Complication and Reoperation Rates After Apical Vaginal Prolapse Surgical Repair: A Systematic Review

A bibliometric analysis on laparoscopic pelvic floor surgery from 1996-2022

INTRODUCTION

Pelvic organ prolapse is a common condition in middle-aged and older women. Laparoscopic pelvic floor surgery is frequently researched as a treatment for this issue. However, the effectiveness of this procedure has only been the subject of a few studies.

METHODS

To quantitatively evaluate and display the relevant literature from the Web of Science database, we set the publication period of the literature from 1996 to 2022 and used VOSviewer and CiteSpace for visual analysis.

RESULTS

Laparoscopic pelvic floor surgery research has increased year-on-year, with 1003 publications identified from 63 countries and published in 210 journals. In the global ranking of studies, the United States was the leader (n = 306; 30.5 %), with the most published authors being Campagna, Giuseppe (n = 17) and Scambia, Giovanni (n = 17). The International urogynecology journal included the most significant articles (n = 173; 17.2 %). Keyword analysis suggests that complications, rectal prolapse, native tissue repair, and warranty may have become hotspots in recent years.

CONCLUSIONS

This bibliometric study shows that the depth and breadth of research on pelvic floor laparoscopic surgery have expanded rapidly over the last twenty-five years and that laparoscopic surgery has been recognized by different scholars or countries as an essential modality for the treatment of pelvic floor organ prolapse.

Three-year outcomes of a randomized clinical trial of perioperative vaginal estrogen as adjunct to native tissue vaginal apical prolapse repair

BACKGROUND

As the muscular and connective tissue components of the vagina are estrogen responsive, clinicians may recommend vaginal estrogen to optimize tissues preoperatively and as a possible means to reduce prolapse recurrence, but long-term effects of perioperative intravaginal estrogen on surgical prolapse management are uncertain.

OBJECTIVE

This study aimed to compare the efficacy of perioperative vaginal estrogen vs placebo cream in reducing composite surgical treatment failure 36 months after native tissue transvaginal prolapse repair.

STUDY DESIGN

This was an extended follow-up of a randomized superiority trial conducted at 3 tertiary US sites. Postmenopausal patients with bothersome anterior or apical vaginal prolapse were randomized 1:1 to 1-g conjugated estrogen cream (0.625 mg/g) or placebo, inserted vaginally twice weekly for ≥5 weeks preoperatively and continued twice weekly for 12 months postoperatively. All participants underwent vaginal hysterectomy (if the uterus was present) and standardized uterosacral or sacrospinous ligament suspension at the surgeon's discretion. The primary report's outcome was time to failure by 12 months postoperatively, defined by a composite outcome of objective prolapse of the anterior or posterior walls beyond the hymen or the vaginal apex descending below one-third the total vaginal length, subjective bulge symptoms, and/or retreatment. After 12 months, participants could choose to use-or not use-vaginal estrogen for atrophy symptom bother. The secondary outcomes included Pelvic Organ Prolapse Quantification points, subjective prolapse symptom severity using the Patient Global Impression of Severity and the Patient Global Impression of Improvement, and prolapse-specific subscales of the 20-Item Pelvic Floor Distress Inventory and the Pelvic Floor Impact Questionnaire-Short Form 7. Data were analyzed as intent to treat and "per protocol" (ie, ≥50% of expected cream use per medication diary).

RESULTS

Of 206 postmenopausal patients, 199 were randomized, and 186 underwent surgery. Moreover, 164 postmenopausal patients (88.2%) provided 36-month data. The mean age was 65.0 years (standard deviation, 6.7). The characteristics were similar at baseline between the groups. Composite surgical failure rates were not significantly different between the estrogen group and the placebo group through 36 months, with model-estimated failure rates of 32.6% (95% confidence interval, 21.6%-42.0%) and 26.8% (95% confidence interval, 15.8%-36.3%), respectively (adjusted hazard ratio, 1.55; 95% confidence interval, 0.90-2.66; P=.11). The results were similar for the per-protocol analysis. Objective failures were more common than subjective failures, combined objective and subjective failures, or retreatment. Using the Patient Global Impression of Improvement, 75 of 80 estrogen participants (94%) and 72 of 76 placebo participants (95%) providing 36-month data reported that they were much or very much better 36 months after surgery (P>.99). These data included reports from 51 of 55 "surgical failures." Pelvic Organ Prolapse Quantification measurements, Patient Global Impression of Severity scores, and prolapse subscale scores of the 20-Item Pelvic Floor Distress Inventory and Pelvic Floor Impact Questionnaire-Short Form 7 all significantly improved for both the estrogen and placebo groups from baseline to 36 months postoperatively without differences between the groups. Of the 160 participants providing data on vaginal estrogen usage at 36 months postoperatively, 40 of 82 participants (49%) originally assigned to the estrogen group were using prescribed vaginal estrogen, and 47 of 78 participants (60%) assigned to the placebo group were using vaginal estrogen (P=.15).

CONCLUSION

Adjunctive perioperative vaginal estrogen applied ≥5 weeks preoperatively and 12 months postoperatively did not improve surgical success rates 36 months after uterosacral or sacrospinous ligament suspension prolapse repair. Patient perception of improvement remained very high at 36 months.

Apical Suspension Repair for Vaginal Vault Prolapse: A Randomized Clinical Trial

Importance

The optimal surgical repair of vaginal vault prolapse after hysterectomy remains undetermined.

Objective

To compare the efficacy and safety of 3 surgical approaches for vaginal vault prolapse after hysterectomy.

Design, Setting, and Participants

This was a multisite, 3-arm, superiority and noninferiority randomized clinical trial. Outcomes were assessed biannually up to 60 months, until the last participant reached 36 months of follow-up. Settings included 9 clinical sites in the US National Institute of Child Health and Human Development (NICHD) Pelvic Floor Disorders Network. Between February 2016 and April 2019, women with symptomatic vaginal vault prolapse after hysterectomy who desired surgical correction were randomized. Data were analyzed from November 2022 to January 2023.

Interventions

Mesh-augmented (either abdominally [sacrocolpopexy] or through a vaginal incision [transvaginal mesh]) vs transvaginal native tissue repair.

Main Outcomes and Measures

The primary outcome was time until composite treatment failure (including retreatment for prolapse, prolapse beyond the hymen, or prolapse symptoms) evaluated with survival models. Secondary outcomes included patient-reported symptom-specific results, objective measures, and adverse events.

Results

Of 376 randomized participants (mean [SD] age, 66.1 [8.7] years), 360 (96%) had surgery, and 296 (82%) completed follow-up. Adjusted 36-month failure incidence was 28% (95% CI, 20%-37%) for sacrocolpopexy, 29% (95% CI, 21%-38%) for transvaginal mesh, and 43% (95% CI, 35%-53%) for native tissue repair. Sacrocolpopexy was found to be superior to native tissue repair (adjusted hazard ratio [aHR], 0.57; 99% CI, 0.33-0.98; P = .01). Transvaginal mesh was not statistically superior to native tissue after adjustment for multiple comparisons (aHR, 0.60; 99% CI, 0.34-1.03; P = .02) but was noninferior to sacrocolpopexy (aHR, 1.05; 97% CI, 0-1.65; P = .01). All 3 surgeries resulted in sustained benefits in subjective outcomes. Mesh exposure rates were low (4 of 120 [3%] for sacrocolpopexy and 6 of 115 [5%] for transvaginal mesh) as were the rates of dyspareunia.

Conclusions and Relevance

Among participants undergoing apical repair for vaginal vault prolapse, sacrocolpopexy and transvaginal mesh resulted in similar composite failure rates at study completion; both had lower failure rates than native tissue repair, although only sacrocolpopexy met a statistically significant difference. Low rates of mesh complications and adverse events corroborated the overall safety of each approach.

Trial Registration

ClinicalTrials.gov Identifier: NCT02676973.

Efficacy of Sacrospinous Fixation or Uterosacral Ligament Suspension for Pelvic Organ Prolapse in Stages III and IV: Randomized Clinical Trial

OBJECTIVE

 To evaluate the efficacy and outcomes of the surgical treatment for pelvic organ prolapse (POP) in stages III and IV by sacrospinous ligament fixation (SSLF) or uterosacral ligament suspension (USLS) by comparing anatomical and subjective cure rates and quality-of-life parameters (through the version validated for the Portuguese language of the Prolapse Quality of Life [P-QoL] questionnaire) under two definitions: genital prolapse Ba, Bp, and C < -1 (stage I) and Ba, Bp, and C ≤ 0 (stage II).

MATERIALS AND METHODS

 After we obtained approval from the Ethics Committee (under CAAE 0833/06) and registered the study in ClinicalTrials.gov (NCT01347021), 51 patients were randomized into two groups: the USLS group (N = 26) and the SSLF group (N = 25), with follow-up 6 and 12 months after the procedures.

RESULTS

 There was a significant improvement in the P-QoL score and anatomical measurements of all compartments in both groups after 12 months (p < 0.001). The anatomical cure rates in the USLS and SSLF groups, considering stage 1, were of 34.6% and 40% (anterior) respectively; of 100% both for groups (apical); and of 73.1% and 92% (posterior) respectively. The rates of adverse outcomes were of 42% (N = 11) and 36% (N = 11) for the USLS and SSLF groups respectively (p = 0.654), and those outcomes were excessive bleeding, bladder perforation (intraoperative) or gluteal pain, and urinary infection (postoperative), among others, without differences between the groups.

CONCLUSION

 High cure rates in all compartments were observed according to the anatomical criterion (stage I), without differences in P-QoL scores and complications either with USLS or SSLF for the surgical treatment of accentuated POP.

