PORCINE DERMIS INTERPOSITION GRAFT FOR REPAIR OF HIGH GRADE ANTERIOR COMPARTMENT DEFECTS WITH OR WITHOUT CONCOMITANT PELVIC ORGAN PROLAPSE PROCEDURES

Use of a Non-Crosslinked Porcine Dermal Matrix in Repair of the Achilles and Other Tendons of the Foot

BACKGROUND

Ankle tendon augmentation with biological matrixes has been shown to be beneficial, especially for Achilles tendon rupture as it adds to the integrity of the repair. Biologic matrix augmentation has been used increasingly in chronic and complex injuries where reinforcement is required. The objective of this study was to present outcomes of a series of patients who underwent tendon repair augmented with a new biologic matrix.

METHODS

Sixteen patients underwent ankle tendon repair, augmented with Proformix biologic tissue matrix. Patients were evaluated pre- and postoperatively for function and pain, and were followed for up to 3 years for complications.

RESULTS

This study included 10 females and 6 males, with a mean age of 44.6 years (range, 23-71 years). Patients were evaluated at 2 months postoperatively, and then further followed for a mean 19.0 months (range 7-38 months) to assess complications and reinjuries. Foot and Ankle Disability Index scores significantly increased from preoperatively (38.3) to 2 months postoperatively (85.2) ( P < .001). Furthermore, there were no reports of reruptures or significant complications.

CONCLUSIONS

Weakness or rupture in tendons of the foot, especially the Achilles tendon, can be treated surgically and the repair augmented with Proformix, a new, biological matrix. Our study presented a series of 16 patients whose surgical repairs had been augmented with the new biological matrix, all of whom have achieved excellent results.

LEVELS OF EVIDENCE

Level IV: Case series.

Efficacy of Pelvisoft® Biomesh for cystocele repair: assessment of long-term results

INTRODUCTION AND HYPOTHESIS

To our knowledge a study regarding the efficacy of Pelvisoft® Biomesh for cystocele repair has not previously been reported in the literature. The aim of our study was to assess the long-term efficacy, subjective outcomes and complications in the use of a non-synthetic porcine skin mesh graft (Pelvisoft® Biomesh) associated with transvaginal anterior colporrhaphy in the treatment of cystocele prolapse.

MATERIALS AND METHODS

A retrospective study was performed at a single centre. Thirty-three women aged 35-77 years underwent cystocele repair using Pelvisoft® graft between December 2005 and June 2009. Twenty-nine women who underwent transvaginal cystocele repair with Pelvisoft® Biomesh for over a 2 years period were assessed. Four patients were lost to follow-up. Cystocele repair was performed via the vaginal route using Pelvisoft® Biomesh implant by inserting it in the anterior vaginal wall.

RESULTS

The median follow-up time was 54.0 months. The rate of recurrence was 17.3%. A total of 6.9% of patients presented early mesh exposure treated by conservative treatment. The mean PFDI-20 score was 72.2. Among sexually active women, the mean PISQ 12 was 33.9 but 56.2% had dyspareunia. After surgery, 6 patients had de novo intercourse.

CONCLUSIONS

Our results show that the use of Pelvisoft® biomaterial associated with anterior colporrhaphy for cystocele repair appears to be safe with acceptable failure and complication rates at long term. Nevertheless, an adverse impact on sexual function was reported by the majority of patients.

The outcome of transobturator anterior vaginal wall prolapse repair using porcine dermis graft: intermediate term follow-up

INTRODUCTION AND HYPOTHESIS

We evaluated the anatomical success and complications of Perigee® with porcine dermis Graft in the repair of anterior vaginal wall prolapse (AVWP) MATERIALS AND METHODS: After Institutional Review Board (IRB) approval, the charts of all patients who underwent AVWP repair using the Perigee/InteXen® kit from July 2005 to July 2009 were reviewed. Patients who had less than 6-month follow-up were excluded. Preoperative data including patient age, previous AVWP repairs, hysterectomy status, preoperative dyspareunia and pertinent physical findings were collected and recorded. Postoperative success was defined as anatomical stage 0 or I using the Pelvic Organ Prolapse Quantification (POP-Q) scoring system. Graft related complications were also recorded.

