Clinical pathway for tension-free vaginal mesh procedure: evaluation in 300 patients with pelvic organ prolapse

Iatrogenic bladder injury following gynecologic and obstetric surgery: A systematic review and meta-analysis

INTRODUCTION

Iatrogenic bladder injury is a rare complication following obstetric and gynecologic surgery and only sparse information is available regarding length of transurethral catheterization following injuries, suturing techniques including choice of suture, and complications. The primary aim of this systematic review was to evaluate length of transurethral catheterization in relation to complications following iatrogenic bladder injury. Second, we aimed to evaluate the number of complications following repair of iatrogenic bladder injuries and to describe suture technique and best choice of suture.

MATERIAL AND METHODS

A systematic review and meta-analysis was conducted, and the results were presented in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. PubMed, Embase, and Medline electronic databases were searched, and followed by screening from two independent reviewers. Studies published between January 2000 and March 2023 describing methods of bladder injury repair following obstetric or gynecologic benign surgery were included. Data extraction was done using Covidence. We performed a meta-analysis on complications after repair and explored this with a meta-regression analysis (Metafor package R) on length of catheterization to determine if length of catheterization influenced the risk of complication. A risk of bias tool from Cochrane was used to assess risk of bias and the study was registered in PROSPERO (CRD42021290586).

RESULTS

Out of 2175 articles, we included 21 retrospective studies, four prospective studies, and one case-control study. In total, 595 bladder injuries were included. Cesarean section was the most prominent surgery type, followed by laparoscopically assisted vaginal hysterectomy. We found no statistically significant association between length of transurethral catheterization and numbers of complications following repair of iatrogenic bladder injuries. More than 90% of injuries were recognized intraoperatively. Approximately 1% had complications following iatrogenic bladder injury repair (0.010, 95% confidence interval 0.0015-0.0189, 26 studies, 595 participants, I2  = 4%).

CONCLUSIONS

Our review did not identify conclusive evidence on the length of postoperative catheterization following bladder injury warranting further research. However, the rate of complications was low following iatrogenic bladder injury with a wide range of repair approaches.

Are anterior mesh arms necessary in Japanese-style transvaginal mesh surgery for cystocele?

AIM

In this study, we retrospectively analyzed the medium-term efficacy and safety of surgery with transobturator two-arm transvaginal mesh for cystocele and to verify whether the anterior arms are necessary for Japanese-style transvaginal mesh surgery.

METHODS

The study included 203 patients with cystocele who underwent transobturator two-arm transvaginal mesh at our hospital between August 2015 and June 2017 and received appropriate follow-up care for at least 48 months after surgery.

RESULTS

The Pelvic Organ Prolapse Quantification stage was III in all the patients. Intraoperative complications included two cases of bladder injury and one case of more than 200 mL of blood loss. The mean observation period was 51.9 months, and prolapse recurred in the operated compartment in nine patients (4.4%). No cases of mesh exposure were observed. In comparing the preoperative characteristics of the 9 patients with prolapse recurrence at the surgical site with those of the other 194 patients, we found that the recurrence rate was significantly higher among patients in whom point Ba being 3.5 cm or more and among patients younger than 66 years.

CONCLUSIONS

Transobturator two-arm transvaginal mesh for cystocele was as good and safe as the procedure previously reported with four-arm mesh; thus, it was possible to omit the anterior mesh arms in Japanese-style transvaginal mesh surgery. Patients should be informed preoperatively that prolapse recurs at a significantly higher rate among younger patients and in those whose point Ba being 3.5 cm or more.

Is transvaginal mesh procedure a potential measure for pelvic organ prolapse repair when performed by expert surgeons?

OBJECTIVES

The aim of this study was to verify the safety and efficacy of transvaginal mesh by analyzing the 2-year follow-up data of patients performed by a surgeon with a high volume of procedures.

METHODS

A total of 617 patients with pelvic organ prolapse underwent transvaginal mesh by a single surgeon. Complications and anatomical status of each patient were examined up to 24 months after surgery. Risk factors for the recurrence were also analyzed.

