Serious complications and recurrences after pelvic organ prolapse surgery for 2309 women in the VIGI-MESH registry

Complications of Pelvic Prolapse Surgery Using Mesh: A Systematic Review

BACKGROUND

Pelvic organ prolapse (POP) is a public health problem that influences millions of women around the globe, and it has a significant impact on the quality of life. From the FDA statement regarding the complications of using mesh implants in POP surgery to studies that have shown the benefits and side effects, we conducted a systematic review investigating the complications associated with surgical mesh implantation for POP repair.

METHODS

Relevant studies were identified through a comprehensive search of scientific databases. Studies evaluating the use of mesh in POP surgery and reporting on associated complications were included.

RESULTS

Among 2816 studies, 28 studies met the research criteria, with a total number of 8958 patients, revealing that in laparoscopic mesh surgery, the rate of mesh exposure was lower compared to vaginal mesh surgery, among other complications.

CONCLUSIONS

Laparoscopic mesh surgery is superior as a long-term approach for POP repair compared to vaginal mesh surgery, offering lower complication rates and potentially better anatomical success. However, vaginal mesh surgery remains a valuable option for patients who are unsuitable for laparoscopy due to specific factors. Future research should explore alternative techniques, like pectopexy with or without mesh, to further improve surgical outcomes and patient experience.

Long-Term Mesh Exposure 5 Years Following Minimally Invasive Total Hysterectomy and Sacrocolpopexy

INTRODUCTION AND HYPOTHESIS

The objective was to assess long-term mesh complications following total hysterectomy and sacrocolpopexy.

METHODS

In this second extension study, women from a multicenter randomized trial were followed for more than 36 months after surgery. Owing to COVID-19, participants were assessed through either in-person visits or telephone questionnaires. The primary outcome was the incidence of permanent suture or mesh exposure. Secondary outcomes included surgical success and late adverse outcomes.

RESULTS

Out of the 200 initially enrolled participants, 82 women took part in this second extension study. Among them, 46 were in the permanent suture group, and 36 in the delayed absorbable group. The mean follow-up duration was 5.3 years, with the cumulative mesh or suture exposure of 9.9%, involving 18 cases, of which 4 were incident cases. Surgical success after more than 5 years stood at 95%, with few experiencing bothersome bulge symptoms or requiring retreatment. No serious adverse events occurred, including mesh erosion into the bladder or bowel. The most common adverse events were vaginal pain, bleeding, dyspareunia, and stress urinary incontinence, with no significant differences between suture types.

CONCLUSION

The study found that mesh exposure risk gradually increased over time, reaching nearly 10% after more than 5 years post-surgery, regardless of suture type. However, surgical success remained high, and no delayed serious adverse events were reported.

Diagnosis and management of complications following pelvic organ prolapse surgery using a synthetic mesh: French national guidelines for clinical practice

Complications associated with pelvic organ prolapse (POP) surgery using a synthetic non-absorbable mesh are uncommon (<5%) but may be severe and may hugely diminish the quality of life of some women. In drawing up these multidisciplinary clinical practice recommendations, the French National Authority for Health (Haute Autorité de santé, HAS) conducted an exhaustive review of the literature concerning the diagnosis, prevention, and management of complications associated with POP surgery using a synthetic mesh. Each recommendation for practice was allocated a grade (A,B or C; or expert opinion (EO)), which depends on the level of evidence (clinical practice guidelines).

PREOPERATIVE PATIENTS' INFORMATION

Each patient must be informed concerning the risks associated with POP surgery (EO).

HEMORRHAGE, HEMATOMA

Vaginal infiltration using a vasoconstrictive solution is not recommended during POP surgery by the vaginal route (grade C). The placement of vaginal packing is not recommended following POP surgery by the vaginal route (grade C). During laparoscopic sacral colpopexy, when the promontory seems highly dangerous or when severe adhesions prevent access to the anterior vertebral ligament, alternative surgical techniques should be discussed per operatively, including colpopexy by lateral mesh laparoscopic suspension, uterosacral ligament suspension, open abdominal mesh surgery, or surgery by the vaginal route (EO).

BLADDER INJURY

When a bladder injury is diagnosed, bladder repair by suturing is recommended, using a slow resorption suture thread, plus monitoring of the permeability of the ureters (before and after bladder repair) when the injury is located at the level of the trigone (EO). When a bladder injury is diagnosed, after bladder repair, a prosthetic mesh (polypropylene or polyester material) can be placed between the repaired bladder and the vagina, if the quality of the suturing is good. The recommended duration of bladder catheterization following bladder repair in this context of POP mesh surgery is from 5 to 10 days (EO).

URETER INJURY

After ureteral repair, it is possible to continue sacral colpopexy and place the mesh if it is located away from the ureteral repair (EO).

