Should we use meshes in the management of vaginal prolapse?:

Vaginal Hysterectomy with Anterior Four-Arm Mesh Implant Technique in the Surgical Treatment of a Woman with Total Pelvic Organ Prolapse and Urinary Incontinence: A Case Report and Review of the Literature

Purpose. We present a case report of a woman with total POP and SUI who was treated with a technique utilizing vaginal hysterectomy followed by the placement of a four-arm synthetic polypropylene mesh implant system. Methods. An 81-year-old grand-multiparous woman presented to our clinic complaining of a vaginally protruding mass and urinary incontinence. A surgical approach including vaginal hysterectomy, anterior four-arm mesh implant, posterior large segment vaginal enterocele repair, and perineoplasty with levator ani fixation was planned. Results. The patient was discharged home at the second postoperative day. Follow-up visits at the first, 3rd, and 6th months were normal. There was complete symptomatic relief and objective cure of the POP and urinary incontinence symptoms. Conclusion. We believe that anterior four-arm mesh implant and large posterior repair should be considered after vaginal hysterectomy. Future studies are needed to evaluate the utility of this technique for treatment of POP.

A clinical study on the trocar-guided mesh repair system for pelvic organ prolapse surgery

Objective

To evaluate the complication and recurrence rates in patients undergoing trocar-guided mesh implant for pelvic organ prolapse (POP) treatment.

Methods

A retrospective study was performed based on the medical records of patients who had undergone mesh implant by one surgeon from May 2006 to August 2013 at the Presbyterian Medical Center in Korea. We evaluated perioperative complications such as bladder injury, mesh exposure, urinary symptoms, infections, and chronic pelvic pain. Recurrence was defined as a POP-quantification system stage ≥II or any symptomatic prolapse.

Results

Sixty-seven patients were evaluated, and the mean age of patients was 65.4±7.2 years. Stage ≥III POP-quantification Ba was noted in 61 patients (91%). Intraoperative complications included three cases of bladder injury (4.5%). The mean follow-up period was 44.1±7.9 months. Postoperative complications occurred in seven women (10.5%): four cases of urinary symptoms (6%), two cases of infections (3%), and one case of chronic pelvic pain (1.5%). Mesh exposure did not occur (0%). Prolapse recurrence was reported in five patients (7.5%).

Conclusion

Based on our operational result, the trocar-guided mesh implant seems to provide safe and effective outcomes.

In vivo biomechanical properties of heavy versus light weight monofilament polypropylene meshes. Does the knitting pattern matter?

AIMS

This work evaluated the post-implant biomechanical properties of light-weight (LW) and heavy-weight (HW) monofilament polypropylene (PP) meshes with different knitting patterns in an animal model in vivo.

METHODS

Forty-five adult female Wistar rats were divided into three groups and randomly implanted with 32 × 32 mm HW-PP (62 gm^-2 ) orLW-PP (16 gm^-2 ) in the lower abdomen. LW-PPwas tested orthogonally (called LWL and LWT) to reproduce the longitudinal and transverse planes of the vaginal wall, respectively. Abdominal walls were removed at 7, 30, and 60 days, and then tested for tensile load (maximum load until avulsion from the tissue), deflection, and stiffness to maximum load. Explants were compared over time and between groups.

RESULTS

LW-PP meshes implanted in the LWT fashion (vaginal transverse plane) showed comparable maximum load and stiffness to HW-PP meshes, and LW-PP meshes implanted in the LWL fashion (vaginal longitudinal plane) presented lower maximum load and stiffness than the HW-PP meshes. There were no significant differences in the values of deflection at maximum load between the studied meshes as a function of time.

CONCLUSIONS

The final mechanical behavior of PP mesh can be changed by its weight and knitting pattern. These properties may be useful in making more biocompatible prostheses for pelvic organ prolapse (POP) with less foreign material to maintain longitudinal vaginal elasticity and minimize sexual symptoms while maintaining transverse resistance (i.e., between vaginal fornixes) to prevent POP recurrence. Neurourol. Urodynam. 36:73-79, 2017. © 2015 Wiley Periodicals, Inc.

Mesh-related and intraoperative complications of pelvic organ prolapse repair

INTRODUCTION

To evaluate the rates of complications of pelvic organ prolapse repair and to determine their risk factors.