A systematic review of the surgical management of apical pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

This systematic review (PROSPERO:CRD42022275789) is aimed at comparing qualitatively the success, recurrence, and complication rates of sacrocolpopexy with concomitant hysterectomy, hysteropexy, sacrospinous fixation (SSF) with and without vaginal hysterectomy (VH) and uterosacral fixation (USF) with and without VH.

METHODS

A systematic search was performed using Embase, PubMed, Scopus, and Cochrane databases for studies published from 2011, on women with apical pelvic organ prolapse requiring surgical interventions. Risk of bias was assessed via the National Institutes of Health study quality assessment tool. The primary outcomes are the success and recurrence rate of each technique, for ≥12 months' follow-up. Findings were summarised qualitatively.

RESULTS

A total of 21 studies were included. Overall significant findings for a high success and low recurrence rate are summarised as: minimally invasive sacrocolpopexy (MISC) is superior to abdominal sacrocolpopexy (ASC); sacrospinous hysteropexy (SSHP) is superior to USF + VH, which is superior to uterosacral hysteropexy and mesh hysteropexy (MHP). Significant findings related to complications include: MISC recorded a lower overall complication rate than ASC except in mesh exposure; USF + VH tends to perform better than SSHP and SSF, with SSHP performing better than MHP in faecal incontinence and overactive bladder rates.

CONCLUSION

There is no evidence to conclude that hysterectomy is superior to uterine-sparing approaches. MISC should be considered over ASC given similar efficacy and reduced complications. Superiority of MHP is unproven against native tissue hysteropexy. Further studies under standardised settings are required for direct comparisons between the surgical management methods.

Ex Vivo Uniaxial Tensile Properties of Rat Uterosacral Ligaments

This manuscript presents new experimental methods for testing the ex vivo tensile properties of the uterosacral ligaments (USLs) in rats. The USL specimens ([Formula: see text]) were carefully dissected to preserve their anatomical attachments, and they were loaded along their main in vivo loading direction (MD) using a custom-built uniaxial tensile testing device. During loading, strain maps in both the MD and the perpendicular direction (PD) were collected using the digital image correlation technique. The mean (± S.E.M.) maximum load and displacement at the maximum load were [Formula: see text] N and [Formula: see text] mm, respectively. The USLs were found to be highly heterogeneous structures, with some specimens experiencing strains in the MD that were lower than [Formula: see text] and others reaching strains that were up to [Formula: see text] in the intermediate region. At 0.5 kPa stress, a value reached by all the specimens, the mean strain in the MD was [Formula: see text] while at 5 kPa stress, a value achieved only by 9 out of the 21 specimens, the mean strain increased to [Formula: see text]. Under uniaxial loading, the specimens also elongated in the PD, with strains that were one order of magnitude lower than the strains in the MD; at the 0.5 kPa stress, the mean strain in the PD was recorded to be [Formula: see text] and, at the 5 kPa stress, the strain in the PD was [Formula: see text]. The directions of maximum principal strains remained almost unchanged with the increase in stress, indicating that little microstructural re-organization occurred due to uniaxial loading. This study serves as a springboard for future investigations on the supportive function of the USLs in the rat model by offering guidelines on testing methods that capture their complex mechanical behavior.

Management of female pelvic organ prolapse-Summary of the 2021 HAS guidelines

When a patient presents with symptoms suggestive of pelvic organ prolapse (POP), clinical evaluation should include an assessment of symptoms, their impact on daily life and rule out other pelvic pathologies. The prolapse should be described compartment by compartment, indicating the extent of the externalization for each. The diagnosis of POP is clinical. Additional exams may be requested to explore the symptoms associated or not explained by the observed prolapse. Pelvic floor muscle training and pessaries are non-surgical conservative treatment options recommended as first-line therapy for pelvic organ prolapse. They can be offered in combination and be associated with the management of modifiable risk factors for prolapse. If the conservative therapeutic options do not meet the patient's expectations, surgery should be proposed if the symptoms are disabling, related to pelvic organ prolapse, detected on clinical examination and significant (stage 2 or more of the POP-Q classification). Surgical routes for POP repair can be abdominal with mesh placement, or vaginal with autologous tissue. Laparoscopic sacrocolpopexy is recommended for cases of apical and anterior prolapse. Autologous vaginal surgery (including colpocleisis) is a recommended option for elderly and fragile patients. For cases of isolated rectocele, the posterior vaginal route with autologous tissue should be preferentially performed over the transanal route. The decision to place a mesh must be made in consultation with a multidisciplinary team. After the surgery, the patient should be reassessed by the surgeon, even in the absence of symptoms or complications, and in the long term by a primary care or specialist doctor.

Surgical management of genital prolapse and combined gynecological pathologies in women: A meta-analysis

<b>Introduction:</b> Prolapse can be fixed using a variety of surgical procedures. The goal of the present study was to examine the current literature on various surgical techniques for treating female genital organ prolapse.<br /> <b>Methods:</b> The PubMed and Medline databases were explored for pertinent literature up through August 2022 for this meta-analysis. The terms [surgery] AND [management] AND [genital prolapse OR gynaecological diseases] AND [randomised control studies OR randomised control trials] were used as search criteria. The studies that met the inclusion criteria were considered qualified using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Cochrane handbook of “Systematic reviews of interventions” was used for risk of bias assessment.<br /> <b>Results:</b> The investigations found significant difference in the heterogeneity between the groups with a 76% I² value (p&lt;0.00001). There was little variability among the six trials that examined robotic and laparoscopic therapy of prolapse (I²=0%, p=0.94). In six investigations, the odd ratio revealed no statistically significant difference between groups (1.05; 95% CI, 0.52, 2.12). However, generally there were no appreciable differences between robotic and laparoscopic treatment of female prolapse. There was a low-risk bias among the selected studies.<br /> <b>Conclusion:</b> According to this meta-analysis study, laparoscopic surgery performed better job of managing prolapse than abdominal surgery.

Comparison of 2-year follow-up outcomes of laparoscopic lateral suspension and sacrospinous fixation in apical compartment prolapse: an observational study

PURPOSE

This study aimed to compare the results of patients with laparoscopic lateral suspension (LLS) and sacrospinous fixation (SSF).

METHODS

This prospective observational study included 52 patients who underwent LLS and 53 patients who underwent SSF due to pelvic organ prolapse. The pelvic organ prolapse's anatomical cure and the frequency of recurrence have been recorded. Female Sexual Function Index, Pelvic Organ Prolapse Symptom Score, and complications were evaluated preoperatively and at the postoperative 24th month.

RESULTS

In the LLS group, the subjective treatment rate was 88.4% and the anatomical cure rate for apical prolapse was 96.1%. In the SSF group, the subjective treatment rate was 83.0% and the anatomical cure rate for apical prolapse was 90.5%. There was a significant difference between the groups regarding Clavien-Dindo classification and reoperation (p < 0.05). Female Sexual Function Index, and the Pelvic Organ Prolapse Symptom Score were different between the groups (p < 0.05).

CONCLUSIONS

This study showed that there is no difference between two surgical techniques in apical prolapse cure rates. However, the LLS seem preferable in terms of the Female Sexual Function Index, Pelvic Organ Prolapse Symptom Score, reoperation, and complications. We need larger sample size studies in terms of incidence of complications and reoperation.

Prolapse and mesh reoperations following sacrocolpopexy: comparing supracervical hysterectomy, total hysterectomy, and no hysterectomy

INTRODUCTION AND HYPOTHESIS

Sacrocolpopexy is effective for apical prolapse repair and is often performed with hysterectomy. It is unknown whether supracervical or total hysterectomy at time of sacrocolpopexy influences prolapse recurrence and mesh complications. The primary objective of this study is to compare reoperations for recurrent prolapse after sacrocolpopexy with either supracervical hysterectomy or total hysterectomy, or without concomitant hysterectomy. We also sought to compare these three groups for the incidence of mesh complications and describe cervical interventions following supracervical hysterectomy.

METHODS

A retrospective cohort study of sacrocolpopexy was performed using the MarketScan® Research Database. Women > 18 years who underwent sacrocolpopexy between 2010 to 2014 were identified. Utilizing diagnostic and procedural codes, reoperations for prolapse and mesh complications were identified. Women with < 2 years of follow-up were excluded.

RESULTS

From 2010 to 2014, 3463 women underwent sacrocolpopexy with at least 2 years of follow-up, 910 (26.3%) with supracervical hysterectomy, 1243 (35.9%) with total hysterectomy, and 1310 (37.8%) without hysterectomy. Reoperations for prolapse were similar after supracervical hysterectomy (1.5%), after total hysterectomy (1.1%, p = 0.40), and without hysterectomy (1.5%, p = 0.98). Mesh complications after sacrocolpopexy were similar after supracervical hysterectomy (1.8%), after total hysterectomy (1.5%, p = 0.68), and without hysterectomy (2.8%, p = 0.11). Following supracervical hysterectomy, 0.9% underwent cervical procedures.

CONCLUSIONS

When comparing supracervical and total hysterectomy at time of sacrocolpopexy, there were no significant differences in reoperations for recurrent prolapse, reoperations for mesh complications, or mesh complication diagnoses. This study shows that surgeons can be reassured on performing hysterectomy with sacrocolpopexy.

Racial and socioeconomic disparities in cost and postoperative complications following sacrocolpopexy in a US National Inpatient Database

PURPOSE

We sought to determine the association between socioeconomic factors, procedural costs, and postoperative complications among patients who underwent sacrocolpopexy.

METHODS

The 2016-2017 US National Inpatient Sample from the Healthcare Cost and Utilization Project was used to identify females > 18 years of age with an ICD10 diagnosis code of apical prolapse who received open or laparoscopic/robotic sacrocolpopexy. We analyzed relationships between socioeconomic factors, procedural costs, and postoperative complications in these patients. Multivariate logistic and linear regressions were used to identify variables associated with increased complications and costs, respectively.

