Evidence-based outcomes for mesh-based surgery for pelvic organ prolapse

Comparison of efficacy between laparoscopic pectopexy and laparoscopic high uterosacral ligament suspension in the treatment of apical prolapse-short term results

To compare the clinical efficacy of laparoscopic pectopexy and laparoscopic high uterosacral ligament suspension in women suffering from apical prolapse. The clinical data of 170 patients with apical prolapse (POP-Q score ≥ II) treated in the Third Affiliated Hospital of Zhengzhou University from January 2018 to July 2020 were retrospectively analyzed to assess the clinical efficacy of three surgical methods [laparoscopic pectopexy with uterine preservation, laparoscopic pectopexy with hysterectomy, laparoscopic high uterosacral ligament suspension (LHUSLS) with hysterectomy]. Patients were divided into three groups depending on Surgical methods: laparoscopic uterine pectopexy group (n = 23), laparoscopic pectopexy with hysterectomy group (n = 78) and LHUSLS with hysterectomy group (n = 69). The POP-Q points before and after operation were analyzed. The operation-related indices, perioperative periods and post-operative complications were compared. 1. The operation time of laparoscopic uterine pectopexy group was the shortest (p < 0.05). There was no significant difference in the incidence of apical prolapse and new stress urinary incontinence among the three groups during the follow-up period (p > 0.05). 2. The POP-Q points (Aa, Ba, C) in the three groups were better than those before operation (p < 0.05). Laparoscopic pectopexy with hysterectomy group had better Ap, Bp and C points and a longer TVL than LHUSLS with hysterectomy group (p < 0.05). 3. The postoperative PFDI-20, PFIQ-7 and PISQ-12 scores of the three groups were significantly improved than those before operation (p < 0.05). The PISQ-12 scores in laparoscopic uterine pectopexy group were significantly higher than that in the other two groups one year after operation (p < 0.05). The study concludes that laparoscopic pectopexy and LHUSLS can significantly improve the quality of life and sexual function for patients with apical prolapse. One year after operation, laparoscopic pectopexy has a more satisfactory anatomical reduction than LHUSLS with hysterectomy. The laparoscopic uterine pectopexy group had lower postoperative complications and better sexual function than that with hysterectomy group. Laparoscopic pectopexy should be used for the treatment of apical prolapse (POP-Q score ≥ II) patients who aim to better clinical efficacy and sexual function improvement.

A modified technique for paravaginal repair of cystocele with paravaginal defect: A retrospective study

OBJECTIVE

We aimed to determine the efficacy and safety of a modified protocol for paravaginal repair of symptomatic paravaginal defects and cystocele.

METHODS

This study was an observational case series of 98 consecutive female patients, referred to our hospital between June 2014 and May 2018, with symptomatic grade II to IV paravaginal defects and cystocele. Our modified technique for paravaginal repair is based on the conventional protocol but incorporates reverse bridge repair and the cross-stitching of bilateral sutures. The curative effect of this new technique was evaluated subjectively and objectively during postoperative follow-up.

RESULTS

All operations were successful. Patients were followed up for 12 to 48 months, until June 2019; the mean follow-up period was 32.4 months. Three months after surgery, the rate of success was 100% (98/98 cases); in each case, the top of the vagina lay above the level of the sciatic spine. The rate of success was 94.9% (93/98 cases) at 12 months after surgery, 91.0% (61/71 cases) at 24 months after surgery, and 76.2% (16/21 cases) at 48 months after surgery. Four cases required a second surgery; three of these cases were treated with sacrocolpopexy, and one case was treated with sacrospinous ligament fixation.

CONCLUSION

Our modified technique for paravaginal repair was safe and effective for anterior vaginal prolapse and cystocele, as confirmed by the results observed over a mean follow-up period of 32.4 months.

Comparison of synthetic mesh erosion and chronic pain rates after surgery for pelvic organ prolapse and stress urinary incontinence: a systematic review

BACKGROUND

The aim of this study is to systematically compare rates of erosion and chronic pain after mesh insertion for pelvic organ prolapse (POP) and stress urinary incontinence (SUI) surgery.

METHODS

A systematic electronic search was performed on studies that evaluated the incidence of erosion and chronic pain after mesh insertion for POP or SUI. The primary outcome measurement was to compare mesh erosion rates for POP and SUI surgery. Secondary outcome measurements were incidence of de novo pain and a comparison of patient demographics for both surgeries.

