A Novel Operative Procedure for Pelvic Organ Prolapse Utilizing a MRI-Visible Mesh Implant: Safety and Outcome of Modified Laparoscopic Bilateral Sacropexy

AbsorbaTack™ vs. ProTack™ vs. sutures: a biomechanical analysis of cervical fixation methods for laparoscopic apical fixations in the porcine model

PURPOSE

Treatment of pelvic organ prolapse (POP) often requires the use of synthetic mesh. In case of a novel and standardized bilateral apical fixation, both uterosacral ligaments are replaced by polyvinylidene-fluoride (PVDF) tapes. One of the main problems remains the fixation method, which should be stable, but also simple and quick to use. The current study evaluated biomechanical differences between the cervical tape fixation with sutures (group 1), non-absorbable tacks (group 2) and absorbable tacks (group 3) in an in vitro porcine model.

METHODS

A total of 28 trials, conducted in three groups, were performed on porcine, fresh cadaver uteri. All trials were performed until mesh, tissue or fixation device failure occurred. Primary endpoints were the biomechanical properties maximum load (N), displacement at failure (mm) and stiffness (N/mm). The failure mode was a secondary endpoint.

RESULTS

There was a significant difference between all three groups concerning the maximum load. Group 1 (sutures) supported a maximum load of 64 ± 15 N, group 2 (non-absorbable tacks) yielded 41 ± 10 N and group 3 (absorbable tacks) achieved 15 ± 8 N. The most common failure mode was a mesh failure for group 1 and 2 and a fixation device failure for group 3.

CONCLUSION

The PVDF-tape fixation with sutures supports 1.5 times the load that is supported by non-absorbable tacks and 4.2 times the load that is supported by absorbable tacks. Nevertheless, there was also a stable fixation through tacks. Sutures are the significantly stronger and cheaper fixation device but may prolong the surgical time in contrast to the use of tacks.

Tacks vs. sutures: a biomechanical analysis of sacral bony fixation methods for laparoscopic apical fixations in the porcine model

Purpose

There is a novel surgical procedure, called cervicosacropexy (CESA) and vaginosacropexy (VASA) to treat pelvic organ prolapse and a concomitant urgency and mixed urinary incontinence. As there is little experience with the tapes so far and literature is scanty, the aim of this study was to investigate biomechanical properties for the fixation of the PVDF-tapes with three different fixation methods in context of apical fixations.

Methods

Evaluation was performed on porcine, fresh cadaver sacral spines. A total of 40 trials, divided into 4 subgroups, was performed on the anterior longitudinal ligament. Recorded biomechanical properties were displacement at failure, maximum load and stiffness in terms of the primary endpoints. The failure mode was a secondary endpoint. Group 4 was a reference group to compare single sutures on porcine tissue with those on human tissue. Biomechanical parameters for single sutures on the human anterior longitudinal ligament were evaluated in a previous work by Hachenberg et al.

Results

The maximum load for group 1 (two single sutures) was 65 ± 12 N, for group 2 (three titanium tacks arranged in a row) it was 25 ± 10 N and for group 3 (three titanium tacks arranged in a triangle) it was 38 ± 12 N. There was a significant difference between all three groups. The most common failure mode was a “mesh failure” in 9/10 trials for groups 1–3.

Conclusion

The PVDF-tape fixation with two single sutures endures 2.6 times more load than titanium tacks arranged in a row and 1.7 times more load than titanium tacks arranged in a triangle. The presacral fixation with titanium tacks reduced surgical time compared to the fixation with sutures, nevertheless sutures represent the significantly stronger and cheaper fixation method.

Use of polyvinylidene fluoride in treatment of female stress urinary incontinence: Efficacy and safety of midurethral slings: 24-month follow-up results

OBJECTIVE

To evaluate the safety and efficacy rate of polyvinylidene fluoride (PVDF) slings in the treatment of female stress urinary incontinence (SUI).

MATERIAL AND METHODS

A prospective pilot study was conducted with women with SUI who underwent PVDF slings. Data regarding subjective (International Consultation on Incontinence Questionnaire - Urinary Incontinence [ICIQ-UI] and International Consultation on Incontinence Questionnaire - Overactive Bladder [ICIQ-OAB]) and objective (stress test and bladder diary) outcomes and complication rates were evaluated. Primary outcomes were objective (negative pad and stress test) and subjective (no leakage episodes) success after a median follow-up of 24 months.