RESULTS

Regarding complications, we experienced 10 patients (3.8%) of bladder injuries in anterior transvaginal mesh and eight (3.4%) in anterior and posterior transvaginal mesh. Massive blood loss was observed in four patients, but there was no case of blood transfusion. Mesh exposures were seen in seven patients (1.2%). A total of 100 patients (16.2%) had prolapse recurrence, defined as the Pelvic Organ Prolapse Quantification System stage ≥II. As to recurrences on the operated compartments, we observed five patients (2.0%) for anterior transvaginal mesh, three (6.5%) for posterior transvaginal mesh, five (7.4%) for combined transvaginal mesh, and 31 (14.2%) in anterior and posterior transvaginal mesh. Regarding Point C before operation in the anterior and posterior transvaginal mesh, the recurrence rates were more than 23% in patients with a Point C of 4 or more. Binominal regression analyses showed that higher body mass index, younger age, and higher stage of uterine prolapse were significant risk factors.

CONCLUSIONS

The transvaginal mesh surgery is safe when conducted by experts. However, the recurrence rate may exceed 20% for high-stage uterine prolapse even when conducted by experts.

Comparison of effectiveness between modified transvaginal mesh surgery and vaginal pessary treatment in patients with symptomatic pelvic organ prolapse

OBJECTIVES

This study aimed to compare the efficacy of modified transvaginal mesh (TVM) surgery and vaginal pessary in patients with symptomatic pelvic organ prolapse (POP).

METHODS

We retrospectively analyzed 130 patients with symptomatic POP treated with either modified TVM (n = 62) or vaginal pessary (n = 68). To evaluate the prolapse, lower urinary tract, bowel, and sexual symptoms and prolapse-related quality of life (QOL) were assessed using the prolapse QOL questionnaire. All questionnaires were completed before treatment and 1 year after the treatment.

RESULTS

One year after the treatment, the prolapse and voiding symptoms and all prolapse-related QOL domains, except for the personal relationships and sleep/energy, were significantly improved in the pessary group. The prolapse, urinary storage, voiding, bowel, and sexual symptoms and all QOL domains significantly improved in the modified-TVM group.

CONCLUSIONS

Both the modified TVM surgery and vaginal pessary effectively treated prolapse and voiding symptoms and improved most of the prolapse-related QOL domains. Modified TVM surgery was more effective in improving urinary storage, bowel, and sexual symptoms than the pessary treatment. Modified TVM seemed to position the organs more correctly to improve bladder, bowel, and sexual function than pessary insertion.

Bladder cancer invasion along a tension-free vaginal mesh

INTRODUCTION

The effect of synthetic mesh after pelvic organ prolapse surgery on the progression of bladder cancer remains unclear.

CASE PRESENTATION

A 79-year-old woman who underwent a tension-free vaginal mesh procedure 8 years prior was diagnosed with carcinoma in situ of the bladder. Although intravesical Bacillus Calmette-Guérin therapy was started, the tumor rapidly became muscle invasive. Laparoscopic radical cystectomy was performed following radiochemotherapy; however, the tumor extended to the left internal obturator muscle along the mesh arm. Pathological findings showed desmoplastic high-grade urothelial carcinoma infiltrating around the mesh. Finally, cancer recurred rapidly in the left internal obturator muscle.

CONCLUSION

Synthetic mesh can become an abnormal anatomical pathway for tumor infiltration. Therefore, in high-risk bladder cancer patients who underwent a tension-free vaginal mesh procedure, radical cystectomy should be performed without delay before the tumor invades the perivesical tissue.

Clinical outcomes after laparoscopic sacrocolpopexy for pelvic organ prolapse: A 3-year follow-up study

OBJECTIVES

To evaluate the mid-range subjective and objective success rate of laparoscopic sacrocolpopexy.

METHODS

Of the 317 women with pelvic organ prolapse who underwent laparoscopic sacrocolpopexy surgery at the same center between January 2013 and March 2015, we assessed 233 patients who were followed up for >3 years. We carried out urogynecological examinations and used questionnaires for the postoperative assessment of the patients. Scoring 0 points on question 3 of the Pelvic Floor Distress Inventory-20 was considered to show subjective success. Objective success was defined as stage 0 or 1 on the Pelvic Organ Prolapse Quantification.

RESULTS

The subjective and objective success rates in the third year after surgery were 89.7% (209/233) and 90.6% (211/233), respectively, and those in the first year were 90.6% (211/233) and 91.0% (212/233), respectively. Perioperative complications included bladder injury (0.4%) in one case and vaginal wall injury (0.4%) in one case. Postoperative complications included the incidence of chronic pain (mesh retraction) in one case, which was the only case requiring re-operation due to complications (0.4%); vaginal suture exposure (0.4%) in one case; port-site hernia (0.4%) in one case; and subileus (0.4%) in one case. The complications associated with voiding function included de novo stress urinary incontinence (20.6%) in 48 cases, out of which there were 12 cases of de novo overactive bladder (5.2%) and eight cases required midurethral sling procedures.