RESULTS

Out of 89 patients, 69 completed at least 6-month follow-up. Median follow-up was 13 (6-48) months. Seventeen patients (25%) had previous AVWP repair and 32 (46%) had previous hysterectomy. Preoperatively, AVWP stage II was found in 9 (13%), stage III in 27 (39%) and stage IV in 33 (48%) patients. Anatomic success was found in 48 (69%) patients, with 23 (33%) having stage 0 and 25 (36%) stage I AVWP. Intraoperative complications included incidental cystotomy in one patient and bladder perforation in one. Postoperative complications included vaginal exposure and dyspareunia in one case, wound dehiscence in one and tenderness over the graft arm with dyspareunia in one.

CONCLUSIONS

The use of porcine dermis in AVWP repair is safe with minimal graft related complications; however, anatomical success is lower than that reported with the use of synthetic grafts.

Porcine dermis compared with polypropylene mesh for laparoscopic sacrocolpopexy: a randomized controlled trial

OBJECTIVE

To compare the surgical outcomes 12 months after laparoscopic sacrocolpopexy performed with porcine dermis and the current gold standard of polypropylene mesh.

METHODS

Patients scheduled for laparoscopic sacrocolpopexy were eligible for this randomized controlled trial. Both our clinical research nurse and the patients were blinded as to which material was used. Our primary end point was objective anatomic cure defined as no pelvic organ prolapse quantification (POP-Q) points Stage 2 or greater at any postoperative interval. Our sample size calculation called for 57 patients in each group to achieve 90% power to detect a 23% difference in objective anatomic cure at 12 months (α=0.05). Our secondary end point was clinical cure. Any patient with a POP-Q point greater than zero, or Point C less than or equal to -5, or any complaints of prolapse symptoms whatsoever on Pelvic Floor Distress Inventory-20 or Pelvic Floor Impact Questionnaire, Short Form 7, or reoperation for prolapse were considered "clinical failures"; the rest were "clinical cures." Statistical comparisons were performed using the χ or independent samples t test as appropriate.

RESULTS

As expected, there were no preoperative differences between the porcine (n=57) and mesh (n=58) groups. The 12-month objective anatomic cure rates for the porcine and mesh groups were 80.7% and 86.2%, respectively (P=.24), and the "clinical cure" rates for the porcine and mesh groups were 84.2% and 89.7%, respectively (P=.96). Pelvic Floor Distress Inventory-20 and Pelvic Floor Impact Questionnaire, Short Form 7 score improvements were significant for both groups with no differences found between groups. There were no major operative complications.

CONCLUSIONS

There were similar outcomes in subjective or objective results 12 months after laparoscopic sacrocolpopexy performed with either porcine dermis or polypropylene mesh.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT00564083.

LEVEL OF EVIDENCE

I.

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

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

Complications of grafts used in female pelvic floor reconstruction: Mesh erosion and extrusion

Introduction:

Various grafts have been used in the treatment of urinary incontinence and pelvic prolapse. Autologous materials such as muscle and fascia were first utilized to provide additional anatomic support to the periurethral and pelvic tissues; however, attempts to minimize the invasiveness of the procedures have led to the use of synthetic materials. Complications such as infection and erosion or extrusion associated with these materials may be troublesome to manage. We review the literature and describe a brief overview of grafts used in pelvic floor reconstruction and focus on the management complications specifically related to synthetic materials.

Materials and Methods:

We performed a comprehensive review of the literature on grafts used in pelvic floor surgery using MEDLINE and resources cited in those peer-reviewed manuscripts. The results are presented.