RESULTS

We identified 4439 women who underwent sacrocolpopexy, of which 10.7% had complications. 34.6% of whites, 29.1% of Blacks, 29% of Hispanics, and 34% of Others underwent a laparoscopic/robotic procedure. Hispanic patients had the highest median charge associated with surgical admission for sacrocolpopexy at $51,768, followed by Other ($44,522), White ($43,471), and Black ($40,634) patients. Procedure being within an urban teaching hospital (+ $2602), laparoscopic/robotic (+ $6790), or in the West (+ $9729) were associated with a significantly higher median cost of surgical management.

CONCLUSIONS

In women undergoing sacrocolpopexy, the protective factors against postoperative complications included private insurance status, a laparoscopic approach, and concurrent hysterectomy. Procedures held within an urban teaching hospital, conducted laparoscopically/robotically or in the West are associated with significantly higher costs of surgical management. Hispanic patients observe significantly higher procedure charges and costs, possibly resulting from the large number of this ethnic group living in the Western United States.

Complications After Uterosacral Ligament Suspension Versus Sacrospinous Ligament Fixation at Vaginal Hysterectomy: A Retrospective Cohort Study of the National Surgical Quality Improvement Program Database

IMPORTANCE

Apical suspension, including uterosacral ligament suspension (USLS) and sacrospinous ligament fixation (SSLF), is the standard of care at vaginal hysterectomy. Although the equivalence of anatomic and clinical outcomes after USLS and SSLF is established, comparing surgical complications specific to patients undergoing concurrent vaginal hysterectomy further informs decision making regarding operative approach.

OBJECTIVE

This study aims to compare complications in the first 30 days after surgery in patients undergoing USLS and SSLF at vaginal hysterectomy for pelvic organ prolapse.

STUDY DESIGN

This retrospective, population-based cohort study used the American College of Surgeons National Surgical Quality Improvement Program database to identify patients undergoing USLS or SSLF at vaginal hysterectomy for pelvic organ prolapse between 2012 and 2019. The primary outcome was a composite of surgical complications excluding urinary tract infection (UTI). Odds of the primary outcome, readmission, reoperation, and UTI were evaluated by multivariable logistic regression models.

RESULTS

Of 10,210 eligible patients, 7,127 patients underwent USLS and 3,083 patients underwent SSLF. Uterosacral ligament suspension was associated with a 25% lower odds of the composite complication outcome that excluded UTI compared with SSLF (adjusted odds ratio, 0.75; 95% confidence interval, 0.63-0.90). Urinary tract infection was the most common complication and occurred more commonly in patients undergoing USLS (6.5% vs 4.9%; adjusted odds ratio, 1.29; 95% confidence interval, 1.06-1.56). There was no significant difference in Clavien-Dindo class IV complications, readmission, or reoperation between approaches.

CONCLUSION

Uterosacral ligament suspension was associated with a lower odds of complications excluding UTI compared with SSLF. Urinary tract infection was more common among patients having USLS. The odds of serious complications, readmission, and reoperation were low and comparable between groups.

Adverse outcomes after minimally invasive surgery for pelvic organ prolapse in women 65 years and older in the United States

INTRODUCTION AND HYPOTHESIS

To describe complications at the time of surgery, 90-day readmission and 1-year reoperation rates after minimally invasive pelvic organ prolapse (POP) in women > 65 years of age in the US using Medicare 5% Limited Data Set (LDS) Files.

METHODS

Medicare is a federally funded insurance program in the US for individuals 65 and older. Currently, 98% of individuals over the age of 65 in the US are covered by Medicare. We identified women undergoing minimally invasive POP surgery, defined as laparoscopic or vaginal surgery, in the inpatient and outpatient settings from 2011-2017. Patient and surgical characteristics as well as adverse events were abstracted. We used logistic regression for complications at index surgery and Cox proportional hazards regression models for time to readmission and time to reoperations.

RESULTS

A total of 11,779 women met inclusion criteria. The mean age was 72 (SD ± 8) years; the majority were White (91%). Most procedures were vaginal (76%) and did not include hysterectomy (68%). The rate of complications was 12%; vaginal hysterectomy (aOR 2.4, 95% CI 2.2-2.7) was the factor most strongly associated with increased odds of complications. The 90-day readmission rate was 7.3%. The most common reason for readmission was infection (2.0%), three quarters of which were urinary tract infections. Medicaid eligibility (aHR 1.5, 95% CI 1.3-1.8) and concurrent sling procedures (aHR 1.2, 95% CI 1.04-1.4) were associated with a higher risk of 90-day readmission. The 1-year reoperation rate was 4.5%. The most common type of reoperation was a sling procedure (1.8%). Obliterative POP surgery (aHR 0.6, 95% CI 0.4-0.9) was associated with a lower risk of reoperation than other types of surgery.

CONCLUSIONS

US women 65 years and older who are also eligible to receive Medicaid are at higher risk of 90-day readmission following minimally invasive surgery for POP with the most common reason for readmission being UTI.

In-plane and out-of-plane deformations of gilt utero-sacral ligaments

The uterosacral ligaments (USLs) are supportive structures of the uterus and apical vagina. The mechanical function of these ligaments within the pelvic floor is crucial not only in normal physiological conditions but also in reconstructive surgeries for pelvic organ prolapse. Discrepancies in their anatomical and histological description exist in the literature, but such discrepancies are likely due to large variations of these structures. This makes mechanical testing very challenging, requiring the development of advanced methods for characterizing their mechanical properties. This study proposes the use of planar biaxial testing, digital image correlation (DIC), and optical coherence tomography (OCT) to quantify the deformations of the USLs, both in-plane and out-of-plane. Using the gilts as an animal model, the USLs were found to deform significantly less in their main direction (MD) of in vivo loading than in the direction perpendicular to it (PD) at increasing equibiaxial stresses. Under constant equibiaxial loading, the USLs deform over time equally, at comparable rates in both the MD and PD. The thickness of the USLs decreases as the equibiaxial loading increases but, under constant equibiaxial loading, the thickness increases in some specimens and decreases in others. These findings could contribute to the design of new mesh materials that augment the support function of USLs as well as noninvasive diagnostic tools for evaluating the integrity of the USLs.

36-Month Prospective Study of Transvaginal Bovine Graft versus Native Tissue Repair for the Treatment of Pelvic Organ Prolapse

OBJECTIVE(S)

To compare the safety and effectiveness of dermal bovine transvaginal graft, Xenform, to native tissue in the surgical treatment of anterior and/or apical pelvic organ prolapse. This study was designed in conjunction with FDA requirements.

METHODS

This was a prospective, non-randomized, parallel cohort, multi-center trial. The primary objective was to demonstrate non-inferiority between transvaginal graft and native tissue repair at 36 months compared to baseline. Treatment success was based on a composite of objective and subjective measures. The co-primary outcome was the rate of serious device- or procedure-related adverse events. A total of 228 patients at 25 sites were included in the study arm and 485 patients underwent native tissue repair. Propensity score stratification was applied to achieve balance between treatment groups. Study outcomes were compared in per protocol and intent-to-treat analysis.

RESULTS

The primary outcome, treatment success at 36 months, was 83.6% (191/228) for transvaginal graft and 80.5% (390/485) native tissue repair (0.2%, 90%CI [-5.6%, 5.9%]), demonstrating non-inferiority at a preset margin of -12%. The overall rate of severe adverse events was 5.3% (12/228) in transvaginal graft vs 2.7% (13/485) in native tissue repair groups. The study group demonstrated non-inferiority in serious adverse events at the preset margin of 11.6% (2.0%, 90%CI [-0.8%, 4.7%]). There were no reports of graft erosion, and graft exposure rates were low (0.9% [2/228]).

CONCLUSIONS

Transvaginal repair of anterior and/or apical prolapse with a biological graft is non-inferior to traditional native tissue repair in effectiveness and safety at 36 months.

Transvaginal Mesh Compared With Native Tissue Repair for Pelvic Organ Prolapse

OBJECTIVE

To compare the safety and effectiveness of transvaginal mesh repair and native tissue repair, in response to a U.S. Food and Drug Administration (FDA) 522 study order to assess co-primary endpoints of superiority and noninferiority.

METHODS

This was a prospective, nonrandomized, parallel cohort, multi-center trial comparing transvaginal mesh with native tissue repair for the treatment of pelvic organ prolapse. The primary endpoints were composite treatment success at 36 months comprised of anatomical success (defined as pelvic organ prolapse quantification [POP-Q] point Ba≤0 and/or C≤0), subjective success (vaginal bulging per the PFDI-20 [Pelvic Floor Distress Inventory]), and retreatment measures, as well as rates of serious device-related or serious procedure-related adverse events. Secondary endpoints included a composite outcome similar to the primary composite outcome but with anatomical success defined as POP-Q point Ba<0 and/or C<0, quality-of-life measures, mesh exposure and mesh- and procedure-related complications. Propensity score stratification was applied.