RECTAL INJURY

Regardless of the approach, when a rectal injury occurs, a posterior mesh should not be placed between the rectum and the vagina wall (EO). Concerning the anterior mesh, it is recommended to use a macroporous monofilament polypropylene mesh (EO). A polyester mesh is not recommended in this situation (EO).

VAGINAL WALL INJURY

After vaginal wall repair, an anterior or a posterior microporous polypropylene mesh can be placed, if the quality of the repair is found to be satisfactory (EO). A polyester mesh should not be used after vaginal wall repair (EO).

MESH INFECTION (ABSCESS, CELLULITIS, SPONDYLODISCITIS)

Regardless of the surgical approach, intravenous antibiotic prophylaxis is recommended (aminopenicillin + beta-lactamase inhibitor: 30 min before skin incision +/- repeated after 2 h if surgery lasts longer) (EO). When spondylodiscitis is diagnosed following sacral colpopexy, treatment should be discussed by a multidisciplinary group, including especially spine specialists (rheumatologists, orthopedists, neurosurgeons) and infectious disease specialists (EO). When a pelvic abscess occurs following synthetic mesh sacral colpopexy, it is recommended to carry out complete mesh removal as soon as possible, combined with collection of intraoperative bacteriological samples, drainage of the collection and targeted antibiotic therapy (EO). Non-surgical conservative management with antibiotic therapy may be an option (EO) in certain conditions (absence of signs of sepsis, macroporous monofilament polypropylene type 1 mesh, prior microbiological documentation and multidisciplinary consultation for the choice of type and duration of antibiotic therapy), associated with close monitoring of the patient.

BOWEL OCCLUSION RELATED TO NON-CLOSURE OF THE PERITONEUM

Peritoneal closure is recommended after placement of a synthetic mesh by the abdominal approach (EO).

URINARY RETENTION

Preoperative urodynamics is recommended in women presenting with urinary symptoms (bladder outlet obstruction symptoms, overactive bladder syndrome or incontinence) (EO). It is recommended to remove the bladder catheter at the end of the procedure or within 48 h after POP surgery (grade B). Bladder emptying and post-void residual should be checked following POP surgery, before discharge (EO). When postoperative urine retention occurs after POP surgery, it is recommended to carry out indwelling catheterization and to prefer intermittent self-catheterization (EO).

POSTOPERATIVE PAIN

Before POP surgery, the patient should be asked about risk factors for prolonged and chronic postoperative pain (pain sensitization, allodynia, chronic pelvic or non-pelvic pain) (EO). Concerning the prevention of postoperative pain, it is recommended to carry out a pre-, per- and postoperative multimodal pain treatment (grade B). The use of ketamine intraoperatively is recommended for the prevention of chronic postoperative pelvic pain, especially for patients with risk factors (preoperative painful sensitization, allodynia, chronic pelvic or non-pelvic pain) (EO). Postoperative prescription of opioids should be limited in quantity and duration (grade C). When acute neuropathic pain (sciatalgia or pudendal neuralgia) resistant to level I and II analgesics occurs following sacrospinous fixation, a reintervention is recommended for suspension suture removal (EO). When chronic postoperative pain occurs after POP surgery, it is recommended to systematically seek arguments in favor of neuropathic pain with the DN4 questionnaire (EO). When chronic postoperative pelvic pain occurs after POP surgery, central sensitization should be identified since it requires a consultation in a chronic pain department (EO). Concerning myofascial pain syndrome (clinical pain condition associated with increased muscle tension caused by myofascial trigger points), when chronic postoperative pain occurs after POP surgery, it is recommended to examine the levator ani, piriformis and obturator internus muscles, so as to identify trigger points on the pathway of the synthetic mesh (EO). Pelvic floor muscle training with muscle relaxation is recommended when myofascial pain syndrome is associated with chronic postoperative pain following POP surgery (EO). After failure of pelvic floor muscle training (3 months), it is recommended to discuss surgical removal of the synthetic mesh, during a multidisciplinary discussion group meeting (EO). Partial removal of synthetic mesh is indicated when a trigger point is located on the pathway of the mesh (EO). Total removal of synthetic mesh should be discussed during a multidisciplinary discussion group meeting when diffuse (no trigger point) chronic postoperative pain occurs following POP surgery, with or without central sensitization or neuropathic pain syndromes (EO).

POSTOPERATIVE DYSPAREUNIA

When de novo postoperative dyspareunia occurs after POP surgery, surgical removal of the mesh should be discussed (EO).