Results:

Biologic materials provide adequate cure rates but have associated downfalls including potential complications from harvesting, variable tissue quality and cost. The use of synthetic materials as an alternative graft in pelvic floor repairs has become a popular option. Of all synthetic materials, the type I macroporous polypropylene meshes have demonstrated superiority in terms of efficacy and fewer complication rates due to their structure and composition. Erosion and extrusion of mesh are common and troublesome complications that may be managed conservatively with observation with or without local hormone therapy, with transvaginal debridement or with surgical exploration and total mesh excision, dependent upon the location of the mesh and the mesh type utilized.

Conclusions:

The ideal graft would provide structural integrity and durability with minimal adverse reaction by the host tissue. Biologic materials in general tend to have fewer associated complications, however, the risks of harvesting, variable integrity of allografts, availability and high cost has led to the development and use of synthetic grafts. Synthetic grafts have a tendency to cause higher rates of erosion and extrusion; however, these complications can be managed successfully.

Biological Mesh in Hernia Repair, Abdominal Wall Defects, and Reconstruction and Treatment of Pelvic Organ Prolapse: A Review of the Clinical Evidence

The use of biological meshes seems to be an innovation that influences all surgical fields. The existing evidence indicates that biological meshes cannot only be applied on the area of hernia repair, but also on cases of abdominal reconstruction and pelvic organ prolapse treatment, especially in the presence of contaminated or potentially contaminated surgical fields. Low risks of graft rejection, complications, and infection seem to be the main advantages of biological meshes in comparison with the synthetic nonabsorbable ones. Nevertheless, the elevated costs suggest that biological mesh implantation should be evaluated in correlation to the needs of each clinical case.

Use of a non-cross-linked porcine dermal scaffold in abdominal wall reconstruction

BACKGROUND

Reconstruction of complex abdominal wall defects is challenging. The use of prosthetic mesh can be associated with surgical site infection, fistula formation, and adhesions. This study presents our experience using a non-cross-linked porcine dermal scaffold (NCPDS) in abdominal wall reconstruction.

METHODS

Patients undergoing abdominal wall reconstruction with NCPDS between May 2006 and January 2008 underwent a retrospective chart review. Demographics, indications for NCPDS placement, surgical technique, complications, and follow-up data were evaluated.

RESULTS

Sixteen patients were identified in whom NCPDS was implanted into complex abdominal wall defects. These included 13 planned and 3 emergency surgeries. Indications for surgery included delayed reconstruction of giant ventral hernia secondary to decompressive laparotomy and open management of abdominal trauma, recurrence of large incisional hernia, temporary coverage of open abdomen secondary to intra-abdominal catastrophes, and open abdominal closure owing to compartment syndrome secondary to necrotizing fasciitis. In all, NCPDS was positioned in a subfascial underlay technique. Forty-four percent required a combination of components separation and NCPDS insertion. At a mean follow-up period of 16.5 months, the majority had desirable outcomes. Complications included seroma (21%), superficial wound dehiscence (7%), recurrence (7%), and infection (7%). Two patients died from multiorgan failure unrelated to NCPDS placement. The material only had to be removed in 1 patient because of wound infection and superficial wound dehiscence.

CONCLUSIONS

NCPDS seems to be a safe and effective alternative to prosthetic mesh in the reconstruction of complicated abdominal wall defects.

Posterior repair with perforated porcine dermal graft

OBJECTIVE

To compare postoperative vaginal incision separation and healing in patients undergoing posterior repair with perforated porcine dermal grafts with those that received grafts without perforations. Secondarily, the tensile properties of the perforated and non-perforated grafts were measured and compared.

MATERIALS AND METHODS

This was a non-randomized retrospective cohort analysis of women with stage II or greater rectoceles who underwent posterior repair with perforated and non-perforated porcine dermal grafts (Pelvicol(TM) CR Bard Covington, GA USA). The incidence of postoperative vaginal incision separation (dehiscence) was compared. A secondary analysis to assess graft tensile strength, suture pull out strength, and flexibility after perforation was performed using standard test method TM 0133 and ASTM bending and resistance protocols.