RESULTS

PVDF slings demonstrated a high level of satisfaction with objective cure (transobturator 90% compared with retropubic 100%, P = .90), urgency to urinate, frequency of de novo incontinence (transobturator 90% compared with retropubic 80%, P = .85), ability of physical and sexual activity (transobturator 90% compared with retropubic 100%, P = .90). The multivariate logistic regression model for satisfaction was associated with overall treatment success (odds ratio [OR] = 3.55, 95% confidence interval [CI] 2.32-6.1), greater reduction in ICIQ-UI (OR = 0.85; 95% CI 0.78-1.85) and ICIQ-OAB (OR =0.99; 95% CI 0.89-1.78). The total Female Sexual Function Index (FSFI) score for both groups was 19.3 ± 1.2 and 20.7 ± 1.8, statistically significant when compared with perioperative FSFI score 16.7 ± 1.1 and 17.6 ± 1.4 (P < .001).

CONCLUSION

PVDF mid-urethral slings are safe with clinically efficacies at 3, 6, 12, and 24-month follow-up for the treatment of SUI. The high level of satisfaction seen after PVDF sling procedures is associated with objective improvement of SUI and fewer slings related complications. Further studies using larger sample sizes with longer and comparative clinical follow-up are required.

A prospective pilot study on MRI visibility of iron oxide-impregnated polyvinylidene fluoride mesh after ventral rectopexy

Background

Magnetic resonance imaging (MRI) provides excellent information about pelvic anatomy after ventral rectopexy, but the position of the conventional mesh is not seen constantly. Iron oxide-impregnated polyvinylidene fluoride (PVDF) meshes are proven to have MRI visibility in hernia or vaginal reconstructive surgery. This prospective pilot study was designed to assess the visualization, position, and shape of the magnetic resonance (MR)–visible synthetic pelvic mesh used in minimally invasive ventral rectopexy.

Methods

Eight patients with pelvic organ prolapse were recruited for laparoscopic (LVMR) or robotic-assisted ventral mesh rectopexy (RVMR) with a synthetic MR–visible PVDF mesh. A follow-up visit was scheduled at 3 months after surgery. MR imaging was performed to evaluate the position and dimensions of the mesh and anatomical result. The visibility of the mesh in each sequence was assessed subjectively.

Results

The visibility of the mesh was best on T1-weighted flash images. The mesh was also well visualized on T2-weighted sagittal images. T2-weighted images, in general, provided best visualization of the surrounding anatomical structures and enabled assessment of the mesh fixation.

Conclusions

T2 sagittal and T1-weighted flash images provide the best information about the position and integrity of the iron oxide-impregnated PVDF mesh after LVMR or RVMR with a short examination time.

Transvaginal PVDF-mesh for cystocele repair: A cohort study

INTRODUCTION

Optimized biocompatibility of new materials is a major requirement for transvaginal meshes for pelvic organ prolapse (POP) repair. Polyvinylidene fluoride (PVDF) presented good characteristics in prior animal experiments and clinical use in humans.

METHODS

Between 01/2012 and 04/2016 37 women underwent transvaginal repair of symptomatic prolapse of the anterior vaginal wall (cystocele) with PVDF-mesh in a single institution. A chart review for recurrence, continence, peri- and early postoperative complications was performed. Referring practitioners were interviewed by telephone and mail. Additionally patient reported outcome and satisfaction were measured by Patient Global Improvement Inventory (PGI-I) scale.

RESULTS

34 women were eligible for a mean follow up of 19 months. The functional outcome improved significantly. One symptomatic vault prolapse (2.9%) and two reoperations for incontinence (5.9%) occurred. Two mesh exposures (5.9%) occurred and were treated conservatively. No other severe complications were registered. 87.5% of treated women felt very much better or much better and would undergo the surgery again. A cohort study including development steps in accordance with the IDEAL system is presented.

CONCLUSIONS

For the first time we report on effectivity and safety of transvaginal application of PVDF-mesh in real-life practice. A prospective long-term evaluation in a registry is justified.

