The use of synthetic mesh in female pelvic reconstructive surgery

Anatomical outcomes and complications of sacrocolpopexy using Surelift Uplift mesh: A multicentric observational study

OBJECTIVE

The study evaluated the anatomical and functional outcomes, as well as the safety data of laparoscopic sacrocolpopexy (LSC) for pelvic organ prolapse (POP) using a lightweight macroporous mesh.

METHODS

A multicentric observational study was developed including five expert centers between March 2011 and December 2019. Inclusion criteria were female patients with symptomatic ≥stage II POP (POP-Q classification), who underwent a LSC. A lightweight and macroporous mesh device (Surelift Uplift) was used. Baseline anatomical positions were evaluated using POP-Q stage. The anatomical outcomes and procedural complications were assessed during the postoperative period. Primary outcomes were anatomical success, defined as POP-Q stage ≤I, and subjective success, defined as no bothersome bulge symptoms, and no repeat surgery or pessary use for recurrent prolapse.

RESULTS

A total of 325 LSCs were analyzed with a median patient age of 66 (interquartile range [IQR] 61-73). After a median follow-up of 68 months (IQR 46.5-89), anatomical success was found in 88.9%, whereas subjective success was seen in 98.5% of the patients. Recurrent prolapse presented as cystocele (1.5%). Reported complications were bladder (4.6%) or rectum lesions (0.6%), de novo urinary incontinence (12.9%), and mesh extrusion (1.2%).

CONCLUSIONS

LSC provides significant clinical improvement and excellent anatomical results, with a low risk of serious complications for women with ≥2 grade POP in a real clinical practice setting.

Titanium Membranes with Hydroxyapatite/Titania Bioactive Ceramic Coatings: Characterization and In Vivo Biocompatibility Testing

Titanium membranes and meshes are used for the repair of trauma, tumors, and hernia in dentistry and maxillofacial and abdominal surgery. But such membranes demonstrate the limited effectiveness of integration in recipients due to their bioinertness. In this study, we prepared titania oxide (by microarc oxidation) and/or HAp (by electrophoresis deposition) coatings with alginate soaking. We used annealing at 700 °C for 2.5 h for HAp crystallinity increasing with achievement of an acceptable Ca²⁺ release rate. The feedstock HAp and prepared coatings were characterized by X-ray diffraction, IR spectroscopy, electron and optical confocal microscopy, and thermal analysis, as well as the in vitro study of solubility in saline and in vivo tests with the animal model of subcutaneous implantation (with Wistar rats). Biocompatible compounds were found for all deposited coatings. We noted that the best biological response was detected for the annealed Ca-P/TiO₂ bilayer with alginate binding. In this case, the coating crystallinity was ≈40.5-50.0%. The Ca²⁺ release rate was 2.042 ± 0.058%/mm² at 168 h after immersion in saline. Thin and mature tissue capsules with minimal inflammation and vascularization were found in histological sections. We did not detect any unwanted responses around the implants, including inflammation infiltration, suppuration, bacterial infections, tissue lyses, and, finally, implant rejection. This information is expected to be useful for understanding the properties of bioactive ceramic coatings and improving the quality of medical care in dentistry and maxillofacial surgery and other applications of titanium membranes in medicine.

Anterior Vaginal Wall Prolapse Repair and the Rise and Fall of Transvaginal Mesh. Did We Come Full Circle? A Historical Perspective

OBJECTIVE

To present a brief historical review of treatment options for pelvic organ prolapse with a focus on anterior vaginal wall defects and highlight changing practice patterns in the era of synthetic mesh controversy.

METHODS

A MEDLINE and PubMed search was performed using the keywords pelvic organ prolapse, anterior colporrhaphy, and cystocele followed by a manual search of bibliographies.

RESULTS

Ancient treatments included Hippocratic succession, local astringent, and use of pomegranates as crude pessaries. More sophisticated surgical techniques evolved in the 19th century with further refinement in the early 20th century. Numerous native tissue apposition techniques were popularized by Kelly, Kennedy, Burch, and Raz. Due to poor durability, surgeons sought alternate approaches including biologic and synthetic grafts. Synthetic transvaginal mesh (TVM) initially included use of Tantalum and Marlex to repair anterior wall defects. Both were eventually abandoned due to complications. TVM was re-designed, re-marketed, and re-introduced. Type 1 polypropylene monofilament TVM use became ubiquitous in female pelvic surgery peaking between 2004 and 2008. Initial promising outcomes were soon eclipsed by a surge of adverse events leading to multiple FDA warnings, reclassification to Class III, high-risk medical device, and ultimately a complete recall in 2019.

CONCLUSION

The bidirectional pendulum swing on use of synthetic TVM has been occurring since its introduction 50 years ago. In the current era of mesh controversy, more practitioners are now revisiting previously described native tissue and biologic graft techniques. It appears that history has repeated itself.