CONCLUSIONS

Laparoscopic sacrocolpopexy provides a good outcome with a low rate of subjective and objective recurrence and surgical complications.

Mesh exposure after transvaginal mesh prolapse surgery: Out of permissible range?

OBJECTIVES

To investigate the prevalence of postoperative complications after transvaginal mesh prolapse surgery, and whether modified transvaginal mesh prolapse surgery (without transobturator arms or posterior mesh) has less prevalence of mesh exposure compared with conventional transvaginal mesh prolapse surgery.

METHODS

Medical charts were retrospectively examined for 2648 patients who underwent transvaginal mesh prolapse surgery in a general hospital (2006-2017). Conventional transvaginal mesh prolapse surgery (Prolift-type, n = 2258) was used, with a shift from 2015 to modified transvaginal mesh prolapse surgery (Uphold-type, n = 330). Patients were instructed to have >2 years of follow up and to report if they had problems regarding the operation.

RESULTS

The prevalence of mesh exposure was 34 out of 2648 (1.28%); 18 vagina (0.68%), 10 bladder (0.38%), two ureter (0.08%) and four rectum (0.15%). The modified transvaginal mesh prolapse surgery group had only one case with vaginal exposure. Vaginal exposure was managed transvaginally or followed by observation. Rectal exposure was managed transvaginally without colostomy. Bladder exposure was managed by transurethral resection with saline. Open ureterocystostomy was carried out to treat ureteral exposure. In the conventional transvaginal mesh prolapse surgery group, three cases of ureteral stenosis and one case with vaginal evisceration of the small intestine were managed transvaginally. The prevalence of postoperative chronic pain was 13 out of 2648 (0.49%; with one patient in the modified transvaginal mesh prolapse surgery group). The patients underwent pharmacotherapy, and one patient underwent additional surgical treatment.

CONCLUSIONS

The reoperation rate as a result of complications after transvaginal mesh prolapse surgery seems to be low. The reoperation rate as a result of prolapse recurrence is also low. A shift from conventional transvaginal mesh prolapse surgery to modified transvaginal mesh prolapse surgery might contribute to a further decrease in the risk of complications.

Predictors of persistent stress urinary incontinence after transvaginal mesh repair

BACKGROUND

We evaluated the effect of transvaginal mesh (TVM) surgery for voiding function and continence using noninvasive examination and questionnaire. The present study aimed to ascertain which categories of patients need concomitant mid-urethral sling (MUS) after TVM surgery.

METHODS

We included women who underwent TVM procedure between November 2009 and October 2013. Data from noninstrumented uroflowmetry and questionnaires about urinary symptoms were analyzed.

RESULTS

The present study investigated the cases of 961 women who underwent TVM surgery. The persistence of stress urinary incontinence (SUI) was 57.6%. Almost all the parameters measured using uroflowmetry and questionnaires significantly improved in all types of urinary incontinence 12 months after surgery. A history of hysterectomy, preoperative high flow (corrected maximum flow rate > 1.5), and preoperative urge urinary incontinence were independent risk factors for the persistence of SUI.

CONCLUSIONS

TVM for pelvic organ prolapse improved subjective and objective voiding function. Mixed urinary incontinence (MUI) patients with high urinary flow may be suitable for concomitant MUS with TVM because of the high level of SUI persistence.

[ABDOMINAL MASS AND ASCITES AS RISK FACTORS OF PELVIC ORGAN PROLAPSE]