RESULTS

Primary endpoint composite success at 36 months was 89.3% (201/225) for transvaginal mesh and 80.2% (389/485) for native tissue repair, demonstrating noninferiority at the preset margin of 12% (propensity score-adjusted treatment difference 6.5%, 90% CI -0.2% to 13.2%). Using the primary composite endpoint, transvaginal mesh was not superior to native tissue repair (P=.056). Using the secondary composite endpoint, superiority of transvaginal mesh over native tissue repair was noted (P=.009), with a propensity score-adjusted difference of 10.6% (90% CI 3.3-17.9%) in favor of transvaginal mesh. Subjective success for both the primary and secondary endpoint was 92.4% for transvaginal mesh, 92.8% for native tissue repair, a propensity score-adjusted difference of -4.3% (CI -12.3% to 3.8%). For the primary safety endpoint, 3.1% (7/225) of patients in the transvaginal mesh (TVM) group and 2.7% (13/485) of patients in the native tissue repair (NTR) group developed serious adverse events, demonstrating that transvaginal mesh was noninferior to native tissue repair (-0.4%, 90% CI -2.7% to 1.9%). Overall device-related and/or procedure-related adverse event rates were 35.1% (79/225) in the TVM group and 46.4% (225/485) in the NTR group (-15.7%, 95% CI -24.0% to -7.5%).

CONCLUSION

Transvaginal mesh repair for the treatment of anterior and/or apical vaginal prolapse was not superior to native tissue repair at 36 months. Subjective success, an important consideration from the patient-experience perspective, was high and not statistically different between groups. Transvaginal mesh repair was as safe as native tissue repair with respect to serious device-related and/or serious procedure-related adverse events.

FUNDING SOURCE

This study was sponsored by Boston Scientific and developed in collaboration with FDA personnel from the Office of Surveillance and Biometrics, Division of Epidemiology.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT01917968.

Complications After Vaginal Vault Suspension Versus Minimally Invasive Sacrocolpopexy in Women With Elevated Body Mass Index: A Retrospective Cohort Study Using Data From the National Surgical Quality Improvement Program Database

IMPORTANCE

Overweight and obese women represent a growing share of pelvic floor reconstruction surgeons' practices. Determining perioperative risk specific to this population is essential to inform decision making regarding operative approach in this population.

OBJECTIVE

The aim of the study was to compare surgical complications among overweight and obese women undergoing apical compartment prolapse surgery by either minimally invasive abdominal or vaginal approach.

STUDY DESIGN

The American College of Surgeons National Surgical Quality Improvement Database was used to identify overweight and obese patients (body mass index ≥ 25) undergoing either minimally invasive sacrocolpopexy (MISC) or vaginal vault suspension (VVS) in the form of a sacrospinous vault fixation or uterosacral ligament fixation for pelvic organ prolapse from 2012 to 2019. Odds ratios for surgical complications, readmission, and reoperation were estimated using multivariable logistic regression.

RESULTS

Of 8,990 eligible patients, 5,851 underwent a VVS and 3,139 patients underwent MISC. There was a greater odds of any complication in the first 30 days following VVS (n = 608 [10.4%]) compared with MISC (n = 247 [7.9%]; odds ratio, 1.27; 95% confidence interval, 1.08-1.48) on multivariable analysis. Urinary tract infections (UTIs) were the most common complication and were more likely following VVS (112 (3.6%) versus 350 (6.0%), P < 0.001). When UTIs were excluded, there was no difference in complications between approaches (1.00; 95% CI, 0.82-1.22). There were no statistically significant odds of readmission, reoperation, or serious complications between approaches.

CONCLUSIONS

Vaginal vault suspension may be associated with a higher odds of any complication compared with MISC in overweight and obese women, but the rate of serious complications, readmission, and reoperation are low, and approaches were comparable when considering complications other than UTI.

Long-term reoperation risk after apical prolapse repair in female pelvic reconstructive surgery

BACKGROUND

Although several different apical suspension procedures are available to women with pelvic organ prolapse, data on long-term efficacy and safety profiles are limited.

OBJECTIVE

The primary aim of this study was to analyze longitudinal reoperation risk for recurrent prolapse among the 4 apical suspension procedures over 2 to 15 years. Secondary aims included evaluation of all-cause reoperation, defined as a repeated surgery for the indications of recurrent prolapse and adverse events, and total retreatment rate, which included a repeated treatment with another surgery or a pessary.

STUDY DESIGN

This was a multicenter, retrospective cohort study within Kaiser Permanente Southern California that included women who underwent sacrocolpopexy, uterosacral ligament suspension, sacrospinous ligament fixation, or colpocleisis from January 2006 through December 2018. Women who underwent concomitant rectal prolapse repair or vaginal prolapse repair with mesh augmentation were excluded. Data were abstracted using procedural and diagnostic codes through July 2021, with manual review of 10% of each variable. Patient demographics and pessary use were compared using analysis of variance or chi square tests for continuous and categorical variables, respectively. Time-to-event analysis was used to contrast reoperation rates. A Cox regression model was used to perform an adjusted multivariate analysis of the following predictors of reoperation for recurrence: index surgery, concomitant procedures, patient demographics, baseline comorbidities, and year of index surgery. Censoring events included exit from the health maintenance organization and death.

RESULTS

The cohort included 9681 women with maximum follow-up of 14.8 years. The overall incidence of reoperation for recurrent prolapse was 7.4 reoperations per 1000 patient-years, which differed significantly by type of apical suspension (P<.0001). The incidence of reoperation was lower after colpocleisis (1.4 events per 1000 patient-years) and sacrocolpopexy (4.8 events per 1000 patient-years) when compared with uterosacral ligament suspension (9 events per 1000 patient-years) and sacrospinous ligament fixation (13.9 events per 1000 patient-years). All pairwise comparisons between procedures were significant (P=.0003-.0018) after correction for multiplicity, except for uterosacral ligament suspension or uterosacral ligament hysteropexy vs sacrospinous ligament fixation or sacrospinous ligament hysteropexy (P=.05). The index procedure was the only significant predictor of reoperation for recurrence (P=.0003-.0024) on multivariate regression analysis. Reoperations for complications or sequelae (overall 2.9 events per 1000 patient-years) also differed by index procedure (P<.0001) and were highest after sacrocolpopexy (4.4 events per 1000 patient-years). The incidence of all-cause reoperation for recurrence and adverse events after sacrocolpopexy, however, was comparable to that of the other reconstructive procedures (P=.1-.4) in pairwise comparisons with Bonferroni correction. Similarly, frequency of pessary use differed by index procedure (P<.0001) and was highest after sacrospinous ligament fixation at 9.3% (43/464).

CONCLUSION

Among nearly 10,000 patients undergoing prolapse surgery within a large managed care organization, colpocleisis and sacrocolpopexy offered the most durable obliterative and reconstructive prolapse repairs, respectively. All-cause reoperation rates were lowest after colpocleisis by a large margin, but similar among reconstructive apical suspension procedures.

Recurrent surgery in uterine prolapse: A nationwide register study

INTRODUCTION

One in three women with pelvic organ prolapse (POP) undergoing surgery have a relapse. Currently, no optimal surgical treatment has been identified for correcting a uterine prolapse. This population-based register study aims to compare the relapse rate in patients with uterine prolapse undergoing hysterectomy with suspension or uterine-sparing surgical procedures.

MATERIAL AND METHODS

All women with uterine prolapse undergoing prolapse surgery in Sweden from January 1, 2015 to December 31, 2018, were identified from the Gynecological Operation Register (GynOp). The primary outcome was the number of recurrent POP surgeries up to December 31, 2020.

RESULTS

Sacrospinous hysteropexy (SSHP) without graft and sacrohysteropexy (SHP) were associated with a significantly higher rate of recurrent POP surgery (SSHP without graft: adjusted odds ratio [aOR] 2.6, 95% CI 2.0-3.5; SHP aOR 2.6, 95% CI 1.8-3.7) and patients describing a sense of globe (SSHP without graft, aOR 2.0, 95% CI 1.6-2.6; SHP, aOR 1.8, 95% CI 1.1-3.1) compared with cervical amputation with uterosacral ligament fixation (Manchester procedure). There was no difference in the reoperation rate or sense of a globe between SSHP with graft and Manchester procedure. Patients undergoing SSHP without graft had a higher frequency of 1-year postoperative complications compared with Manchester procedure (aOR 2.0, 95% CI 1.6-2.6) and SHP (aOR 2.4, 95% CI 1.4-3.9). Moreover, the frequency of 1-year postoperative complications was higher in SSHP with graft (aOR 1.6, 95% CI 1.1-2.2) than in Manchester procedure.

CONCLUSIONS

The Manchester procedure was associated with a low rate of recurrent POP surgery, symptomatic recurrence and low surgical morbidity compared with other surgical methods in women with uterine prolapse.

Surgical treatment of advanced anterior wall and apical vaginal prolapse using the anchorless self-retaining support implant: long-term follow-up

INTRODUCTION AND HYPOTHESIS

Following health notification by the FDA in 2008 of serious complications with transvaginal mesh for anterior pelvic organ prolapse, there has been a return to native tissue repairs. Earlier work with a self-retaining support (SRS) implant showed a high anatomical success rate with minimal implant-related complications over a medium-term follow-up. It is proposed that post-implant complications are more a consequence of the method of mesh anchoring rather than the implant itself. Our system incorporates an ultralight mesh with a frame that provides level I, II, and III support without the need for fixation. The first long-term outcomes of SRS implantation are presented.

METHODS

A prospective multicenter trial was conducted using two consecutive identical protocols of the use of the SRS implant in women with symptomatic anterior compartment prolapse extending their follow-up to 36 months. Anatomical success (Pelvic Organ Prolapse Quantification stage 0 or 1 or a Ba ≤ -2) was recorded along with subjective success as defined by regular quality-of-life (PFDI-20 and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire) assessments.

RESULTS

Sixty-seven patients completed 36 months of follow-up. Mean Ba measurements improved from 3.1 (-1 to 6) cm to -2.8 (-1 to -3) cm and C point from 0.4 (-8 to 6) cm to -6.9 (-10 cm to 1) cm. accumulating to a significant anatomical success rate of 94.3%. Subjective success based on question #3 of the PFDI-20, analyzed for the index surgical compartment, reached 95.7%. Post-operative complications included 2 cases of urinary retention, 1 minor frame exposure, 1 case of delayed voiding dysfunction, and 2 cases of de novo stress urinary incontinence. Untreated pre-operative second-degree Bp measurements had increased in 27% at follow-up.

