A new operation for genitourinary prolapse

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.

Trans-vaginal anterior vaginal wall prolapse repair using a customized tension-free bell-shaped prolene mesh: A single-center experience with long-term functional analysis

Introduction:

The existing literature shows that mesh reinforcement improves the anatomical success rate of cystocele repair. We report the long-term results of a custom bell-shaped mesh with simultaneous urethral support for the repair of cystocele.

Materials and Methods:

The present study was a single-center, single-surgeon case series of 36 patients. Only patients with Pelvic Organ Prolapse Quantification system (POP-Q) stage 2 and above were included in the study. Patients having rectocele or uterine/vault prolapse were excluded. Body of the mesh was used for reinforcement of the cystocele repair and two limbs were left tension free in the retropubic space. Patients were followed 3 monthly for the first year and yearly thereafter. Recurrence was defined as cystocele ≥stage 2 (Aa or Ba 0) any time after the first follow-up.

Results:

Mean patient age was 58.5 ± 6.2 years. The mean parity was 3.2 ± 1.6. Of 36 patients, 11 (30.5%) of the patients were POPQ stage 2, 15 (41.7%) were stage 3 and 10 (27.7%) were stage 4 cystocele. The mean follow-up period was 53.4 months, with 32 patients reporting for follow-up till date (88.9%). There was no bladder injury, no mesh erosion or infection. No patient required CIC (clean intermittent catheterization) or had stress urinary incontinence post-operatively at 5 years of follow-up.

Conclusion:

The bell-shaped mesh is a simple, effective and safe procedure in the surgical management of cystocele with excellent long-term outcome.

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.

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.

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.

Operative Therapie bei Genitaldeszensus der Frau: Pro und Kontra der Verwendung von Mesh-Materialien

The development of different mesh materials has led to an improvement of the individual surgical correction of genital prolapse. Macroporous monofilamentous synthetic meshes seem to be the optimal material in case of recurrent prolapse or of severe insufficiency of the pelvic floor. The use of biological meshes shows a markedly better tolerance with fewer infections or erosions despite the lack of evidence-based information on their long-term efficacy and safety. The surgical correction of genital prolapse has to carefully consider all risks and benefits in order to improve quality of life. In this respect, mesh materials can be particularly advantageous in the recurrent situation.

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.

Comparison of host response to polypropylene and non-cross-linked porcine small intestine serosal-derived collagen implants in a rat model

OBJECTIVE

To compare the host response, architectural integration and tensile strength of polypropylene and porcine small intestine submucosa-derived implants in a rat model.

DESIGN

Experimental study.

SETTING

Center for Surgical Technologies, Faculty of Medicine, Katholieke Universiteit Leuven, Belgium.

SAMPLE

Forty-eight adult male Wistar rats weighing 220-250 g randomised to receive either implant.

METHODS

Full thickness abdominal wall defects were primarily repaired with polypropylene mesh (Marlex) (MX group) or porcine small intestine submucosa (Surgisis) (SIS group). Animals were sacrificed at 7, 14, 30 and 90 days after implantation.

MAIN OUTCOME MEASURES

The presence of herniation, infection and intra-peritoneal adhesions. Change in thickness and tensile strength of implant. Histopathological and immunohistochemical appearances of inflammatory response and collagen deposition.

RESULTS

Implants from the SIS group showed a short term increase in thickness in the first 14 days. Formation of adhesions was significantly more intense in the MX group at 30 days, and more extensive in the SIS group at 90 days. Tensile strength increased over time in both groups but was significantly lower in the SIS group than the MX group at 30 days. Implants in the MX group showed a more pronounced inflammatory response and more pronounced new vessel formation than the SIS group. Collagen formation was initially more fibrous and better organised in the MX group but became greater in the SIS group at 90 days.

CONCLUSIONS

Biologically derived implant material induced a less pronounced inflammatory response and differences in collagen deposition. At 30 days tensile strength was weaker in the biological implant group but was equivalent by 90 days. These differences may have implications for the in vivo performance of the materials.

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.

Functional and anatomical outcome of anterior and posterior vaginal prolapse repair with prolene mesh

OBJECTIVE

To evaluate the effects of prolene mesh on urinary, bowel and sexual function in prolapse surgery.

DESIGN

Prospective observational study on consecutive women.

SETTING

Two referral uorgynaecological units in Italy.

POPULATION

Women requiring prolapse repair for anterior or posterior vaginal prolapse.

METHODS

All women were assessed for urinary, bowel, prolapse symptoms and dyspareunia pre- and post-operatively. Urodynamics was performed in selected cases. Surgery consisted of an anterior or posterior repair plus a prolene mesh. Follow up was after 1, 6 and 12 months. The ANOVA test was used for statistical analysis.

MAIN OUTCOME MEASURES

Vaginal anatomical restoration, urinary, bowel and sexual function.

RESULTS

We recruited 63 women (mean age 63 years) with a mean follow up of 17 months. Anatomically, the success rate was 94%. Thirty-two women had an anterior repair. Among this group, the sexual activity rate did not alter but dyspareunia increased by 20%. Urge and stress incontinence did not change post-operatively but urgency improved in 10% and 13% had vaginal erosion of the mesh. Thirty-one women had a posterior repair. Among this group, sexual activity decreased by 12% and dyspareunia increased in 63%. Constipation improved in 15% and anal incontinence in 4%, and 6.5% of women had vaginal erosion of the mesh and one required mesh removal for pelvic abscess.

CONCLUSIONS

Although this study shows good anatomical results with the use of prolene mesh for prolapse repair, there was a high rate of morbidity. We believe that the use of prolene mesh should be abandoned.

Factors that affect recurrence after anterior colporrhaphy procedure reinforced with four-corner anchored polypropylene mesh

The purpose of this study was to evaluate the effectiveness of the anterior colporrhaphy procedure reinforced with four-corner anchored polypropylene mesh in patients with severe (stage III or IV) anterior vaginal prolapse. Thirty-eight consecutive women were enlisted for this prospective study. The procedure consisted of an extensive vaginal dissection to join the vesicovaginal and retropubic space and an anchoring of a polypropylene mesh patch between the two Arcus Tendineus Fasciae Pelvis in a tension-free manner. The mean age of the study group was 63 (33-80) years. The success rate was 87% (33/38) at a mean follow-up interval of 21 (12-29) months. A total of eight (100%) patients were also cured of concomitant stress incontinence (five overt and three occult type) with an additional tension-free vaginal tape (TVT) operation. During follow-up, there were five de-novo stress incontinence cases (16.7%) and four vaginal erosions of mesh (10.5%). Four clinical variables--diabetes mellitus, recurrent anterior vaginal prolapse, chronic cough and vaginal erosions of mesh--were found to have a significant correlation with an unsatisfactory surgical result with large values of hazard ratios found by survival analysis. We concluded that the anterior colporrhaphy procedure reinforced with four-corner anchored polypropylene mesh was effective for most, but failed in some patients who had specific risk factors within short convalescence periods. Concomitant stress incontinence can be successfully treated by a TVT operation in combination with the anterior colporrhaphy procedure reinforced with four-corner anchored polypropylene mesh. However, the anterior colporrhaphy procedure may itself have adverse effects on urethral sphincter function.