(Objective) A rise of intra-abdominal pressure may exacerbate pelvic organ prolapse (POP) as well as abdominal hernias. This paper aims to assess the possible risk factors of an abdominal mass and ascites as comorbidities of POP. (Methods) We retrospectively reviewed the medical charts of 2,748 POP patients between 2010 and 2016 and extracted eight cases (0.3%) with abdominal mass and ascites as risk factors. (Results) All eight patients were multiparous women aged between 52 and 88 years old. Three patients (cases 1-3) were referred to us for surgery related to POP from gynecologists with previously undetected ovarian tumors. In case 1, we noticed abdominal distension during a transvaginal mesh (TVM) operation. Postoperative CT and MRI scans confirmed the presence of an ovarian tumor 24 cm in diameter (mucinous cystic tumor, borderline malignant). In case 2, transvaginal ultrasound could not detect the ovaries, but a transabdominal ultrasound, which was done to investigate urinary retention, revealed an ovarian tumor 18 cm in diameter (mucinous cystic adenoma). In case 3, a detailed patient history outlined the patient's sense of abdominal fullness and a transvaginal ultrasound found ovarian cancer 10 cm in diameter with ascites (serous adenocarcinoma). Case 4 suffered from autosomal dominant polycystic kidney disease (ADPKD) with large liver cysts. The patient underwent a TVM operation to treat the presenting POP with unusual bleeding (460 g). Case 5 had abdominal distension and cystocele due to huge abdominal mass (recurrence of malignant lymphoma); she desired conservative follow-up to tumor and POP due to old age (88 years old). Two patients suffered from end-stage cancer (case 6: colorectal cancer, case 7: breast cancer) with liver metastasis. In cases 6 and 7, the patients' POP worsened with the increase of ascites, which was managed conservatively. Case 8 presented with liver cirrhosis related ascites and a total uterine prolapse, simultaneously. Colpocleisis was cancelled due to the onset of hepatic coma. (Conclusions) Abdominal mass and ascites are risk factors of POP by increasing abdominal pressure and lesions such as ovarian tumors may present as POP. Even when POP patients are referred from gynecologists, a vaginal examination, carefully recorded patient history, and abdominal palpation should be included as part of a standard treatment regimen to reliably exclude underlying diseases.

Perioperative complications in abdominal sacrocolpopexy, sacrospinous ligament fixation and prolift procedures

BACKGROUND

Pelvic organ prolapse is an important problem for women. To overcome this issue, different operational technics are in use, such as abdominal sacrocolpopexy, sacrospinous fixation, and the total Prolift procedure.

AIMS

This study assessed perioperative complications in abdominal sacrocolpopexy, sacrospinous fixation, and the total Prolift procedure.

STUDY DESIGN

Retrospective comparative study.

METHODS

Perioperative complications were defined as any complication occurring during surgery or the first 6 weeks postoperatively. Forty-five patients underwent abdominal procedures, 60 patients underwent sacrospinous fixation, and 43 patients underwent the total Prolift procedure.

RESULTS

In the abdominal group, one bladder injury, four hemorrhages, and three wound dehiscences occurred. In the sacrospinous group, one rectal injury and one postoperative vault infection occurred. In the Prolift group, one bladder injury and one hemorrhage occurred. Minor complications were more frequent in the abdominal group than the others. The operating time and hospital stay of the abdominal group were significantly longer than the others. The Pro-lift procedure had less operating time and hospital stay than other procedures.

CONCLUSION

The total Prolift may be a novel alternative for apical prolapse with low perioperative morbidities and complications.

Perioperative complications in vaginal mesh procedures using trocar in pelvic organ prolapse repair

INTRODUCTION AND HYPOTHESIS

This study aimed to document intraoperative and early postoperative complications associated with the use of vaginal mesh with trocar in pelvic organ prolapse (POP) repair.

METHODS

This is a retrospective review of 120 cases of vaginal repair of POP using vaginal mesh. Of the 120 patients, 31 underwent anterior mesh repair (Light mesh 10, Avaulta 1, Perigee 1, and Prolift 19); 35 underwent posterior mesh repair (Light mesh 2, Posterior IVS 17, and Prolift 16); and 54 underwent anterior and posterior mesh (total) repair (Light mesh 8, Prolift 32, and Prolift M 14).

RESULTS

Three bladder injuries (2.5%) and one distal rectal injury (0.8%) occurred during dissection. Three of four organ injuries (75%) had previous prolapse repair. Overall four patients (3%) required transfusion. Urinary retention exceeding 5 days occurred in four patients. Three of them (60%) also underwent TVT-O. Groin pain occurred in two patients one of whom underwent TVT-O. Gluteal pain occurred in one patient. Early mesh exposure occurred in the vaginal cuff of a patient who underwent hysterectomy.

CONCLUSIONS

The vaginal mesh procedures may be done with relatively few perioperative complications. However, there is a need for more randomized controlled trials with long-term follow-up to clarify its postoperative long-term complications and morbidities.