CONCLUSION

The long-term outcome of the SRS implant shows an excellent subjective and objective success with minimal risk of complications or need for reintervention.

Efficacy and safety of pelvic organ prolapse surgery with porcine small intestinal submucosa graft implantation

OBJECTIVE

The ideal implant material for the surgical repair of pelvic organ prolapse in women is yet to be found. This retrospective study aims to evaluate a porcine small intestinal submucosa (SIS) graft (Surgisis™).

STUDY DESIGN

We reviewed the medical records of women that were operated upon for pelvic organ prolapse using implantation of SIS graft and we examined the short-term complications and recurrence rates.

RESULTS

A total of 155 surgical procedures were reviewed. SIS graft was placed in the anterior, posterior and middle compartments in 93 (60%), 71 (45.8%) and 13 (8.4%) cases, respectively. At three-month follow-up, 22.6% of anterior graft repairs displayed anatomical recurrence (POP-Q stage ≥ 2), compared to 4.8% of posterior and none of the middle compartment graft repairs. During the three postoperative months, 56% of the women were recorded with complications, mostly urinary retention (19%) and pain (12%). The incidence of grade III complications was 5.3%. Persistent complications at three months were observed in 28% of all cases. Logistic regression analysis showed that previous prolapse surgery at the same compartment was a significant predictor for recurrence of prolapse after SIS graft application, whereas lower age, smoking and longer duration of surgery were significant predictors for the development of complications. Younger women had higher risk of developing pain postoperatively.

CONCLUSION

Pain and urinary tract symptoms hold a central position in the complications profile of SIS graft-augmented prolapse surgery. The relatively high recurrence rates do not suggest a clear benefit from SIS graft use.

Pessary or surgery for a symptomatic pelvic organ prolapse: the PEOPLE study, a multicentre prospective cohort study

OBJECTIVE

To compare the 24-month efficacy of pessary or surgery as the primary treatment for symptomatic pelvic organ prolapse (POP).

DESIGN

Multicentre prospective comparative cohort study.

SETTING

Twenty-two Dutch hospitals.

POPULATION

Women referred with symptomatic POP of stage ≥2 and moderate-to-severe POP symptoms.

METHODS

The primary outcome was subjective improvement at the 24-month follow-up according to the Patient Global Impression of Improvement (PGI-I) scale. Secondary outcomes included improvement in prolapse-related symptoms measured with the Pelvic Floor Distress Inventory (PFDI-20), improvement in subjective severeness of symptoms according to the Patient Global Impression of Severity (PGI-S) scale and crossover between therapies. The primary safety outcome was the occurrence of adverse events.

MAIN OUTCOME MEASURE

PGI-I at 24 months.

RESULTS

We included 539 women, with 335 women (62.2%) in the pessary arm and 204 women (37.8%) in the surgery arm. After 24 months, subjective improvement was reported by 134 women (83.8%) in the surgery group compared with 180 women (74.4%) in the pessary group (risk difference 9.4%, 95% CI 1.4-17.3%, P < 0.01). Seventy-nine women (23.6%) switched from pessary to surgery and 22 women (10.8%) in the surgery group underwent additional treatment. Both groups showed a significant reduction in bothersome POP symptoms (P ≤ 0.01) and a reduction in the perceived severity of symptoms (P ≤ 0.001) compared with the baseline.

CONCLUSIONS

Significantly more women in the surgery group reported a subjective improvement after 24 months. Both therapies, however, showed a clinically significant improvement of prolapse symptoms.

TWEETABLE ABSTRACT

Pessary treatment and vaginal surgery are both efficacious in reducing the presence and severity of prolapse symptoms, although the chance of significant improvement is higher following surgery.

Surgical interventions for uterine prolapse and for vault prolapse: the two VUE RCTs

BACKGROUND

New surgical approaches for apical prolapse have gradually been introduced, with few prospective randomised controlled trial data to evaluate their safety and efficacy compared with traditional methods.

OBJECTIVE

To compare surgical uterine preservation with vaginal hysterectomy in women with uterine prolapse and abdominal procedures with vaginal procedures in women with vault prolapse in terms of clinical effectiveness, adverse events, quality of life and cost-effectiveness.

DESIGN

Two parallel randomised controlled trials (i.e. Uterine and Vault). Allocation was by remote web-based randomisation (1 : 1 ratio), minimised on the need for concomitant anterior and/or posterior procedure, concomitant incontinence procedure, age and surgeon.

SETTING

UK hospitals.

PARTICIPANTS

Uterine trial - 563 out of 565 randomised women had uterine prolapse surgery. Vault trial - 208 out of 209 randomised women had vault prolapse surgery.

INTERVENTIONS

Uterine trial - uterine preservation or vaginal hysterectomy. Vault trial - abdominal or vaginal vault suspension.

MAIN OUTCOME MEASURES

The primary outcome measures were women's prolapse symptoms (as measured using the Pelvic Organ Prolapse Symptom Score), prolapse-specific quality of life and cost-effectiveness (as assessed by incremental cost per quality-adjusted life-year).

RESULTS

Uterine trial - adjusting for baseline and minimisation covariates, the mean Pelvic Organ Prolapse Symptom Score at 12 months for uterine preservation was 4.2 (standard deviation 4.9) versus vaginal hysterectomy with a Pelvic Organ Prolapse Symptom Score of 4.2 (standard deviation 5.3) (mean difference -0.05, 95% confidence interval -0.91 to 0.81). Serious adverse event rates were similar between the groups (uterine preservation 5.4% vs. vaginal hysterectomy 5.9%; risk ratio 0.82, 95% confidence interval 0.38 to 1.75). There was no difference in overall prolapse stage. Significantly more women would recommend vaginal hysterectomy to a friend (odds ratio 0.39, 95% confidence interval 0.18 to 0.83). Uterine preservation was £235 (95% confidence interval £6 to £464) more expensive than vaginal hysterectomy and generated non-significantly fewer quality-adjusted life-years (mean difference -0.004, 95% confidence interval -0.026 to 0.019). Vault trial - adjusting for baseline and minimisation covariates, the mean Pelvic Organ Prolapse Symptom Score at 12 months for an abdominal procedure was 5.6 (standard deviation 5.4) versus vaginal procedure with a Pelvic Organ Prolapse Symptom Score of 5.9 (standard deviation 5.4) (mean difference -0.61, 95% confidence interval -2.08 to 0.86). The serious adverse event rates were similar between the groups (abdominal 5.9% vs. vaginal 6.0%; risk ratio 0.97, 95% confidence interval 0.27 to 3.44). The objective anterior prolapse stage 2b or more was higher in the vaginal group than in the abdominal group (odds ratio 0.38, 95% confidence interval 0.18 to 0.79). There was no difference in the overall prolapse stage. An abdominal procedure was £570 (95% confidence interval £459 to £682) more expensive than a vaginal procedure and generated non-significantly more quality-adjusted life-years (mean difference 0.004, 95% confidence interval -0.031 to 0.041).

CONCLUSIONS

Uterine trial - in terms of efficacy, quality of life or adverse events in the short term, no difference was identified between uterine preservation and vaginal hysterectomy. Vault trial - in terms of efficacy, quality of life or adverse events in the short term, no difference was identified between an abdominal and a vaginal approach.

FUTURE WORK

Long-term follow-up for at least 6 years is ongoing to identify recurrence rates, need for further prolapse surgery, adverse events and cost-effectiveness.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN86784244.

FUNDING

This project was funded by the National Institute for Health Research Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 13. See the National Institute for Health Research Journals Library website for further project information.

Mechanics of Uterosacral Ligaments: Current Knowledge, Existing Gaps, and Future Directions

The uterosacral ligaments (USLs) are important anatomical structures that support the uterus and apical vagina within the pelvis. As these structures are over-stretched, become weak, and exhibit laxity, pelvic floor disorders such as pelvic organ prolapse occur. Although several surgical procedures to treat pelvic floor disorders are directed toward the USLs, there is still a lot that is unknown about their function. This manuscript presents a review of the current knowledge on the mechanical properties of the USLs. The anatomy, microstructure, and clinical significance of the USLs are first reviewed. Then, the results of published experimental studies on the in vivo and ex vivo, uniaxial and biaxial tensile tests are compiled. Based on the existing findings, research gaps are identified and future research directions are discussed. The purpose of this exhaustive review is to help new researchers navigate scientific literature on the mechanical properties of the USLs. The use of these structures remains very popular in reconstructive surgeries that restore and augment the support of pelvic organs, especially as synthetic surgical mesh implants continue to be highly controversial.

Complications of Pelvic Organ Prolapse Surgery in the 2015 Finnish Pelvic Organ Prolapse Surgery Survey Study

OBJECTIVE

To describe the major complications of pelvic organ prolapse (POP) surgery in Finland.

METHODS

The Finnish Pelvic Organ Prolapse Surgery Survey 2015 study is a prospective cohort of POP surgeries performed in Finland in 2015. Perioperative, postoperative, and late complications during 1 year of follow-up were compared among native tissue repair, transvaginal mesh, and abdominal mesh surgery. Major complications were assessed using the Clavien-Dindo grading system. Predictive factors for major complications were studied with logistic regression analysis.