The autologous pubovaginal fascial sling: An update in 2019

The contemporary management of stress urinary incontinence (SUI) has seen renewed interest in the use of autologous fascia for the formation of a retropubic suburethral sling. Traditionally, it has been used in only the most severe of incontinence cases, such as those women with intrinsic sphincter deficiency, or in patients requiring concomitant reconstructive procedures. In the current climate surrounding transvaginal mesh, many doctors and patients are shying away from the less morbid synthetic midurethral sling. International literature has demonstrated that the fascial sling is a safe and efficacious procedure for all patients with SUI, adequately treating both urethral hypermobility and intrinsic sphincter deficiency. This paper will discuss the indications, technique, and outcomes of autologous fascial slings. We will explore the use of fascial slings following failed synthetic slings and also the troubleshooting of commonly encountered issues intra- and postoperatively.

Scaffolds for Pelvic Floor Prolapse: Logical Pathways

Pelvic organ prolapse (POP) has borrowed principles of treatment from hernia repair and in the last two decades we saw reinforcement materials to treat POP with good outcomes in terms of anatomy but with alarming complication rates. Polypropylene meshes to specifically treat POP have been withdrawn from market by manufactures and a blank space was left to be filled with new materials. Macroporous monofilament meshes are ideal candidates and electrospinning emerged as a reliable method capable of delivering production reproducibility and customization. In this review, we point out some pathways that seem logical to be followed but have been only researched in last couple of years.

Past, Present and Future of Surgical Meshes: A Review

Surgical meshes, in particular those used to repair hernias, have been in use since 1891. Since then, research in the area has expanded, given the vast number of post-surgery complications such as infection, fibrosis, adhesions, mesh rejection, and hernia recurrence. Researchers have focused on the analysis and implementation of a wide range of materials: meshes with different fiber size and porosity, a variety of manufacturing methods, and certainly a variety of surgical and implantation procedures. Currently, surface modification methods and development of nanofiber based systems are actively being explored as areas of opportunity to retain material strength and increase biocompatibility of available meshes. This review summarizes the history of surgical meshes and presents an overview of commercial surgical meshes, their properties, manufacturing methods, and observed biological response, as well as the requirements for an ideal surgical mesh and potential manufacturing methods.

Biomaterials for pelvic floor reconstructive surgery: how can we do better?

Stress urinary incontinence (SUI) and pelvic organ prolapse (POP) are major health issues that detrimentally impact the quality of life of millions of women worldwide. Surgical repair is an effective and durable treatment for both conditions. Over the past two decades there has been a trend to enforce or reinforce repairs with synthetic and biological materials. The determinants of surgical outcome are many, encompassing the physical and mechanical properties of the material used, and individual immune responses, as well surgical and constitutional factors. Of the current biomaterials in use none represents an ideal. Biomaterials that induce limited inflammatory response followed by constructive remodelling appear to have more long term success than biomaterials that induce chronic inflammation, fibrosis and encapsulation. In this review we draw upon published animal and human studies to characterize the changes biomaterials undergo after implantation and the typical host responses, placing these in the context of clinical outcomes.

Application of layer-by-layer coatings to tissue scaffolds – development of an angiogenic biomaterial

Development of flexible coating strategies to promote angiogenesis is critical to effectively treat chronic, non-healing wounds.

Meta-analysis of the efficacy and safety of the application of adjuvant material in the repair of anterior vaginal wall prolapsed

INTRODUCTION

This study is a meta-analysis of the efficacy and safety of the application of adjuvant material in the repair of anterior vaginal wall prolapse and a sub-category analysis of the use of nonabsorbable synthetic mesh, biological graft and absorbable synthetic mesh.

METHOD

Pubmed, Embase and Ovid databases were searched for published randomized controlled trials from 1980 to February 2012 on the treatment of anterior vaginal wall prolapse with adjuvant materials. A comprehensive meta-analysis applying Revman5.1 analysis software was performed.

RESULTS

A total of 20 randomized controlled trials including 2,313 participants were recognized. The result showed that repair with adjuvant materials was better and more effective; nevertheless, use of adjuvant materials resulted in longer duration of surgery and more peri-operative bleeding when compared with the control group, but no significant differences were observed between the two groups regarding visceral injury, postoperative pain, urinary tract infection rate, new stress incontinence and new dyspareunia.

CONCLUSION

Adjuvant material is worthy of clinical popularization, especially the biological graft type because of its lower anatomy failure rate and no difference in safety compared with the control group. However, exposure to adjuvant materials and erosion rate are high, which are the most important aspects to be improved.

I nuovi Materiali Nella Chirurgia del Prolasso e Dell'incontinenza

In line with the results of general surgeons, who revolutionised the surgical approach and the success rate of ventral hernia repair using synthetic mesh, urologists and gynaecologists recently moved towards the use of prosthesis to augment the native tissues.

The rationale was based on the relatively high failure rates of the traditional anterior vaginal compartment repair and the recognition that the native tissue may no longer assume the position, strength or functionality by simple re-approximation. Actually the plethora of mesh or graft material, ranging from absorbable (synthetic and biological) to non-absorbable materials, indicates how uncertain we are about the best management.