RESULTS

Seventeen percent of patients (21/127) who received grafts without perforations developed vaginal incision dehiscence compared to 7% (5/71) of patients who received perforated grafts (p = 0.078). Four patients with vaginal incision dehiscence with non-perforated grafts required surgical revision to facilitate healing. Neither tensile strength or suture pull out strength were significantly different between perforated and non-perforated grafts (p = 0.81, p = 0.29, respectively). There was no difference in the flexibility of the two grafts (p = 0.20).

CONCLUSION

Perforated porcine dermal grafts retain their tensile properties and are associated with fewer vaginal incision dehiscences.

Isolation of fibroblasts for coating of meshes for reconstructive surgery: differences between mesh types

Aims: An extensive colonization of surgical meshes with autologous fibroblasts may reduce complications. Therefore, we aimed to establish a technique that allows isolation and propagation of fibroblasts from vaginal biopsies. Using these cells we tested the applicability of several clinically applied meshes for fibroblast coating. Materials & methods: Fibroblasts were isolated from vaginal tissue after digestion with collagenase. Characterization was performed by immunostaining for cytokeratin 5, 6 and 14, smooth muscle actin and vimentin. A semiquantitative technique was applied to determine the degree of mesh coating 5 h and 5 weeks after seeding of fibroblasts. Seven meshes of different mesh types have been tested. Results: Cells with a fibroblast-like morphology have been isolated from vaginal tissue and could be propagated for at least 12 passages, resulting in a total number of 1.2 × 107 cells. Immunostaining showed that cells were positive for the mesenchymal cell marker vimentin and negative for smooth muscle actin, as well as the epithelial cell markers cytokeratin 5, 6 and 14, supporting their classification as fibroblasts. Clear differences in fibroblast colonization between the seven tested mesh types have been observed. Polypropylene mesh Obtape® showed an acceptable covering with fibroblasts. The best coating was obtained for xenograft-based meshes, but under cell-culture conditions the mesh showed signs of decomposition. Conclusion: We have established a technique that allows isolation and propagation of vaginal fibroblasts. The result of vaginal fibroblast colonization of allograft-based meshes strongly depends on the mesh type, whereby the best coating could be achieved for a polypropylene mesh.

[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.

Vaginal paravaginal repair with an AlloDerm graft: Long-term outcomes

OBJECTIVE

The aim of this study was to describe the long-term objective and subjective outcomes after vaginal paravaginal repair with AlloDerm graft (LifeCell, Branchburg, NJ).

STUDY DESIGN

Thirty-three women with either recurrent stage II or primary or recurrent stage III-IV anterior vaginal wall prolapse underwent a vaginal paravaginal repair with AlloDerm graft between November 1998 and April 2002. Postoperative follow-up was obtained on an annual basis. Objective failure was defined as a stage II or greater anterior wall defect. Descriptive statistics were performed.

RESULTS

Long-term follow-up was obtained on 24/33 subjects (72.7%). The mean length of follow-up for the 24 women was 52.0 months (range, 18-86 months). Fourteen of the 24 subjects (58.3%) had recurrent stage II prolapse in the anterior compartment, of which only 4 of 14 (28.6%) were symptomatic.

CONCLUSIONS

Long-term evaluation of vaginal paravaginal repairs with AlloDerm graft reveals good subjective success, despite a moderate rate of objective failure within the first 24 months.

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.

Severe cystocele: Optimizing results

Despite multiple variations in cystocele repair techniques, success rates have been historically low. In this review we summarize strategies to optimize long-term results of vaginally approached cystocele repair for the high-grade defect. Our proposed strategies include addressing prolapse of the vaginal apex (the uterus or the vaginal cuff), using the obturator fascia as an anchor for lateral cystocele defect repair, augmenting the repair with loosely woven polypropylene mesh, and placing a midurethral sling.

[Medium-term results of grade 3 and 4 cystocele repair by porcine xenograft matrix (pelvicol)]

OBJECTIVE

To evaluate the medium-term results of grade 3 and 4 (Baden-Walker classification) cystocele repair by transvaginal porcine xenograft matrix (Pelvicol).