VAGINAL MESH EXPOSURE

To reduce the risk of vaginal mesh exposure, when hysterectomy is required during sacral colpopexy, subtotal hysterectomy is recommended (grade C). When asymptomatic vaginal macroporous monofilament polypropylene mesh exposure occurs, systematic imaging is not recommended. When vaginal polyester mesh exposure occurs, pelvic +/- lumbar MRI (EO) should be used to look for an abscess or spondylodiscitis, given the greater risk of infection associated with this type of material. When asymptomatic vaginal mesh exposure of less than 1 cm2 occurs in a woman with no sexual intercourse, the patient should be offered observation (no treatment) or local estrogen therapy (EO). However, if the patient wishes, partial excision of the mesh can be offered. When asymptomatic vaginal mesh exposure of more than 1 cm2 occurs or if the woman has sexual intercourse, or if it is a polyester prosthesis, partial mesh excision, either immediately or after local estrogen therapy, should be offered (EO). When symptomatic vaginal mesh exposure occurs, but without infectious complications, surgical removal of the exposed part of the mesh by the vaginal route is recommended (EO), and not systematic complete excision of the mesh. Following sacral colpopexy, complete removal of the mesh (by laparoscopy or laparotomy) is only required in the presence of an abscess or spondylodiscitis (EO). When vaginal mesh exposure recurs after a first reoperation, the patient should be treated by an experienced team specialized in this type of complication (EO).

SUTURE THREAD VAGINAL EXPOSURE

For women presenting with vaginal exposure to non-absorbable suture thread following POP surgery with mesh reinforcement, the suture thread should be removed by the vaginal route (EO). Removal of the surrounding mesh is only recommended when vaginal mesh exposure or associated abscess is diagnosed.

BLADDER AND URETERAL MESH EXPOSURE

When bladder mesh exposure occurs, removal of the exposed part of the mesh is recommended (grade B). Both alternatives (total or partial mesh removal) should be discussed with the patient and should be debated during a multidisciplinary discussion group meeting (EO).

Impact of preoperative pelvic floor muscle function on the success of surgical treatment of pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

The objective of this study was to identify the potential characteristics of pelvic floor muscles (PFM) in the preoperative assessment that could be associated with post-surgical prolapse severity. We hypothesized that the same variables, if identified, could be addressed in preoperative rehabilitation to improve surgical results.

METHODS

This was a single-center prospective observational study that included women who underwent surgical pelvic organ prolapse repair between 2020-2022. Genital prolapse was evaluated according to the Pelvic Organ Prolapse Quantification (POP-Q) system. All the participants underwent a PFM assessment, including a vaginal digital assessment and manometry (Peritron™ 9300 V) before surgery and at 1-, 3-, and 6-month follow-ups. Several PFM variables were recorded: vaginal resting pressure, vaginal pressure during maximal voluntary contraction (MVC), area under the curve during a 10-second MVC, ability to correctly contract the PFMs, and reflexive activation during cough and relaxation. The primary endpoint of the analysis was objective surgical success defined as POP-Q 0 or 1 at the 6-month follow-up. Additionally, a change in pelvic floor muscle function was recorded during postoperative visits.

RESULTS

A total of 106 females were included in the study. Fifty-one were lost during the 6-month follow-up, which is a major limitation of the study. None of the examined parameters evaluating PFM were associated with surgical success. No statistically significant difference was found in MVC and PFM endurance before and after surgery. Post-surgery, a significant change was observed in the vaginal resting pressure and the ability to correct PFM activation and relaxation.

CONCLUSIONS

Preoperative PFM function is not associated with surgical success 6 months after surgery.

Microbiome alterations in women with pelvic organ prolapse and after anatomical restorative interventions

Pelvic organ prolapse (POP) is a benign gynecological disease in which the pelvic organ descends into the vagina and causes voiding, and defecatory dysfunction, mainly occurs in older women. This study aimed to investigate the vaginal microbiome of POP and associated changes after anatomical restorative pessary or reconstructive pelvic operation. We analyzed the vaginal microbiome using 16S ribosomal RNA gene sequencing and compared the results among patient groups with POP, pessary, and postoperation. We also measured 10 inflammation-related cytokines in vaginal swab samples using multiplex immunoassay. In pelvic organ prolapse, vaginal community status type IV was the most prevalent, which showed a low abundance of Lactobacillus with increased diversity and abundance of anaerobic species. The alpha diversity of species richness was highest in the POP group. The beta diversity distance differed significantly between the three groups (p = 0.001). While human intestinal taxa-associated bacteria were reduced after pessary or operation, vaginitis-associated bacterial composition was altered but vaginal microbiome homeostasis was not improved. IFN-γ, IL-10, IL-12p70, IL-1β, IL-4 and TNF-α levels increased in the pessary group. Therefore, in addition to anatomical restorative treatment, supplementary treatment focusing on the recovery of the vaginal microbiome may be needed to maintain the health of gynecological organs in old age.