The surgical results are variable on the basis of 1) the material used (synthetic or biological, absorbable or not absorbable); 2) the position of the mesh (incorporated in the suture, overlay the suture, below or under the fascia); 3) the tension adopted.

Major problems concern the complications related to the use of the meshes in urogynaecological surgery and the final message is that surgeons may want to consider adopting use of graft techniques to improve surgical results with care given to carefully monitor complications.

Complications associated with transobturator sling procedures: analysis of 233 consecutive cases with a 27 months follow-up

Backround

The transobturator tape procedure (TOT) is an effective surgical treatment of female stress urinary incontinence. However data concerning safety are rare, follow-up is often less than two years, and complications are probably underreported. The aim of this study was to describe early and late complications associated with TOT procedures and identify risk factors for erosions.

Methods

It was a 27 months follow-up of a cohort of 233 women who underwent TOT with three different types of slings (Aris^®, Obtape^®, TVT-O^®). Follow-up information was available for 225 (96.6%) women.

Results

There were few per operative complications. Forty-eight women (21.3%) reported late complications including de novo or worsening of preexisting urgencies (10.2%), perineal pain (2.2%), de novo dyspareunia (9%), and vaginal erosion (7.6%). The risk of erosion significantly differed between the three types of slings and was 4%, 17% and 0% for Aris^®, Obtape^® and TVT-O^® respectively (P = 0.001). The overall proportion of women satisfied by the procedure was 72.1%. The percentage of women satisfied was significantly lower in women who experienced erosion (29.4%) compared to women who did not (78.4%) (RR 0.14, 95% CI 0.05-0.38, P < 0.001).

Conclusion

Late post operative complications are relatively frequent after TOT and can impair patient's satisfaction. Women should be informed of these potential complications preoperatively and require careful follow-up after the procedure. Choice of the safest sling material is crucial as it is a risk factor for erosion.

Severe cystocele: Optimizing results

Despite multiple variations in cystocele repair techniques, success rates have been historically low. In this review we summarize strategies to optimize long-term results of vaginally approached cystocele repair for the high-grade defect. Our proposed strategies include addressing prolapse of the vaginal apex (the uterus or the vaginal cuff), using the obturator fascia as an anchor for lateral cystocele defect repair, augmenting the repair with loosely woven polypropylene mesh, and placing a midurethral sling.

[Pelviperineoscopy. Preliminary study of feasibility on cadavers]

OBJECTIVE

The traditional access of perineum for the treatment of the pelvic organ prolapse by vaginal route is probably responsible for the risk of mesh exposure and a longer convalescence. So, endoscopic access to perinemeum needs to be evaluated.

PATIENTS AND METHODS

Feasibility study on cadavers. Details of the procedure: opening of the pararectal space by digital dissection first after incision on the level of the posterior commissure. Introduction of an optical trocart to the level of the perineum incision; dissection of pararectal space with optics and CO(2); individualization of the various elements; installation of a transobturator trocart and a transgluteal trocart; dissection of the rectovaginal septum and visualization of the sacrospinous ligament and pudendal nerve. The measured variables were: operational incidents, possibility of creation of working space, dissection of the rectovaginal septum; finally, visualization of the sacrospinous ligament and pudendal pedicle.

RESULTS

On the 4 studied cadavers, we could carry out a dissection of pelvirectal space in all the cases. On the 8 pararectal fosses, in all the cases we could carry out a cavity of dissection and to open the recto vaginal septum, visualization of the sacrosciatic ligament and pudendal pedicle was possible in 6 cases out of 8. There were one rectal injury, two vaginal injuries and one lesion of the pudendal pedicle.

DISCUSSION AND CONCLUSION

This endoscopic access allows in the majority of cases to see the structures necessary to the realization of a vaginal sacrospinofixation or the installation of posterior mesh without a colpotomy and a traumatic exposure. The incidents are probably due to our inexperience and should disappear in time. The pelvi-perineoscopy is an endoscopic access of perineum which should be evaluated.

What??s new in slings: an update on midurethral slings

PURPOSE OF REVIEW

Surgical management of female stress incontinence has progressed rapidly over the past decade. The purpose of this review is to provide up-to-date information regarding surgical outcomes of midurethral slings and to discuss management of sling complications. Additionally, the newer commercially available products will be outlined and the data comparing new versus established techniques will be examined.

RECENT FINDINGS

Long-term data are available for the Tension-free Vaginal Tape procedure which demonstrates durable efficacy. Comparisons between the Tension-free Vaginal Tape and Suprapubic Arch sling procedure demonstrate no significant difference in cure rates or complications. In an effort to avoid the retropubic space, the transobturator slings were developed and short-term data suggest similar efficacy to the transabdominal techniques. The transobturator approach, while limiting abdominal complications, is not without its own complication profile. Increased experience with synthetic mesh in vaginal surgery has allowed for a more systematic approach to managing mesh erosions.

SUMMARY

The literature indicates that midurethral slings, despite the specific approach, are efficacious and an important therapy in managing stress incontinence. Prospective data will be needed before the surgeon can determine if the new products and techniques are truly an improvement over the existing products or merely a proprietary modification.