MATERIALS

Between February 2002 and October 2005, fifty patients with grade 3 or 4 cystocele were treated by Pelvicol matrix. The preoperative grade of prolapse and symptoms (urinary and pelvic heaviness) were recorded and a sexuality questionnaire was completed retrospectively (BISF-W questionnaire). All patients were reviewed in the outpatients department at 1 month and at the date of last follow-up. The success of the surgical procedure was defined by postoperative grades 0 and 1. Preoperative and postoperative symptoms and sexuality were compared. The operative morbidity was recorded. The success of the surgical procedure was compared in patients operated for the first time and in redo patients.

RESULTS

The mean age was 69.4 years; 29 patients had a grade 3 cystocele (58%), and 21 had a grade 4 cystocele (42%). Preoperative symptoms consisted of dysuria (32%) and symptoms of overactive bladder (22%), accompanied by symptomatic (36%) or asymptomatic (20%) stress urinary incontinence. Pelvic heaviness was present in 100% of cases. An associated procedure was necessary in 70% of cases (29 suburethral tapes, 6 rectocele repairs, 3 vaginal hysterectomies). Mean follow-up was 27.2 months (95%CI [23.3-31.1]). No intraoperative or postoperative complications were observed. During follow-up, no cases of rejection of material, vaginal erosion or delayed healing were observed. The surgical success rate was 94% (37 grade 0 and 10 grade 1). Dysuria and pelvic heaviness were significantly improved. None of the 10 women who were sexually active preoperatively reported postoperative discomfort. Among the 50 operated patients, 35 (70%) were treated by Pelvicol as first-line procedure and 15 were redo procedures (30%); no significant difference in surgical success rate was observed between these two groups (94.3% versus 93.4%).

CONCLUSION

The use of a porcine xenograft matrix (Pelvicol) appears to be a safe and effective technique in the medium term for first-line treatment of grade 3 and 4 cystocele.

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.

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.

Incidence and management of vaginal extrusion of acellular porcine dermis after incontinence and prolapse surgery

We report our experience with vaginal extrusion of acellular porcine dermis in women undergoing pelvic reconstructive surgery. Over 5 years, 270 patients received a Pelvicol pubovaginal sling (PVS) or prolapse repair using interposition graft. Charts were retrospectively evaluated for evidence of graft extrusion, management, and outcomes. Chi-square analysis was conducted to evaluate the association of extrusion with perioperative variables. Nineteen women (7%) had partial or complete vaginal graft extrusion. After a PVS, 11 of 13 women healed by re-epithelialization and remained continent, while 2 required operative debridement. Four of six patients receiving interposition grafts healed after small incisional separations. Two women underwent additional surgery to address extensive extrusion, and both prolapses recurred. After statistical analysis, vaginal extrusion was significantly associated with PVS and concomitant urethral diverticulectomy. Small incisional separations frequently heal and cause no symptom recurrence. Larger areas of extrusion may require debridement and may contribute to recurrence of symptoms.

Pelvic floor reconstructive surgery: which aspects remain controversial?

PURPOSE OF REVIEW

The article focuses on recently published original and review papers on current controversial aspects of pelvic reconstructive surgery.

RECENT FINDINGS

A detailed Medline search was performed on records published in the previous 12 months. Controversial areas concerning which important work has been recently published include (a) prophylactic treatment of stress urinary incontinence, (b) the use of prosthetic materials (particularly for anterior segment reconstruction), (c) laparoscopic surgery. The considerations of the recent International Consultation on Incontinence are also reported. Other controversial areas in the field of pelvic reconstructive surgery such as the question of uterine preservation during the surgery for uterovaginal prolapse provided no significant new data in the period of this review.

SUMMARY

In this evolving field, there is still poor standardization of what constitutes anatomical and functional cure. The transvaginal approach is the most promising of all techniques, and new techniques are evolved mainly in this area. There continues to be a need for multicenter prospective randomized trials providing level I evidence. Recurrence rates, particularly in the anterior wall, are still unacceptably high. Evidence is urgently needed to decide whether the use of prosthetic materials may provide the answer, if so, which material and which method?