MATERIAL AND METHODS

The study included 677 patients operated for pelvic organ prolapse with trocar guided Prolift mesh. Patients were followed up within 1 and 3 months. A phone interview was conducted and patients with complaints were invited and evaluated in office settings.

RESULTS

Mean age was 60 years. For the phone interview, 86.5% of patients were available. Overall complication rates were 22.5% (152/677). Fifteen patients (2.2%) developed bleeding over 500 cc; pelvic hematomas - 5.5%; perineal hematomas - 2.5%; urethral injuries - 0.3%; bladder injury in 1.6%; rectal damage in 0.7% and ureteral trauma in 0.2%. MESH RELATED COMPLICATIONS INCLUDED: erosions in 4.8%; vaginal synechiae - 0.3%; protrusion of mesh into the bladder - 0.15%; vesicovaginal fistula with mesh protrusion - 0.3%; mesh shrinkage - 1%; dyspareunia and pain in 2.4% cases. Pelvic abscess was found in 0.6% including one case of lethal necrotizing fasciitis. The risk factors of complications were assessed via logistic regression analysis.

CONCLUSIONS

Younger age, less prominent prolapse, hematomas and concomitant hysterectomies are associated with higher risk of complications.

Do patients prefer mesh or anterior colporrhaphy for primary correction of anterior vaginal wall prolapse: a labelled discrete choice experiment

OBJECTIVE

We investigated patients' preferences for anterior colporrhaphy or mesh surgery as surgical correction of anterior vaginal wall prolapse.

DESIGN

Labelled discrete choice experiment.

SETTING

Three Dutch teaching hospitals.

POPULATION

Women with anterior vaginal wall prolapse Pelvic Organ Prolapse Quantification stage 2 or more, indicated for anterior colporrhaphy (n = 100).

METHODS

Discrete choice experiments are an attribute-based survey method for measuring preferences. In this experiment, women were asked to choose between two treatment scenarios, mesh surgery or anterior colporrhaphy. These surgical treatments differed in four treatment attributes: (i) recurrence rate, (ii) exposure rate, (iii) infection rate, (iv) dyspareunia. Data were analysed using a multinomial logit model.

MAIN OUTCOME MEASURES

Women's preferences for anterior colporrhaphy or mesh surgery for the repair of vaginal wall prolapse.

RESULTS

All treatment attributes, i.e. recurrence, exposure, infection and dyspareunia, proved to be significant in the woman's decision to choose mesh surgery (P < 0.001), while only two attributes out of three, recurrence and infection, were significant for anterior colporrhaphy (P < 0.001). The relative importance data showed that with regards to the four statistically significant attributes for mesh, dyspareunia was the most important attribute, and of the two significant attributes for anterior colporrhaphy, the risk of infection. Based on the attributes and levels in our discrete choice experiment, anterior colporrhaphy was preferred in 74% as a primary correction of anterior vaginal wall prolapse, followed by a preference for mesh in 26% of all choices.

CONCLUSION

This study showed that next to the risk of recurrence, other aspects like risk of infection, dyspareunia and exposure play a role in the woman's preference for a surgical treatment. In addition, our results indicate that anterior colporrhaphy is preferred in the majority of the choices, followed by a preference for mesh surgery in a quarter of all choice sets. However, these results represent the average preference of a sample of women and cannot be taken as the preference of each individual. In the medical decision-making context, information from the current study should be personalised to fit patient's unique circumstances. For patients to construct their own, individual preferences, they should be well informed about the existence and magnitude of the potential benefits and risks related to either anterior colporrhaphy or mesh surgery.

Prospective study of transobturator mesh kit (Prolift™) in pelvic reconstructive surgery with vaginal hysterectomy after 3 years' follow-up

INTRODUCTION AND HYPOTHESIS

This study is to analyze prospectively the anatomical and functional outcomes of transvaginal pelvic reconstructive surgery using the Prolift™ system for pelvic organ prolapse (POP) with hysterectomy.

METHODS

A prospective, observational, noncomparative study was conducted in 80 patients with prolapse ≥ 2. Postoperative pelvic organ prolapse quantification stage was the main outcome measure. Anatomical cure was defined as vaginal vault stage 0 and improvement as stage 1. Secondary outcomes include pelvic floor distress inventory-20, incontinence impact questionnaire short form-7, and pelvic floor impact questionnaire short form-7.