RESULTS

Twenty-six studies on 292,606 patients (n = 9077 for POP surgery and n = 283,529 for SUI surgery) met the inclusion criteria. Median follow-up was 26.38 ± 22.17 months for POP surgery and 39.33 ± 27.68 months for SUI surgery. Overall, the POP group were older (p < 0.0001) and had a lower BMI (p < 0.0001). Mesh erosion rates were significantly greater in the POP group compared to the SUI group (4% versus 1.9%) (OR 2.13; 95% CI 1.91-2.37; p < 0.0001). The duration from surgery to onset of mesh erosion was 306.84 ± 183.98 days. There was no difference in erosion rates between abdominal and transvaginal mesh for POP. There was no difference in erosion rates between the transobturator and retropubic approach for SUI. The incidence of chronic pain was significantly greater in the POP group compared to the SUI group (6.7% versus 0.6%) (OR 11.02; 95% CI 8.15-14.9; p < 0.0001). The duration from surgery to onset of chronic pain was 325.88 ± 226.31 days.

CONCLUSIONS

The risk of mesh erosion and chronic pain is significantly higher after surgery for POP compared to SUI. These significant complications occur within the first year after surgery.

Evolution of patients with and without preoperative stress urinary incontinence after surgical cystocele repair by mesh implantation using a vaginal approach

INTRODUCTION

To review the short-term evolution of stress urinary incontinence (SUI) after Uphold™ LITE mesh implantation for genital prolapse repair.

MATERIAL AND METHODS

Retrospective, descriptive, single centre study of women undergoing genital prolapse surgery with Uphold™ LITE mesh insertion between July 2016 and April 2019. Pre-, peri- and 1-year postoperative follow-up data were collected.

RESULTS

Thirty-six women were included (mean age: 72±7years). Most patients (75%) had grade III cystocele and three (8.3%) had recurrent prolapse. Mean operative time was 41±12min. During surgery, no visceral injury or haemorrhagic complications were noted but there were three intraoperative bladder injuries (8.3%). Twelve patients (33.3%) had preoperative SUI, half of which (n=6; 50%) responded to prolapse repair. De novo SUI was noted in 6/24 (25%) patients. The risk of having persistent postoperative SUI was 50% in patients with preoperative SUI, and the risk of developing de novo postoperative SUI was 25% in patients without preoperative SUI. Thus, patients with preoperative SUI were twice as likely to have persistent postoperative SUI as those without preoperative SUI (RR=2.0 [95% CI: 0.8175-4.8928]; P=0.128). Five patients with de novo SUI and three patients with persistent postoperative SUI were subsequently treated with insertion of a mid-urethral sling (MUS). The other patients improved with physiotherapy.

CONCLUSION

Risk of persistent SUI after implantation of an Uphold™ LITE mesh is higher in patients with preoperative SUI. Surgical correction with a MUS can be offered in cases of de novo SUI before or after physiotherapy.

LEVEL OF EVIDENCE

4.

LeFort colpocleisis for recurrent pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

The causes of recurrence of pelvic organ prolapse (POP) are sufficiently understood. However, few studies are available evaluating reoperation for recurrence of POP. This study evaluates the efficacy and safety of LeFort colpocleisis for recurrent POP.

METHODS

We reviewed data from patients with recurrent POP who underwent LerFort colpocleisis at a center between March 2012 and April 2017. Quality of life was assessed using the Pelvic Floor Distress Inventory Questionnaire (PFDI-20) scores. The Patient Global Impression of Improvement scale (PGI-I) was used to assess self-perceived success and subjective measures of satisfaction. The Clavien-Dindo classification (CD) was used to assess the safety of the procedure. Chi-square and paired t-tests were used to compare the same patients before and after treatment in the follow-up.

RESULTS

Twenty-six patients with recurrent POP after previous prolapse surgery underwent LeFort colpocleisis. Most of these patients had at least one comorbidity. The mean age (years) was 71.8 (7.3). The mean time to recurrent POP was 5.602 (3.643) years. There were no intraoperative bladder lesions or rectal lesions. At mean follow-up of 33.1 months, all patients had no recurrence (< stage 2), significant resolution of awareness of prolapse (P < 0.05), and significantly improved satisfaction on PGI-I after surgery. Minor complications were classified as CD II level in four cases (15.4%).

CONCLUSION

This study suggests that LeFort colpocleisis is feasible and safe for recurrent POP, especially in older women with comorbidities.

Perioperative morbi-mortality after pelvic organ prolapse surgery in a large French national database from gynecologist surgeons

OBJECTIVE

To assess morbidity and mortality following pelvic organ prolapse surgery in France, irrespective of the surgical technique, using a broad national database.

MATERIALS AND METHODS

This descriptive multicenter retrospective study was conducted using a database populated via an application run by a professional association.