RESULTS

Within 1 year after POP surgery, 396 (11.2%) of 3,515 women had at least one complication: 10.9% after native tissue, 11.7% after transvaginal mesh, and 13.5% after abdominal mesh repair. The majority of complications occurred within 2 months after surgery and postoperative infection (4.3%) and bleeding or hematoma (2.6%) were the most frequent. The incidence of organ injuries was low. Mesh-augmented surgery was associated with significantly higher rates of bladder and bowel injuries than native tissue surgery. Complication-related reoperations occurred significantly more often after abdominal mesh repair than native tissue surgery (5.2% vs 1.8%, P=.001). Mesh-related complications were diagnosed more often after transvaginal mesh repair. The overall rate of major complications (Clavien-Dindo grades III-V) was 3.3%. Abdominal mesh surgery was associated with the highest rate of major adverse events (8.8% vs native tissue repair 2.6% and transvaginal mesh 4.9%). The incidence of Clavien-Dindo grade IV or V complications was rare (less than 0.6%). Mesh surgery (transvaginal mesh adjusted odds ratio [aOR] 2.23, 95% CI 1.31-3.80, and abdominal mesh aOR 3.02, 95% CI 1.67-5.46), longer operating time (aOR 2.84, 95% CI 1.78-4.53), prior POP surgery (aOR 1.68, 95% CI 1.00-2.81) and difficult surgery (aOR 2.75, 95% CI 1.63-4.62) were associated with an increased risk for occurrence of major complications.

CONCLUSION

Serious adverse events were rare regardless of the operative approach. However, mesh-augmented surgery was associated with higher risk for major complications.

Cost-effectiveness of Surgical Treatment Pathways for Prolapse

OBJECTIVE

To evaluate the cost-effectiveness of surgical treatment pathways for apical prolapse.

STUDY DESIGN

We constructed a stochastic Markov model to assess the cost-effectiveness of vaginal apical suspension, laparoscopic sacrocolpopexy, and robotic sacrocolpopexy. We modeled over 5 and 10 years, with 9 pathways accounting for up to 2 separate surgical repairs, recurrence of symptomatic apical prolapse, reoperation, and complications, including mesh excision. We calculated costs from the health care system's perspective.

RESULTS

Over 5 years, compared with expectant management, all surgical treatment pathways cost less than the willingness-to-pay threshold of US $50,000 per quality adjusted life-years. However, among surgical treatments, all but 2 pathways were dominated. Of the remaining 2, laparoscopic sacrocolpopexy followed by vaginal repair for apical recurrence was not cost-effective compared with the vaginal-only approach (incremental cost-effectiveness ratio [ICER], >$500,000). Over 10 years, all but the same 2 pathways were dominated. However, starting with the laparoscopic approach in this case was more cost-effective with an ICER of US $6,176. If the laparoscopic approach was not available, starting with the robotic approach similarly became more cost-effective at 10 years (ICER, US $35,479).

CONCLUSIONS

All minimally invasive surgical approaches for apical prolapse repair are cost-effective when compared with expectant management. Among surgical treatments, the vaginal-only approach is the only cost-effective option over 5 years. However, over a longer period, starting with a laparoscopic (or robotic) approach becomes cost-effective. These results help inform discussions regarding the surgical approach for prolapse.

Clinical analysis of pain after transvaginal mesh surgery in patients with pelvic organ prolapse

BACKGROUND

The purpose of this study was to investigate the relevant factors of pain after transvaginal mesh (TVM) surgery for the treatment of pelvic organ prolapse and to analyse the management and relief of the pain.

METHODS

A multicentre retrospective study of a clinical database of patients who underwent TVM surgery was conducted, and pain related aspects were analysed.

RESULTS

A total of 1855 patients were included in the study. We divided the patients into two groups: pain-free (1805 patients) and pain (50 patients) group. The incidence of pain after TVM surgery was 2.70%, with a median occurrence time of 7.5 months. Pain mainly involved the vagina, perineum, buttocks, groin, inner thighs, and lower abdomen. Excessive intraoperative blood loss (OR = 1.284, 95% CI 0.868-2.401) and postoperative anatomic failure (OR = 1.577, 95% CI 0.952-3.104) were analysed as risk factors with statistical significance. Mesh exposure rate in the pain group was 38%, showing a significant difference between the groups (P < 0.01). Forty patients underwent non-surgical treatment, with a relief rate of 40.0%, 33 patients received surgical treatment, 15 underwent partial mesh removal, and 18 underwent complete mesh removal, with a relief rate of 84.8%. The total relief rate was 88% within all 50 patients suffering from pain.

CONCLUSIONS

Excessive intraoperative bleeding and unsatisfactory postoperative anatomic outcomes can increase the risk of postoperative pain; mesh exposure is also associated with the pain. Most patients can get pain relief with proper management, more than half of whom may need mesh removal with differing approach.

Comparative analyses of attitude, knowledge, and recollection of preoperative counseling regarding pelvic mesh among women with or without a mesh-related complication

PURPOSE

Our objective was to compare the recollection of preoperative counseling regarding mesh for pelvic organ prolapse (POP) and/or stress urinary incontinence (SUI) among women with or without a mesh-related complication (MRC). We hypothesized that the patients who had MRC would better recollect counseling regarding complications associated with mesh.

METHODS

We conducted a retrospective cohort study among women who had prior implantation of synthetic, non-absorbable mesh for POP and/or SUI at least 3 months prior who presented with or without a MRC. The primary outcome was the proportion of women who recalled being counseled preoperatively about the risk of mesh exposure.

RESULTS

Ninety-six women were included in the final analysis (50 MRC; 46 no MRC). MRC women presented further in time from the index surgery [median 69 months [IQR 26-115] vs 12 months (IQR 6-64), p < 0.01]. After adjustment for time since surgery and age, MRC women were significantly less likely to recall being counseled about the possibility of any MRC [19/50 (38%) vs 32/44 (73%), aOR 0.29, 95% CI 0.11-0.79, p = 0.01]. They were also less likely to report they would undergo the same surgery again 5-point Likert scale [median 3 (IQR 1-4) vs 5 (IQR 3-5), 5-point Likert scale, p < 0.01], less satisfied with their mesh surgery [median 1 (IQR 1-3) vs 5 (IQR 3-5), 5-point Likert scale, p < 0.01] and recommended improved preoperative counseling [27/50 (54%) vs 6/46 (13%), p < 0.01].

CONCLUSION

Women who experienced MRC were less likely to recall being counseled about the possibility of MRC and report more unmet needs regarding perioperative counseling than women without MRC.

Pelvic organ prolapse surgery and health-related quality of life: a follow-up study

BACKGROUND

Symptomatic prolapse impairs quality of life. Health-related quality of life (HRQoL) is considered an important outcome of pelvic organ prolapse (POP) surgery. However, it is rarely reported, and measures are inadequately used. Thus, studies reporting patient-reported surgical outcomes in low-income contexts are needed. This study aims to evaluate the effect of prolapse surgery on patient HRQoL and determine the predictive factors for change in HRQoL.

METHODS

A total of 215 patients who had prolapse stage III or IV were enrolled. Patients underwent vaginal native tissue repair, and their HRQoL was evaluated at baseline, 3 and 6 months postoperatively. Effect of surgery on subjective outcomes were measured using validated Prolapse Quality of Life (P-QoL-20), Prolapse Symptom Score (POP-SS), Body Image in Prolapse (BIPOP), Patient Health Questionnaire (PHQ-9), and Patient Global Index of Improvement (PGI-I) tools. A linear mixed-effect model was used to compare pre- and postoperative P-QoL scores and investigate potential predictors of the changes in P-QoL scores.

RESULTS

In total, 193 (89.7%) patients were eligible for analysis at 3 months, and 185 (86.0%) at 6 months. Participant's mean age was 49.3 ± 9.4 years. The majority of patients had prolapse stage III (81.9%) and underwent vaginal hysterectomy (55.3%). All domains of P-QoL improved significantly after surgery. Altogether more than 72% of patients reported clinically meaningful improvement in condition-specific quality of life measured with P-QoL-20 at 6 months. An improvement in POP-SS, BIPOP, and the PHQ-9 scores were also observed during both follow-up assessments. At 6 months after surgery, only 2.7% of patients reported the presence of bulge symptoms. A total of 97.8% of patients had reported improvement in comparison to the preoperative state, according to PGI-I. The change in P-QoL score after surgery was associated with the change in POP-SS, PHQ, BIPOP scores and marital status (p < 0.001). However, age, type of surgery, and prolapse stage were not associated with the improvement of P-QoL scores.

CONCLUSIONS

Surgical repair for prolapse effectively improves patient's HRQoL, and patient satisfaction is high. The result could be useful for patient counselling on the expected HRQoL outcomes of surgical treatment. Surgical service should be accessible for patients suffering from POP to improve HRQoL.

Ten years' follow-up after iliococcygeus fixation for the treatment of apical vaginal prolapse

INTRODUCTION AND HYPOTHESIS

Various surgical techniques have been described for vaginal vault prolapse repair, but the best surgical approach is still to be proven. The aim of this study is to report the long-term objective and subjective outcomes of women who underwent iliococcygeus fixation for the treatment of vaginal vault prolapse with a minimum follow-up of 10 years.

METHODS

Women with symptomatic vaginal vault prolapse (Pelvic Organ Prolapse Quantification [POP-Q] stage ≥ 2) who had previously undergone hysterectomy for any reason were prospectively enrolled and treated with iliococcygeus fixation. Subjective success was defined as Patient Global Impression of Improvement (PGI-I) ≤ 2 and an absence of bulging symptoms. Objective success was defined as stage of prolapse < 2 in all compartments. Overall success rate was defined as women without prolapse symptoms, PGI-I ≤ 2, stage of prolapse < 2, and no need for other surgery. Prolpase Quality of Life (P-QOL) questionnaires were completed at the preoperative visit and at every follow-up visit. Multiple logistic regression was performed to identify factors involved in the risk of recurrent POP.