RESULTS

A total of 80 patients were recruited. The cure and improvement rates were 96.3 % (77/80) and 3.7 % (3/80) respectively at 1 year. At the follow-up of 3-years, the cure rates were 93.3 % (70/75). Among the five patients, three had stage 2 anterior wall prolapse, two had stage 2 posterior wall prolapse. Only one patient with intraoperative adverse event (rectal perforation) was encountered. Postoperative complications included prolonged catheterization in three patients (3.7 %), postoperative stress urinary incontinence in five patients (6.25 %) and asymptomatic mesh extrusions in five patients (6.25 %). All of them occurred within 1 year follow-up. Significant improvements in quality of life were detected at 1 and 3 years compared with baseline.

CONCLUSION

The total Prolift™ system surgery represents a safe, simple and useful treatment for severe POP with satisfactory objective clinical outcomes.

Laparoscopic sacropexy: a retrospective analysis of the subjective outcome in 310 cases

Background and Objective. The aim of this study was to assess the subjective outcome following laparoscopic sacropexy. Methods. We performed a retrospective cohort study among women treated for descensus with laparoscopic sacropexy between January 2000 and December 2007. 310 patients received questionnaires during followup assessing major pre- and postoperative symptoms and overall satisfaction. Results. 214 (69%) patients responded to the questionnaire. Mean followup was 24.5 months. The number of patients with back or lower abdominal pain, foreign body sensation in the vagina and prolapse-related symptoms, urinary symptoms, vaginal and bladder infections, and the need for pessary usage decreased significantly postsurgically. Bowel symptoms increased slightly but not significantly. Two years after surgery, nearly 2 thirds of the women were satisfied or very satisfied with the outcome. Conclusion. Laparoscopic sacropexy is an effective treatment of descensus, with favorable or satisfactory subjective outcomes.

Outcome of transvaginal pelvic reconstructive surgery with Prolift after a median of 2 years' follow-up

INTRODUCTION AND HYPOTHESIS

This study seeks to analyze the medium- to long-term outcome of transvaginal pelvic reconstructive surgery using the Prolift™ system for pelvic organ prolapse.

METHODS

Sixty-five patients who underwent pelvic floor reconstruction using Prolift™ were followed for 1 to 3 years postoperatively. Assessment included pre- and postoperative Pelvic Organ Prolapse Quantification (POP-Q) stage, Urogenital Distress Inventory (UDI-6), and Incontinence Impact Questionnaire (IIQ-7) scores.

RESULTS

The overall anatomic success rate was 97% after a median of 24.5 months and 94% for the 34 women followed for more than 2 years. POP-Q stage, UDI-6, and IIQ-7 scores all improved significantly after surgery. Complications included one bladder perforation (1.5%) and one bowel perforation (1.5%), prolonged catheterization in four patients (6%), and mesh erosion in one (2%). Eight received blood transfusion (12%).

CONCLUSIONS

Prolift™ surgery yielded a good anatomical outcome and satisfactory symptom improvement that appeared to be durable after 2 years.

A persistent bladder erosion with ureteric involvement following mesh augmented repair of cystocele

We present a case of a 57-year-old woman who sustained bladder erosion with extension to the left ureter after a mesh-augmented recurrent cystocele repair. The persistence of the eroding mesh eventually necessitated a partial cystectomy and distal left ureterectomy, using a Boari flap technique.

[Informing a patient about surgical treatment for pelvic organ prolapse]

Inform consent is a major objective in the relation patient-physician. Patient's information becomes doubt when it is insufficient. To answer to medical persons asking about patient's information, pretreatment clinical and paraclinical assessment will be discussed. Reflexion delay, surgical alternative therapy and pre-operatory examination will be exposed. Several critical situations, such as associated hysterectomy, patient's comorbidity (tobacco, obesity) or synthetic mesh reinforcement have to be well-known to inform patient about failures and outcomes.

Mechanical evaluation of synthetic biomaterials used in the correction of pelvic floor disorders--experimental study in rabbits

OBJECTIVE

To evaluate the biomechanical properties of the principal prosthetic materials currently used in genital prolapse surgery.