RESULTS

286 gynecologists contributed data to the database. Of the 4322 surgeries analyzed, an abdominal approach was used in 975 of cases (22.5%), a vaginal approach in 3277 (75.9%), and a combined approach in 68 (1.6%). After one year, abdominal surgery was associated with higher rates of de novo urinary incontinence, constipation, and intestinal obstruction, whereas vaginal surgery was associated with higher rates of urinary retention, hematoma, de novo chronic pain, and vaginal mesh extrusion. There was no significant difference between the groups in the incidence of severe complications. After one year, vaginal mesh-augmented cystocele repair was associated with higher rates of de novo urinary incontinence, de novo chronic pain, and reoperation than native tissue repair. Mesh repair was also associated with higher rates of severe complications at one year.

CONCLUSION

After pelvic organ prolapse surgery, the perioperative morbidity and mortality associated with transabdominal and transvaginal approaches are similar. However, transvaginal mesh repair is associated with greater perioperative morbidity than transvaginal native tissue repair.

Quality of life in women of non-reproductive age with transvaginal mesh repair for pelvic organ prolapse: A cohort study

BACKGROUND

Transvaginal mesh repair has been discredited due to high complications rates in the past years. Therefore, we evaluated the quality of life (QoL) and complication rates after transvaginal mesh (TVM) repair for pelvic organ prolapse (POP).

METHODS

A total of 148 women who underwent TVM repair for symptomatic POP were retrospectively enrolled. Complication rates and functional outcomes were retrospectively assessed and validated, standardised questionnaires were used prospectively for evaluation of QoL. Univariate analysis by the chi(2)-test as well as a multivariate Cox regression analysis was conducted to predict mesh exposure using various variables as predictors.

RESULTS

Intraoperative complications with bowel or bladder injury appeared in 3.4%. Mesh exposure occurred in 2.7% whereas surgical revision was necessary only in 1.4%. No predictor for mesh exposure could be identified. Postoperative complications according to Clavien-Dindo classification ≥ III occurred in only 2.8%. An improvement of POP-symptoms was reported by 84.6% according the "patients' global impression of improvement" (PGI-I) and 88.2% women would repeat the surgery. The results of the "prolapse-quality of life"-questionnaire were comparable to asymptomatic women. Only 33% reported vaginal pain with a mean vaginal pain score of 0.6 according the international index of pain. Of sexually active women, 29% reported sexual impairments and mean score of sexual impairment was 1.52.

CONCLUSION

Low complication rates and a quality of life comparable to asymptomatic women following TVM repair could be achieved in our cohort. However, a high number of sexual impairments was identified although the impact of impairment was marginal.

Preclinical animal study and human clinical trial data of co-electrospun poly(L-lactide-co-caprolactone) and fibrinogen mesh for anterior pelvic floor reconstruction

Synthetic and biological materials are commonly used for pelvic floor reconstruction. In this study, host tissue response and biomechanical properties of mesh fabricated from co-electrospun poly(l-lactide-co-caprolactone) (PLCL) and fibrinogen (Fg) were compared with those of polypropylene mesh (PPM) in a canine abdominal defect model. Macroscopic, microscopic, histological, and biomechanical evaluations were performed over a 24-week period. The results showed that PLCL/Fg mesh had similar host tissue responses but better initial vascularization and graft site tissue organization than PPM. The efficacy of the PLCL/Fg mesh was further examined in human pelvic floor reconstruction. Operation time, intraoperative blood loss, and pelvic organ prolapse quantification during 6-month follow-up were compared for patients receiving PLCL/Fg mesh versus PPM. According to the pelvic organ prolapse quantification scores, the anterior vaginal wall 3 cm proximal to the hymen point (Aa point), most distal edge of the cervix or vaginal cuff scar point (C point), and posterior fornix point (D point) showed significant improvement (P<0.01) at 1, 3, and 6 months for both groups compared with preoperatively. At 6 months, improvements at the Aa point in the PLCL/Fg group were significantly more (P<0.005) than the PPM group, indicating that, while both materials improve the patient symptoms, PLCL/Fg mesh resulted in more obvious improvement.

What part does mesh play in urogenital prolapse management today?

PURPOSE OF REVIEW

The present review examines the pros and cons of the controversial role of mesh in the management of pelvic organ prolapse (POP). With a view to understanding where we are going, we analyzed recent data, highlighting the most important and interesting articles that were published in the past 12 months.

RECENT FINDINGS

Four main themes emerged. US Food and Drug Administration warnings stimulated an ongoing debate about the role of controversial trans-vaginal mesh, with some uro-gynaecologists tending to provide evidence that trans-vaginal mesh is safe whereas others advocated less aggressive abdominal procedures because minimally invasive techniques such as laparoscopy and robot-assisted surgery seem to provide similar outcomes. Recent systematic reviews and a meta-analysis of POP surgery compared mesh and native tissues, addressing functional outcomes and complications. Finally, ongoing research into new materials might open up further opportunities in the controversial field of POP surgery with mesh.