Fluoroscopic imaging of needle position in the tension-free vaginal mesh procedure for pelvic organ prolapse: two case reports

The tension-free vaginal mesh (TVM) procedure has become one of the commonly used treatments for pelvic organ prolapse (POP) due to good clinical outcome. However, there are several technical difficulties associated with this procedure. We performed fluoroscopy for imaging of the surgical procedure on the TVM to resolve the technical problems regarding needle penetration. Fluoroscopic imaging with rectogram and cystogram demonstrated the positions of the needle, pelvic organs and index finger for needle guidance in the TVM procedure. Fluoroscopic imaging may be useful to understand the movement of surgical devices in the blind space, objectively evaluate the surgeon's skill, avoid injury to the pelvic organs, and detect any such injury immediately should it occur.

Teaching patients clean intermittent self-catheterisation prior to anti-incontinence or prolapse surgery: is it necessary in women with obstructive voiding dysfunction?

PURPOSE

To determine the value of pre-operative teaching of clean intermittent self-catheterisation (CISC) in women who undergo anti-incontinence and/or prolapse surgery and who are at 'high risk' to have post-operative incomplete bladder emptying.

METHODS

Out of the 402 patients who underwent anti-incontinence and/or prolapse surgery at our institute (March 2008-March 2009), 48 patients had at least one obstructive lower urinary tract symptom and one obstructive urodynamic parameter before surgery and were considered at 'high risk' to have post-operative incomplete bladder emptying. They were taught CISC pre-operatively.

RESULTS

Out of the 48 patients, 7 (14.6%) had incomplete bladder emptying. The incidence of post-operative incomplete bladder emptying was higher in the older women (P < 0.01) but was not affected by the type of surgery or by any particular pre-operative urodynamic parameter. None of the patients in this 'high risk' group were required to perform CISC post-operatively.

CONCLUSIONS

Routine teaching of the technique of CISC to 'high risk' patients prior to anti-incontinence and/or prolapse surgery appears to be an unnecessary use of valuable nursing time as well as being an invasive intervention which is unlikely to be required post-operatively.

Uterus preservation in pelvic organ prolapse surgery

Attitudes to sexuality and the psychological value of reproductive organs have changed in Western countries over the last few decades. Nevertheless, repair of pelvic support defects with concomitant hysterectomy is still considered the standard treatment for pelvic organ prolapse. Over the last 10 years, however, interest has been growing in uterus-sparing surgery, which can be divided into vaginal, abdominal, and laparoscopic procedures. The majority of studies on uterus-sparing surgery, with the exception of abdominal techniques, report few cases with short follow-up. Sacrospinous hysteropexy is the most studied vaginal technique for uterus preservation and favorable results have been demonstrated, although the majority of studies are flawed by selection and information bias, short follow-up and lack of adequate control groups. Abdominal and laparoscopic procedures are promising, providing similar functional and anatomical results to hysterectomy and sacrocolpopexy. Consensus is growing that the uterus can be preserved at the time of pelvic reconstructive surgery in appropriately selected women who desire it. The results of comparison trials and prospective studies confirm that uterus-sparing surgery is feasible and is associated with similar outcomes to hysterectomy, as well as shorter operating times. Surgeons should be ready to respond to the wishes of female patients who want to preserve vaginal function and the uterus.

Postoperative urinary retention following vaginal mesh procedures for the treatment of pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

The objective of the study was to assess vaginal mesh procedures and patient characteristics that are associated with postoperative urinary retention (PUR) following pelvic reconstructive surgery.

METHODS

The charts of 142 patients who underwent transvaginal reconstructive surgery with mesh were included in the analysis. Primary outcome was the incidence of PUR following surgery with mesh. Patients were grouped according to discharge from the hospital with or without a catheter based on a standardized voiding trial.

RESULTS

Forty-eight patients (34%) developed PUR after surgery. Of those, 30 patients (62.5%) had a combined anterior and posterior repair (p = 0.033). Mean preoperative anterior stage prolapse for patients with PUR compared with no PUR was 2.31 vs. 1.80 (p = 0.002). There was a greater association of PUR among patients with concomitant retropubic slings compared with transobturator slings (OR = 3.6, 95% confidence interval = 1.3-9.8).

CONCLUSIONS

A higher preoperative anterior stage prolapse, combined anterior and posterior compartment repairs, and retropubic sling procedures appear to be associated with PUR.