Anterior compartment prolapse repair with a hybrid biosynthetic mesh implant technique

The aim of the present study is to assess the safety and feasibility of a new technique for cystocele repair using a hybrid biosynthetic graft fixed by the transobturator approach. This is a retrospective study of 13 women diagnosed with symptomatic anterior compartment prolapse that were in stages II and IV, using Pelvic Organ Prolapse Quantification score and treated between 2003 and 2006. The surgical procedure was carried out through a vaginal approach, exposing the arcus tendineus and the posterior surface of the obturator foramen from the ischial spine to the inferior pubic ramus bone. The patients were followed-up after 3, 6 and 12 months. The anatomical cure rate was 85% (stage 0), although two patients had a recurrence 8 months after surgery. All patients would repeat the procedure, if necessary. No de novo dyspareunia was observed in these small series. The results suggest that this technique is safe and feasible and is a comprehensive surgical approach for anterior compartment prolapse, without postoperative morbidity.

Xenograft use in reconstructive pelvic surgery: a review of the literature

Xenografts, bovine or porcine acellular collagen bioprostheses derived from dermis, pericardium, or small-intestine submucosa, were introduced to overcome synthetic mesh-related complications. Although there are eight commercially available xenografts, there is a paucity of empiric information to justify their use instead of the use of synthetic grafts. In addition, limited data are available about which graft characteristics are important and whether graft-reinforced repairs reduce recurrences and improve outcomes. To address these knowledge gaps, we conducted a Medline search of published reports on xenografts in animal and human trials. Histologic host response to implanted xenograft material depends primarily on chemical cross-linking and porosity, and it is limited to four responses: resorption, incorporation, encapsulation, and mixed. No clinical data unequivocally demonstrate an improved benefit to graft-reinforced repair.

Porcine Skin Collagen Implants to Prevent Anterior Vaginal Wall Prolapse Recurrence: A Multicenter, Randomized Study

PURPOSE

We evaluated the efficacy of the Pelvicol porcine collagen implant for preventing recurrent anterior vaginal wall prolapse in women undergoing primary surgery for pelvic organ prolapse.

MATERIALS AND METHODS

This was a prospective, randomized, multicenter trial in 206 women with stage II or greater anterior vaginal wall prolapse (point Ba -1 or greater) according to the pelvic organ prolapse quantification system. The patients were randomly assigned to undergo anterior vaginal repair or the same procedure with Pelvicol implant reinforcement. SPSS software was used for data analysis.

RESULTS

A total of 201 women were available for surgical outcome analysis, including 98 and 103 in the implant and no implant groups, respectively. All completed the 1-year followup visit. Most women were satisfied with the postoperative condition with a significant decrease in the visual analog scale score in each group (p <0.001). Anatomical anterior recurrence (point Ba greater than -1) was observed in 7 women (7%) in the implant group and in 20 (19%) in the other groups (OR 3.13, 95% CI 1.26-7.78, p = 0.019). Additionally, there were 11 women (3 and 8, respectively, or 5%) with posterior recurrence and 6 (3 per group or 3%) with unsatisfactory results at the upper vaginal segment. One patient who received a porcine implant had vaginal extrusion of the mesh 1 month after surgery.

CONCLUSIONS

Our data show that the Pelvicol implant can be easily and readily used to augment and reinforce anterior colporrhaphy. The prolapse recurrence rate was considerably lower in the implant group compared with outcomes in patients treated with simple anterior repair.

InteXen tissue processing and laboratory study

The goal of this manuscript is to discuss the utilization of InteXen graft material, which is a natural, biocompatible matrix. There is unfortunately little data concerning this material; so, many of the concepts introduced in this manuscript are theoretical. We will discuss the rationale behind using InteXen as the biologic material of choice.

Vaginal paravaginal repair with porcine dermal reinforcement: correction of advanced anterior vaginal prolapse

OBJECTIVE

The objective of the study was to determine the efficacy of the vaginal paravaginal repair using porcine dermal graft reinforcement for the correction of advanced anterior vaginal prolapse.