RESULTS

After a median (range) follow-up of 120 (120-132) months, the subjective, objective, and overall cure rates were 82% (32/39), 74.4% (29/39), and 74.4% (29/39), respectively. Only stage IV vault descensus independently predicted POP recurrence after ICG (OR: 7.66 [95% CI: 1.21-9.02]; p < 0.001).

CONCLUSION

Iliococcygeus fixation seems to be a safe and effective option for the treatment of vaginal vault prolapse at 10 years' follow-up.

It's not that mesh, is it? What providers should know about the transvaginal mesh controversy

The U.S. Food and Drug Administration recent ban on surgical mesh intended for the transvaginal repair of pelvic organ prolapse has called into question the safety of surgical mesh implants in general. As the media firestorm around vaginal mesh kits has continued to grow, important details about the specific type of mesh involved have been lost in the public discourse surrounding the controversy. This has left healthcare providers across the nation in the difficult position of addressing patient anxieties about the use of mesh in gynecologic surgery. This review seeks to educate women's health providers on the historical background and various uses of the different types of mesh in gynecologic surgery.

Complications following vaginal colpopexy for the repair of pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

The primary aim of this study was to compare differences in complication rates across different types of vaginal colpopexy using the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.

METHODS

Patients who underwent intra- or extraperitoneal vaginal colpopexy with or without concurrent hysterectomy were identified in the 2014-2016 NSQIP database using Current Procedural Terminology codes. Patient demographics, preoperative comorbidities, American Society of Anesthesiologists (ASA) classification system scores, and total operating time were obtained. NSQIP-tracked 30-day codes were used to determine the complication, reoperation, and readmission rates.

RESULTS

A total of 9546 colpopexies were performed during the study period. The mean age was 62 ± 12 years, and the mean body mass index (BMI) was 28 ± 6 kg/m². The majority of patients were white (73%) with an ASA class of 2 (65%). The overall rate of postoperative complications was 10.5%. The most common complications were urinary tract infections (UTI) (5.1%), transfusion (1.0%), and superficial surgical site infection (0.7%). Excluding UTI, the rate of postoperative complications was 5.4%. After performing multivariable logistic regression, higher ASA class (class 3: aOR 1.69, 95% CI 1.16-2.51; class 4: aOR 3.98, 95% CI 1.51, 9.30) and extraperitoneal colpopexy with hysterectomy were independently associated with a higher odds of experiencing a non-UTI postoperative complication (aOR1.43, 95% CI 1.10, 1.84). Minority race was also independently associated with higher odds of experiencing a non-UTI postoperative complication (aOR 1.33, 95% CI 1.15, 1.52).

CONCLUSION

One in ten women undergoing vaginal colpopexy experienced a postoperative complication. Minority race and extraperitoneal colpopexy with concurrent hysterectomy were independently associated with an increased risk of a non-UTI postoperative complication.

Comparison of two natural tissue repair-based surgical techniques; sacrospinous fixation and uterosacral ligament suspension for pelvic organ prolapse treatment

INTRODUCTION AND PURPOSE

The present study aims to compare the effectiveness and perioperative results of the natural tissue repair-based treatments sacrospinous fixation (SSF) and uterosacral ligament suspension (USLS) based on the preoperative Pelvic Organ Prolapse Quantification system (POP-Q).

MATERIALS AND METHODS

Medical records of patients with stage ≥2 uterine prolapse between January 2011 and December 2016 were retrospectively examined. Preoperative POP-Q stages, demographic characteristics, perioperative results, and recurrence ratios in mid-term follow-up for patients were compared.

RESULTS

Overall, 235 patients were determined according to our study's inclusion criteria. A total of 155 patients underwent vaginal hysterectomy and USLS (VH/USLS), whereas 80 patients underwent vaginal hysterectomy and SSF (VH/SSF). There were no significant differences between groups in terms of body mass index (BMI), age, and parity as well as cardiovascular disease and diabetes mellitus. There was no significant difference in terms of anatomical success and clinical success rates in the postoperative follow-up period between both groups. (p = 0.588 and 0.692, respectively). However, the assessment of results based on preoperative stages of patients revealed that recurrence and anatomical failure were higher in the stage 4 group (p < 0.001).

CONCLUSION

Our findings indicate that the main determinant factor in evaluating recurrence rates is preoperative POP-Q staging of the patient. Recurrence rates significantly increase with disease stage. Consistent with studies that do not report a clear superiority for USLS or SSF, we observed no significant differences between both procedures in terms of recurrence. The effectiveness of these procedures is similar. We believe that prospective, long-term follow-up studies with larger populations are required to accurately identify preoperative risk factors and compare them with mesh techniques.

[Pelvic and perineal pain after genital prolapse: A literature review]

INTRODUCTION

Pelvic and perineal pain after genital prolapse surgery is a serious and frequent post-operative complication which diagnosis and therapeutic management can be complex.

MATERIALS ET METHODS

A literature review was carried out on the Pubmed database using the following words and MeSH : genital prolapse, pain, dyspareunia, genital prolapse and pain, genital prolapse and dyspareunia, genital prolapse and surgery, pain and surgery.

RESULTS

Among the 133 articles found, 74 were selected. Post-operative chronic pelvic pain persisting more than 3 months after surgery according to the International Association for the Study of Pain. It can be nociceptive, neuropathic or dysfunctional. Its diagnosis is mainly clinical. Its incidence is estimated between 1% and 50% and the risk factors are young age, the presence of comorbidities, history of prolapse surgery, severe prolapse, preoperative pain, invasive surgical approach, simultaneous placement of several meshes, less operator experience, increased operative time and early post-operative pain. The vaginal approach can cause a change in compliance and vaginal length as well as injury to the pudendal, sciatic and obturator nerves and in some cases lead to myofascial pelvic pain syndrome, whereas the laparoscopic approach can lead to parietal nerve damage. Therapeutic management is multidisciplinary and complex.

CONCLUSION

Pelvic pain after genital prolapse surgery is still obscure to this day.

Design of a 3-Arm Randomized Trial for Posthysterectomy Vault Prolapse Involving Sacral Colpopexy, Transvaginal Mesh, and Native Tissue Apical Repair: The Apical Suspension Repair for Vault Prolapse in a Three-Arm Randomized Trial

OBJECTIVE

The objective of this study was to present the design of the Apical Suspension Repair for Vault Prolapse in a Three-Arm Randomized Trial (ASPIRe), which compares the efficacy and safety of 3 apical repairs: native tissue (NT) transvaginal repair, transvaginal mesh, and sacral colpopexy.

METHODS

Patient selection criteria, primary and secondary outcome measures including patient-reported outcome questionnaires, masking, surgeon certification, procedure standardization, adverse events collection and adjudication, and cost analysis will be described for this multi-centered randomized trial. Given the unique risks/benefits of each technique, a noninferiority design will be used to compare apical transvaginal mesh to mesh sacral colpopexy. A superiority design will be used to compare the 2 mesh repairs to NT transvaginal apical repair. Survival analysis will be used to assess a composite primary outcome for success composed of a subjective measure (no prolapse symptoms), objective measure (no prolapse beyond the hymen), and no prolapse retreatment, with a minimum follow-up of 36 months. Secondary outcome measures collected every 6 months include assessment of validated general and condition-specific quality of life measures, global impression of improvement, satisfaction and regret, body image, and sexual function.

RESULTS

Randomization and surgical treatment of 360 participants are complete, and the study is in the follow-up phase.

CONCLUSIONS

This report will provide valuable insight on the design of a novel 3-arm surgical trial using mesh versus NT to repair vaginal vault prolapse. This trial will provide level 1 evidence on the risks and benefits of mesh augmented versus NT apical repairs.

Sacrocolpopexy: Patient Outcomes Support the Use of Non-Crosslinked Acellular Dermal Matrix as an Alternative to the Synthetic Polypropylene Mesh

Objective: This study was conducted to evaluate the use of non-crosslinked acellular dermal matrix (ADM) in laparoscopic sacrocolpopexy by analyzing clinical outcomes and patient-satisfaction surveys.

Materials and Methods: Two hundred and eleven patients underwent laparoscopic sacrocolpopexy for pelvic organ prolapse (POP) between January 6, 2012, and December 31, 2017. Each patient had her pelvic-floor measurements diagrammed with the POP-Q [Quantification] system using the interactive tool provided by the American Urogynecologic Society. The Pelvic Floor Distress Inventory (PFDI-20) and Pelvic Floor Impact Questionnaire (PFIQ-7), used to make comprehensive assessments of women with urogynecologic problems, were mailed to all patients. If responses were not received, the patients were contacted by telephone. Patients who were not reached by either mail or telephone had their charts individually reviewed to extract the information. Trained surveyors scored the PFDI-20 and the PFIQ-7 questionnaires. The de-identified data were analyzed for patient satisfaction and outcomes. This information was obtained by a review of patient charts at 4-week postoperative and annual examinations; any phone calls with complaints and/or problem office visits were noted. Biopsies from the sacrocolpopexy area were taken if a patient had another incidental gynecologic procedure unrelated to the prolapse or at the time of repeat sacrocolpopexy for POP and the paraffin cell block was sent to McGowan Institute for Tissue Regeneration.

Results: One hundred and five patients responded to the survey. Charts were completed for 106. The majority of interviewed patients stated that they were doing a “little better” or “much better” (77/88; 87.5%). The third-quartile PFDI-20 score was 93 with a median of 60 and the PFIQ-7 score was 43 with a median of 29. Five patients underwent reoperations (4.76%). The most-common postoperative complaint was overactive bladder symptoms, followed by vaginal discharge. Histology showed either a lack of regenerative healing tissue at the failure site or good results showing neovascularization and a presence of connective and ligamentous tissue around the matrix. No intense fibrosis or neoplastic formation was reported.