Emerging trends on the mechanism of pelvic organ prolapse from 1997 to 2022: visualization and bibliometric analysis

Objective

At present, there is no feature description of the mechanism of pelvic organ prolapse (POP) in the literature. This study aimed to map the emerging trends regarding the mechanism of POP from inception to 2022 by bibliometric analysis and to analyze its research hotspots and frontiers.

Methods

We downloaded pertinent publications from inception to 2022 from the Web of Science Core Collection (WoSCC) on 30 June 2022. The data were then examined using the Bibliometrix program in R (Version 4.1.0), CiteSpace software, the Online Analysis Platform of Literature Metrology (https://bibliometric.com), and a bibliometrix online interface.

Results

A total of 290 qualified records on the mechanism of POP were identified and included in the analysis. The most productive journal was International Urogynecology Journal. Bump RC and Olsen AL were the most cited authors. Extracellular matrix, collagen, apoptosis, elastin, oxidative stress, gene expression, matrix metalloproteinase, and tissue engineering were among the 25 most relevant terms. According to the analysis of trending topics, tissue engineering has become a new research hotspot.

Conclusion

Extracellular matrix remodeling, oxidative stress and apoptosis are the three main directions for studying the mechanism of POP. In addition, tissue engineering has become a new research hotspot. In the future, in-depth research on the interaction between different mechanisms will be carried out, and attempts will be made to combine biomimetic materials and seed cells to achieve the regeneration and reconstruction of POP-related organs.

Regional practice variation in pelvic organ prolapse surgery in Tuscany, Italy: a retrospective cohort study on administrative health data

OBJECTIVES

To explore determinants of practice variation in both access, and quality and efficiency of surgical care for pelvic organ prolapse (POP).

DESIGN AND SETTING

A retrospective cohort study employing administrative health data from the Tuscany region, Italy.

PARTICIPANTS

All women over 40 years hospitalised for apical/multicompartmental POP reconstructive surgery (excluding anterior/posterior colporrhaphy without concomitant hysterectomy) from January 2017 to December 2019.

OUTCOMES

We first computed treatment rates just for women residing in Tuscany (n=2819) and calculated the Systematic Component of Variation (SCV) to explore variation in access to care among health districts. Then, using the full cohort (n=2959), we ran multilevel models for the average length of stay and reoperations, readmissions and complications, and computed the intraclass correlation coefficient to assess the individual and hospital determinants of efficiency and quality of care provided by hospitals.

RESULTS

The 5.4-fold variation between the lowest-rate (56/100 000 inhabitants) and the highest-rate (302/100 000) districts and the SCV over 10% confirmed high systematic variation in the access to care. Higher treatment rates were driven by greater provisions of robotic and/or laparoscopic interventions, which showed highly variable usage rates. Both individual and hospital factors influenced quality and efficiency provided by hospitals, but just low proportions of variation were explained by hospital and patient characteristics.

CONCLUSIONS

We found high and systematic variation in the access to POP surgical care in Tuscany and in quality and efficiency provided by hospitals. Such a variation may be mainly explained by user and provider preferences, which should be further explored. Also, supply-side factors may be involved, suggesting that wider and more uniform dissemination of robotic/laparoscopic procedures may reduce variation.

Serious Complications and Recurrence following Sacrospinous Ligament Fixation for the Correction of Apical Prolapse

Objective: To evaluate the rates of serious complications and reoperation for recurrence following sacrospinous ligament fixation (SSLF) for apical pelvic organ prolapse. Methods: This was a national registry ancillary cohort comparative study. The VIGI-MESH registry includes data from 24 French health centers prospectively collected between May 2017 and September 2021. Time to occurrence of a serious complication or reoperation for genital prolapse recurrence was explored using the Kaplan-Meier curve and Log-rank test. The inverse probability of treatment weighting, based on propensity scores, was used to adjust for between-group differences. Results: A total of 1359 women were included and four surgical groups were analyzed: Anterior SSLF with mesh (n = 566), Anterior SSLF with native tissue (n = 331), Posterior SSLF with mesh (n = 57), and Posterior SSLF with native tissue (n = 405). Clavien-Dindo Grade III complications or higher were reported in 34 (2.5%) cases, with no statistically significant differences between the groups. Pelvic organ prolapse recurrence requiring re-operation was reported in 44 (3.2%) women, this was higher following posterior compared with anterior SSLF (p = 0.0034). Conclusions: According to this large database ancillary study, sacrospinous ligament fixation is an effective and safe surgical treatment for apical prolapse. The different surgical approaches (anterior/posterior and with/without mesh) have comparable safety profiles. However, the anterior approach and the use of mesh were associated with a lower risk of reoperation for recurrence compared with the posterior approach and the use of native tissue, respectively.