At SHP bifurcation level, the lateral edge of the SHP was detected on the LCIV in 22 cases and on the RIIA in 10 cases for the left and right side of the plexus, respectively. The distance between the SHP bifurcation and the ureter was 27.9 mm on the right and 24.2 mm on the left. The width of the left (LHN) and right hypogastric nerves (RHN) were 4.35 mm and 4.62 mm at 2 cm below the SHP bifurcation, respectively. LHN was on the vascular structures in 13 cases, whereas RHN in only 1 case, 2 cm below the SHP bifurcation.

CONCLUSIONS

Understanding the location of the SHP, including its relationship with important anatomical landmarks, might prevent iatrogenic injury and reduce postoperative morbidity in the pelvic surgery setting.

Meta-analysis of laparoscopic mesh rectopexy versus posterior sutured rectopexy for management of complete rectal prolapse

OBJECTIVES

To evaluate comparative outcomes of laparoscopic mesh rectopexy (LMR) and laparoscopic posterior sutured rectopexy (LPSR) in patients with rectal prolapse.

METHODS

We conducted a systematic search of electronic databases and bibliographic reference lists with application of a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators, and limits. Recurrence, Cleveland Clinic Incontinence Score (CCIS), Cleveland Clinic Constipation Score (CCCS), surgical site infections, procedure time, and length of hospital stay were the evaluated outcome measures.

RESULTS

We identified 5 comparative studies reporting a total of 307 patients evaluating outcomes of LMR (n=160) or LPSR (n=147) in patients with rectal prolapse. LMR was associated with significantly lower recurrence rate (OR: 0.28, P=0.009) but longer procedure time (MD: 23.93, P<0.0001) compared to LPSR. However, there was no significant difference in CCIS (MD: -1.02, P=0.50), CCCS (MD: -1.54, P=0.47), surgical site infection (OR: 1.48, P=0.71), and length of hospital stay (MD: -1.54, P=0.47) between two groups. No mesh erosion was reported in any of the included studies at maximum follow-up point. Sub-group analyses with respect to ventral mesh rectopexy, posterior mesh rectopexy, randomised studies, and adult patients were consistent with the main analysis.

CONCLUSIONS

LMR seems to be associated with lower recurrence but longer procedure time compared to LPSR. Although no mesh-related complications have been reported by the included studies, no definitive conclusions can be made considering that the included studies were inadequately powered for such outcome. Future high-quality randomised studies with adequate sample size are required.

Laparoscopic Rectopexy with Urinary Bladder Xenograft Reinforcement

BACKGROUND AND OBJECTIVES

Rectal prolapse is often repaired laparoscopically, frequently with the use of reinforcement material. Both synthetic and biologically derived materials reduce recurrence rate compared to primary suture repair. Synthetic mesh introduces potential complications such as mesh erosion, fibrosis, and infection. Urinary bladder matrix (UBM) represents a biologically derived material for reinforcement of rectal prolapse repair with the potential to improve durability without risks of synthetic materials. The objective of the study is to evaluate the effectiveness, durability, and functional result of laparoscopic rectopexy using urinary bladder matrix xenograft reinforcement at three years follow up.

METHODS

The 20 cases presented describe rectal prolapse repair by means of laparoscopic rectopexy with presacral UBM reinforcement. Patients were followed up for an average of 3 years and assessed with interviews, physical examination, manometry, and the fecal incontinence severity index (FISI).

RESULTS

Each repair was completed laparoscopically. UBM exhibited favorable handling characteristics when sutured to the sacrum and the lateral rectal walls. One patient underwent laparoscopic drainage of a postoperative abscess; no other complications occurred. In 3 years of follow-up, there have been no full-thickness recurrences, erosions, reoperations, or long-term complications. Two patients exhibited a small degree of mucosal prolapse on follow-up physical examination that did not require surgery. Three-year FISI scores averaged 8 (range, 0-33 of a possible 61), indicating low fecal incontinence symptomatology. Follow-up anorectal manometry was performed in 9 patients, showing mixed results.

CONCLUSION

Surgeons may safely use laparoscopic rectopexy with UBM reinforcement for repair of rectal prolapses. In this series, repairs with UBM grafts have been durable at 3-year follow-up and may be an alternative to synthetic mesh reinforcement of rectal prolapse repairs. Future studies may compare the advantages and cost-effectiveness of reinforcement materials for rectal prolapse repair.

Synthetic Versus Biological Mesh-Related Erosion After Laparoscopic Ventral Mesh Rectopexy: A Systematic Review

Purpose

This review reports the incidence of mesh-related erosion after ventral mesh rectopexy to determine whether any difference exists in the erosion rate between synthetic and biological mesh.

Methods

A systematic search of the MEDLINE and the Ovid databases was conducted to identify suitable articles published between 2004 and 2015. The search strategy capture terms were laparoscopic ventral mesh rectopexy, laparoscopic anterior rectopexy, robotic ventral rectopexy, and robotic anterior rectopexy.

Results

Eight studies (3,956 patients) were included in this review. Of those patients, 3,517 patients underwent laparoscopic ventral rectopexy (LVR) using synthetic mesh and 439 using biological mesh. Sixty-six erosions were observed with synthetic mesh (26 rectal, 32 vaginal, 8 recto-vaginal fistulae) and one (perineal erosion) with biological mesh. The synthetic and the biological mesh-related erosion rates were 1.87% and 0.22%, respectively. The time between rectopexy and diagnosis of mesh erosion ranged from 1.7 to 124 months. No mesh-related mortalities were reported.

Conclusion

The incidence of mesh-related erosion after LVR is low and is more common after the placement of synthetic mesh. The use of biological mesh for LVR seems to be a safer option; however, large, multicenter, randomized, control trials with long follow-ups are required if a definitive answer is to be obtained.