Conclusions: A non-crosslinked ADM patch can be a good alternative to synthetic polypropylene mesh in patients undergoing sacrocolpopexy for POP.

Laparoscopic lateral suspension with mesh for apical and anterior pelvic organ prolapse: A prospective double center study

OBJECTIVE

The present study analyzed long-term outcomes and complications of laparoscopic lateral suspension (LLS) with mesh to treat apical and anterior pelvic organ prolapse (POP).

STUDY DESIGN

A prospective cohort study on 125 patients with vaginal bulge and apical +/- anterior prolapse scheduled for LLS who consecutively underwent LLS between April 2013 and January 2017 in Gynecologic Department of Santa Chiara Hospital in Trento and University of Pisa. The main outcome measure was anatomic and symptomatic POP outcome; the secondary outcomes measures were recurrence, reoperation rate, de novo posterior POP and complications. Percentage distribution of the pre- and postoperative POP-Q stages was compared at mean follow-up. Wilcoxon signed rank sum test was used to compare preoperative POP-Q stage and postoperative POP-Q stage ate mean follow up, for each patient (paired data) and for each type of prolapse.

RESULTS

120 patients were included in the study. At 2 years 89 % of patients were asymptomatic and anatomic success rate was 94.2 % for the anterior compartment, 94.9 % for the apical compartment. Concerning posterior compartment prolapse 2 (1.7 %) patients referred stage 3 de novo prolapse during follow-up. The complication rate of Clavien-Dindo >3 was 0,8 %. Repeat surgery for POP occurred in 6.4 % of cases. The appearance of POP-Q recurrences was concentrated at 6 months follow-up. BMI > 25 was correlated with de novo posterior compartment appearance during follow-up.

CONCLUSIONS

LLS for the treatment of apical and anterior POP is a technique with optimal results in term of safety and effectiveness after 2 years follow-up.

Current Treatments for Female Pelvic Floor Dysfunctions

As global population aging, the issue of pelvic floor dysfunctions becomes increasingly. Millions of women were affected every year. The treatment of pelvic floor dysfunction has evolved in the past decade. This review aims to provide the current information on the treatment for female pelvic floor dysfunction, including pelvic organ prolapse (POP), urinary, fecal incontinence (FI), and myofascial pelvic pain among women. We used PubMed, Embase, and Web of Science to search for studies that were related to pelvic floor dysfunction regarding the POP, urinary, FI, and treatments. The development of laparoscopic surgery and synthetic and biological materials for pelvic floor reconstructive surgery were summarized. The surgical outcomes and complications of different pelvic floor reconstructive surgeries were compared. New devices for FI and the potential modified pelvic floor reconstructive surgery were also discussed here. Female pelvic medicine will continue to evolve for better treatment in the future. The pelvic floor reconstructive surgery tends to be minimally invasive approach with synthetic graft use.

Methacrylic Acid Copolymer Coating Enhances Constructive Remodeling of Polypropylene Mesh by Increasing the Vascular Response

This study reports that a methacrylic acid (MAA)-based copolymer coating generates constructive remodeling of polypropylene (PP) surgical mesh in a subcutaneous model. This coating is non-bioresorbable and follows the architecture of the mesh without impeding connective tissue integration. Following implantation, the tissue response is biased toward vascularization instead of fibrosis. The vessel density around the MAA mesh is double that of the uncoated mesh two weeks after implantation. This initial vasculature regresses after two weeks while mature vessels remain, suggesting an enhanced healing response. Concurrently, the MAA coating alters the foreign body response to the mesh. Fewer infiltrating cells, macrophages, and foreign body giant cells are found at the tissue-material interface three weeks after implantation. The coating also dampens inflammation, with lower expression levels of pro-inflammatory and fibrogenic signals (e.g., Tgf-β1, Tnf-α, and Il1-β) and similar expression levels of anti-inflammatory cytokines (e.g., Il10 and Il6) compared to the uncoated mesh. Contrary to other coatings that aim to mitigate the foreign body response to PP mesh, a MAA coating does not require the addition of any biological agents to have an effect, making the coated mesh an attractive candidate for soft tissue repair.

The Management and Efficacy of Surgical Techniques Used for Erosive Mesh in the Urethra and Bladder: A Systematic Review

BACKGROUND

This study reports the re-operation and symptom resolution rates of different techniques used in surgical excision of genitourinary mesh erosions.

METHODS

A comprehensive systematic review was completed after searching electronic databases for studies involving outcomes of mesh erosion in humans that were managed surgically using a transvaginal, cystoscopic, or abdominal approach. Surgical outcomes were reported in percentages, ranges, and simple pooling to generate trends in management techniques.

RESULTS

There were 177 cases that met our inclusion criteria. Forty-one patients underwent cystoscopic removal of eroded urethral mesh while 40 cases underwent transvaginal removal of urethral mesh.

CONCLUSIONS

For mesh eroded into the urethra, a transvaginal vs. cystoscopic approach showed a trend toward resolution of symptoms and fewer interventions. For mesh eroded into the bladder, abdominal and cystoscopic approaches had similar symptom resolution, but abdominal approach required fewer interventions.

Will registries slow down or accelerate innovation?

The increasing use of regional and national registries of surgical implants has raised concerns that the cost and consequences of these initiatives will adversely influence innovation. The opposite appears to be true, with no evidence of a reduction in overall innovation and an association of increased innovation in countries with more evaluation using registries.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180065

Long-term compliance of vaginal pessaries: Does stress urinary incontinence matter?

Vaginal pessary treatment for pelvic organ prolapse (POP) is relatively safe and cost-effective. Since long-term use is an important key to keep the benefit of pessary treatment, we would like to investigate the factors which might affect the compliance of vaginal pessaries. In this retrospective study, 65 women were included, and we found poor compliance in women with severe stress urinary incontinence (SUI) after reduction (1-hour pad test >10 gm vs ≦10 gm, 57.1% vs. 84.3%, P = .027). Besides, women younger than 60 years-old also had poor compliance (age ≦60-year-old vs >60-year-old, 58.3% vs 83.0%, P = .04). Other factors such as POP stage, history of hysterectomy, and types of pessaries, did not show significant influence on the long-term compliance in this study. Therefore, to evaluate the severity of SUI after reduction before providing pessary treatment is important to predict long-term compliance. Meanwhile, long-term pessary treatment seems to be more acceptable to elderly patients.

Characterization of the T-cell response to polypropylene mesh in women with complications

BACKGROUND

Polypropylene mesh is used widely for surgical treatment of pelvic organ prolapse and stress urinary incontinence. Although these surgeries demonstrate favorable functional and anatomic outcomes, their use has been limited by complications, the 2 most common being exposure and pain. Growing evidence suggests that T lymphocytes play a critical role in the regulation of the host response to biomaterials.

OBJECTIVE

The purpose of this study was to define and characterize the T-cell response and to correlate the response to collagen deposition in fibrotic capsules in mesh tissue complexes that are removed for the complications of pain vs exposure.

STUDY DESIGN

Patients who were scheduled to undergo a surgical excision of mesh for pain or exposure at Magee-Women's Hospital were offered enrollment. Forty-two mesh-vagina tissue complexes were removed for the primary complaint of exposure (n=24) vs pain (n=18). Twenty-one patients agreed to have an additional vaginal biopsy away from the site of mesh that served as control tissue. T cells were examined via immunofluorescent labeling for cell surface markers CD4+ (T_h), CD8+ (cytotoxic) and foxp3 (T-regulatory cell). Frozen sections were stained with hematoxylin-eosin for gross morphologic condition and picrosirius red for collagen fiber analysis. Interrupted sodium-dodecyl sulfate gel electrophoresis was used to quantify the content of collagens type I and III, and the collagen III/I ratio. Transforming growth factor-β and connective tissue growth factor, which are implicated in the development of fibrosis, were measured via enzyme-linked immunosorbent assays. Data were analyzed with the Student's t tests, mixed effects linear regression, and Spearman's correlation coefficients.

RESULTS

Demographic data were not different between groups, except for body mass index, which was 31.7 kg/m² for the exposure group and 28.2 kg/m² for pain (P=.04). Tissue complexes demonstrated a marked, but highly localized, foreign body response. We consistently observed a teardrop-shaped fibroma that encapsulated mesh fibers in both pain and exposure groups, with the T cells localized within the tip of this configuration away from the mesh-tissue interface. All 3 T-cell populations were significantly increased relative to control: CD4⁺ T helper (P<.001), foxp3⁺ T regulatory (P<.001), and CD8⁺ cytotoxic T cell (P=.034) in the exposure group. In the pain group, only T-helper (P<.001) and T-regulatory cells (P<.001) were increased, with cytotoxic T cells (P=.520) not different from control. Picrosirius red staining showed a greater area of green (thin) fibers in the exposure group (P=.025) and red (thick) fibers in the pain group (P<.001). The ratio of area green/(yellow + orange + red) that represented thin vs thick fibers was significantly greater in the exposure group (P=.005). Analysis of collagen showed that collagen type I was increased by 35% in samples with mesh complications (exposure and pain) when compared with control samples (P=.043). Strong correlations between the profibrosis cytokine transforming growth factor-β and collagen type I and III were found in patients with pain (r≥0.833; P=.01) but not exposure (P>.7).

CONCLUSION

T cells appear to play a critical role in the long-term host response to mesh and may be a central pathway that leads to complications. The complexity of this response warrants further investigation and has the potential to broaden our understanding of mesh biology and clinical outcomes.