STUDY DESIGN

Based on an animal model of incisional abdominal hernia, 40 adult rabbits were implanted. Four 2.5 cm x 2.5 cm parietal defects, were created in the abdominal fascia and muscles while respecting the peritoneum. For each rabbit, the defect was repaired by four different large pore size prostheses which varied according to the material used: two with monofilament of heavy (75 g/m(2)) or low (38 g/m(2)) weight polypropylene (PP), and two with multifilament of heavy (115 g/m(2)) or low (59 g/m(2)) weight polyethylene-terephthalate (PET). Animals were sacrificed in groups of 10 after 14, 30, 90 and 180 days to evaluate contraction, solidity and elasticity of the prostheses.

RESULTS

PP and PET retracted, independently of their weight, in 81.25% and 20% respectively. Intensity of contraction was not predictable but median value of retracted surface was 14% with PP, none with PET. Contraction settled quickly after tissue integration and did not subsequently occur. Heavyweight PET was considered the most solid material (70 N cm(-1)), low-weight PP the most fragile (20 N cm(-1)). Heavy forms of PP or PET resisted better to the rupture than the light forms which were sometimes insufficient to resist the extreme values of the human abdominal pressure (16 N cm(-1)). PP was more flexible than PET, but PET was the only form which was able to support extreme values of the abdominal pressure and remain in the elastic range. Duration of implantation did not modify solidity or elasticity of the prostheses.

CONCLUSION

In our abdominal rabbit model, as regards mechanical properties, heavyweight PET seems to be the optimal biomaterial.

Long-term quality-of-life outcome after mesh sacrocolpopexy for vaginal vault prolapse

OBJECTIVE

To evaluate the long-term outcome of mesh sacrocolpopexy (MSC, which aims to restore normal pelvic floor anatomy to alleviate prolapse related symptoms) and its effect on patient's quality of life, as women with vaginal vault prolapse commonly have various pelvic floor symptoms that can affect urinary, rectal and sexual function.

PATIENTS AND METHODS

From January 2000 to June 2006, consecutive patients with confirmed stage 2-4 vaginal vault prolapse subsequently had a MSC. Detailed telephone interviews using the Cleveland Clinic Short Form-20 Pelvic Floor Distress Inventory (PFDI) questionnaire, with Urinary Distress Inventory (UDI), Pelvic Organ Prolapse Distress Inventory (POPDI) and Colorectal-Anal Distress Inventory (CRADI) subscales was completed by all patients to assess symptoms before and after MSC, improvement in sexual function and overall satisfaction.

RESULTS

In all, 21 patients had abdominal MSC; the median (range) follow-up was 52.2 (21-99) months. Total PFDI scores were significantly better after MSC (mean 44.0/300) than before (mean 113.9/300; P < 0.001). Analysis of the subscale scores showed that all patients reported a significant improvement of symptoms in the POPDI category (P < 0.001). CRADI subscale scores showed no significant change after MSC (before, mean 7.43/100 vs after 8.47/100; P = 0.542). There was an improvement of urinary symptoms on the UDI subscale after MSC but it was not statistically significant (P = 0.08). Analysis of score differences over time after MSC showed an insignificant decreasing slope (P = 0.227), suggesting long-term stability of symptoms after surgery; 90% of patients reported a significant improvement in sexual function and excellent long-term overall satisfaction with MSC.

CONCLUSION

Our results suggest that MSC is a safe and effective surgical option for treating vaginal vault prolapse, providing symptom improvement and stability in the long term.

Experimental comparison of abdominal wall repair using different methods of enhancement by small intestinal submucosa graft

INTRODUCTION AND HYPOTHESIS

To assess the biomechanical properties of full-thickness abdominal wall defects, either using Native tissues, with or without Overlay, and by substitution of the Defect by small intestinal submucosa mesh.

METHODS

Seventy-two rats were divided into three groups according to repair method (Native, Overlay or Defect). At 7, 14, 30, and 90 days, six rats were sacrificed to measure tensile strength, collagen ingrowth, and host response.

RESULTS

Explants had comparable strength at 30 days, the majority rupturing at the interface. Afterwards, the Native group was more resistant than both small intestine submucosa (SIS) groups with a more organized fibrotic scar on histology at 90 days.

CONCLUSIONS

SIS augmentation of native tissue repair does not increase strength. Replacement of abdominal wall by SIS is equally strong when compared to the SIS-augmented group; however, materials preferably rupture at the site of the implant itself.