SUMMARY

The use of mesh for reconstruction of pelvic floor anatomical defects plays a key role in POP management. Given the controversy about the pros and cons of native tissue POP repair versus mesh repair and mesh-related complications, uro-gynaecologists are moving toward alternative surgical approaches and new materials.

Use and risks of surgical mesh for pelvic organ prolapse surgery in women in New York state: population based cohort study

OBJECTIVE

To assess the use of mesh in pelvic organ prolapse surgery, and compare short term outcomes between procedures using and not using mesh.

DESIGN

All inclusive, population based cohort study.

SETTING

Statewide surgical care captured in the New York Statewide Planning and Research Cooperative System.

PARTICIPANTS

Women who underwent prolapse repair procedures in New York state from 2008 to 2011.

MAIN OUTCOMES MEASURES

90 day safety events and reinterventions within one year, after propensity score matching. Categorical, time to event, and subgroup analyses (<65 and ≥ 65 year age groups) were conducted.

RESULTS

Of 27,991 patients in total, 7338 and 20, 653 underwent prolapse repair procedures with and without mesh, respectively. Mesh use increased by 44.7%, from 1461 procedures in 2008 to 2114 procedures in 2011. Most patients in the cohort were younger than 65 years (62.3% (n=17,424/27, 991)). However, more patients were aged 65 years and older in the mesh group than in the non-mesh group (44.3% (n=3249) v 35.4% (n=7318)). Complications after surgery were not common, irrespective of the use or non-use of mesh. After propensity score matching, patients who received the surgery with mesh had a higher chance of having a reintervention within one year (mesh 3.3% v no mesh 2.2%, hazard ratio 1.47 (95% confidence interval 1.21 to 1.79)) and were more likely to have urinary retention within 90 days (mesh 7.5% v no mesh 5.6%, risk ratio 1.33 (95% confidence interval 1.18 to 1.51)), compared with those who received surgery without mesh. In subgroup analyses based on age, mesh use was associated with an increased risk of reintervention within one year in patients under age 65 years, and increased risk of urinary retention in patients aged 65 years and over.

CONCLUSIONS

Despite multiple warnings released by the US Food and Drug Administration since 2008, use of mesh in pelvic organ prolapse surgery continues to grow. In this statewide comprehensive study, mesh procedures were associated with an increased risk of reinterventions within one year and urinary retention after surgery.

Transvaginal repair of stage III-IV cystocele using a lightweight mesh: safety and 36-month outcome

INTRODUCTION AND HYPOTHESIS

The aim of this study was to assess the 36-month safety and efficacy of a lightweight polypropylene mesh used for the transvaginal repair of stage III-IV cystocele.

METHODS

A multicenter prospective cohort study was performed. Preoperative assessment included an interview and evaluation with the Pelvic Organ Prolapse Quantification (POP-Q) system. Inclusion criteria were stage III-IV cystocele and no contraindications for mesh use. A lightweight (28 g/m(2)) four-arm transobturator polypropylene mesh was used for the study. Pre- and postoperative symptoms and quality of life were assessed using the Urinary Symptoms Measurement (MHU), Pelvic Floor Distress Inventory (PFDI-20), Pelvic Floor Impact Questionnaire (PFIQ-7), and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). The main endpoint was mesh safety. Secondary endpoints were anatomic (Ba point ≤ -1) and functional success.

RESULTS

In all, 111 patients with a mean age of 67 ± 9 years (range 47-89) were included in the study, and 94 (84.7%) were included in the analysis. Two intraoperative complications occurred (one bladder and one rectal injury, 2.2%). Medium-term analysis of 79 patients (84%) after 36 months showed a satisfaction rate of 98.7% (78/79), a mesh contraction rate of 5.1% (4/78), only one case of vaginal mesh exposure (1.3%), no cases of chronic pelvic pain, and a postoperative dyspareunia rate of 2.8% (1/36). The anatomic success rate of cystocele repair was 75/79 (94.9%) and a highly significant improvement was noted for symptoms and on quality of life questionnaires. Overall, 7/79 patients (8.9%) were reoperated, including 1 for hemorrhage, 1 for vaginal mesh exposure, 3 for stress urinary incontinence, and 2 for cystocele recurrence (2.5%).

CONCLUSION

Transvaginal cystocele repair using a lightweight transobturator polypropylene mesh was safe and efficient in the medium term. Long-term data and comparative studies are needed.