A sequential comparison of postoperative voiding function between two different transobturator sling procedures

INTRODUCTION

We evaluated sequential postoperative voiding function of two types of sling procedures (Monarc^® and ALIGN^®) in patients with stress urinary incontinence.

METHODS

Ninety-one women diagnosed with urodynamic stress incontinence were randomly assigned to the study. All enrolled patients underwent Monarc or ALIGN procedure. They were postoperatively evaluated at one day, one week, one month, three months, 12 months, and 24 months. The voiding function was evaluated with uroflowmetry and post-void residual urine. Patients were asked if voiding had changed after surgery and had to complete the incontinence quality of life scale (I-QoL) questionnaire at 12 months.

RESULTS

The Monarc (n=47) and ALIGN (n=44) groups had similar demographic characteristics. The maximal flow rate (Qmax) was significantly decreased on the first day after surgery and gradually increased during the following weeks. Comparing the two groups at one week, the ALIGN group had a significantly decreased Qmax than the Monarc group (17.6 ± 5.2 vs. 20.7 ± 5.0; p=0.004). However, at one, three, 12, and 24 months, there were no significant differences between the two groups.

CONCLUSIONS

This study demonstrated that an absorbable tensioning suture in the Monarc mesh could increase Qmax compared to ALIGN at one week after surgery. An absorbable tensioning suture may reduce the risk of an early postoperative voiding dysfunction compared to other meshes that do not have this.

Challenges of Longevity: Safety of Vaginal and Laparoscopic Urogynecological Procedures in Septuagenarians and Older Patients

Introduction. Pelvic organ prolapse (POP) and urinary incontinence (UI) have increasing prevalence in the elderly population. The aim of this study was to compare the comorbidities of these procedures between <70 y/o and ≥70 y/o patients. Materials and Methods. In our retrospective study over a period of 2.5 years, 407 patients had received an urogynecological procedure. All patients with POP were treated by reconstructive surgery. Complications were reported using the standardized classification of Clavien-Dindo (CD). The study can be assigned to stage 2b Exploration IDEAL (Idea, Development, Exploration, Assessment, Long-term study)-system of surgical innovation. Results. Operation time, blood loss, and intraoperative complications have not been more frequent in the elderly, whereas hospital stay was significantly longer in ≥70 y/o patients. Regarding postoperative complications, we noticed that ≥70 y/o patients had an almost threefold risk to develop mild early postoperative complications compared to younger patients (OR: 2.86; 95% CI: 1.76–4.66). On the contrary, major complications were not more frequent. No case of life-threatening complication or the need for blood transfusion was reported. Conclusion. After urogynecological procedures, septuagenarians and older patients are more likely to develop mild postoperative complications but not more intraoperative or severe postoperative complications compared to younger patients.

Early safety and efficacy outcomes of a novel technique of sacrocolpopexy for the treatment of apical prolapse

OBJECTIVE

To assess the safety and efficacy of a modified technique of bilateral abdominal sacrocolpopexy in which both uterosacral ligaments are replaced with polyvinylidene fluoride mesh to provide support to the cervix (cervico-sacropexy [CESA]) or vaginal vault (vagino-sacropexy [VASA]).

METHODS

A retrospective observational study was undertaken of women with posthysterectomy vault prolapse or recurrent apical prolapse following previous prolapse repair who underwent bilateral sacrocolpopexy between July 1, 2013, and December 31, 2014, in a tertiary referral unit in the UK. Before surgery and 3 months afterwards, prolapse was assessed using the Pelvic Organ Prolapse Quantification scale and functional outcomes were recorded using the International Consultation on Incontinence Questionnaire for vaginal symptoms and urinary incontinence.

RESULTS

Fifty women were included. At 3 months, 47 (94%) patients reported no bulge symptoms and the mean point C was -7.6. Complications comprised bladder injury in 1 (2%) and minor wound problems in 3 (6%) patients. No mesh erosion was reported.

CONCLUSION

Bilateral abdominal sacrocolpopexy seems to be a safe and effective option for apical prolapse. Longer-term follow-up is needed to detect prolapse recurrence and mesh-related complications.