STUDY DESIGN

One hundred eleven women underwent reinforced vaginal paravaginal repair between September 2001 and January 2004 and met our inclusion criteria. Postoperatively patients were evaluated at 6 weeks, 6 months, and yearly thereafter. Objective cure was defined as point Ba -1 or less.

RESULTS

Eighty-nine of the 111 (80%) patients were available for follow-up. Mean age of patients was 59.5 +/- 11.6 years (range 26 to 82), mean body mass index was 29 +/- 5.5 (range 20 to 44), and median parity was 3 (range 0 to 15). Mean follow-up was 24 +/- 10.1 months (range 6 to 44) with minimum follow-up required for cure of 12 months. Overall cure rate was 78% (68 of 89). Data were analyzed using the Wilcoxon rank test.

CONCLUSION

The reinforced vaginal paravaginal repair procedure is safe and effective for correction of advanced anterior vaginal prolapse.

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.

Outcomes with porcine graft placement in the anterior vaginal compartment in patients who undergo high vaginal uterosacral suspension and cystocele repair

OBJECTIVE

The purpose of this study was to prospectively assess the cases of patients who had undergone a high uterosacral suspension and anterior repair with anterior compartment placement of porcine dermis graft.

STUDY DESIGN

Thirty-six patients who underwent transvaginal high uterosacral suspension and cystocele repair with graft augmentation from June 2001 to July 2004 were identified from the University of Alabama at Birmingham Genitourinary Disorders database. Analysis included the pre- and postoperative Pelvic Organ Prolapse Quantification examinations and incontinence impact questionnaire-7/urogenital distress inventory-6.

RESULTS

Mean Pelvic Organ Prolapse Quantification Ba improved from +3.3 +/- 2.2 cm to -0.6 +/- 1.7 cm (P < .01). Postoperative Ba was prolapse stage II or greater in 50% of subjects. Mean incontinence impact questionnaire-7 scores improved from 36.2 +/- 31.9 to 15.6 +/- 26.2 (P < .01), as did mean urogenital distress inventory-6 scores from 58.2 +/- 26.8 to 23.8 +/- 22.6 (P < .01).

CONCLUSION

Significant improvements in Pelvic Organ Prolapse Quantification measures, urinary symptoms, and the impact of incontinence were seen after the operation. However, a significant proportion of patients had Pelvic Organ Prolapse Quantification stage II prolapse or greater, which made it unclear whether graft use confers a significant advantage.

[Use of prosthetic materials in reconstructive pelvic floor surgery. An evidence-based analysis]

Many surgical procedures for the repair of pelvic organ prolapse are used nowadays. Reconstructive pelvic surgery continues to evolve while surgeons continue to search the definitive surgical cure and have to choose the most appropriate procedures for their patients. Concerning the vaginal approach procedures, there is an increasing interest in the use of synthetic meshes which are at present widely used for surgical repair of pelvic organ prolapse. Prosthetic repair seems to be more reliable, especially when native tissues are of poor quality. The use of synthetic meshes may also simplify surgical procedures and reduce operative duration and morbidity. Material must be inert, permanent and resistant to infection. Based on authors' and other researchers' published experimental and clinical experience, polypropylene is assumed to be the most appropriate material for the vaginal repair of pelvic organ prolapse. However, since no standardized outcome measure is available, it is difficult to compare the results of surgical procedures. Only in recent studies, the subjective cure rates (patient satisfaction and outcome) have been assessed as well as the objective cure rates determined by the investigators. The subjective cure rate is probably more influenced by the functional outcome and sexual activity than by the anatomical result. Continuous evaluation is necessary to study replacement synthetic materials which should improve the rate of prolapse recurrence and reduce the risk of complications. Randomized controlled trials are required to determine which surgical procedures and type of prosthesis are most suitable. This review evaluates the properties of prosthetic materials, their complications and the most common procedures involved in the use of meshes for pelvic reconstructive surgery.