Mesh Arms Research Articles

Obturator Foramen Dissection for Excision of Symptomatic Transobturator Mesh

Groin pain after transobturator synthetic mesh placement can be recalcitrant to conservative therapy and ultimately requires surgical excision. We describe our experiences with and technique of obturator foramen dissection for mesh excision. The records of 8 patients treated from 2005 to 2010, were reviewed. Obturator dissection was performed via a lateral groin incision over the inferior pubic ramus at the level of the obturator foramen, typically in conjunction with orthopedic surgery. Five patients had transobturator mid urethral sling surgery for stress urinary incontinence, 2 had mid urethral sling and trocar based anterior vaginal wall mesh kits with transobturator passage of mesh arms for stress urinary incontinence and pelvic organ prolapse, and 1 had an anterior vaginal wall mesh kit for pelvic organ prolapse. Patients had 0 to 2 prior transvaginal mesh excisions before obturator surgery. All patients presented with intractable pain in the area of the obturator foramen and/or medial groin for which conservative treatment measures had failed. Six patients underwent concurrent vaginal and obturator dissection and 2 underwent obturator dissection alone. In all cases residual mesh (3 to 11 cm) was identified and excised from the obturator foramen. Mesh was closely associated to or traversing the adductor longus muscle and tendon with significant fibrous reaction in all cases. Postoperatively 5 patients were cured of pain and/or infection, and 3 reported no or some improvement at a mean followup of 6 months (range 1 to 12). Our experience suggests that surgical excision of residual mesh can alleviate many of the symptoms in many patients. In all cases mesh remnants were identified and removed, and typically involved neuromuscular structures adjacent to the obturator foramen.

Sacrohysteropexy – A Novel Approach

When performing a sacrohysteropexy, mesh arms are frequently passed through the broad ligament to connect the anterior and posterior pieces of mesh. Passing the mesh arms medial to the uterine vessels may have a theoretical advantage in an ensuing pregnancy as this may reduce constriction on the uterine vasculature as the uterus expands. In this video, we present a novel method for passing mesh arms medial to the uterine vessels using 5mm Mersilene tape with straightened blunt tip needle. The potential advantage of this approach is simplification of the passing of mesh as there is no dissection required.

Single-incision vaginal approach to treat cystocele and vault prolapse with an anterior wall mesh anchored apically to the sacrospinous ligaments

Introduction and hypothesisThe safety and early efficacy of a new technique to treat cystocele and/or concomitant apical prolapse through a single vaginal incision with a lightweight mesh anchored apically bilaterally to the sacrospinous ligaments is reported.MethodsWomen with anterior compartment and/or apical prolapse ≥stage II underwent repair through a single anterior vaginal wall incision with the Anterior Elevate System (AES). The technique utilizes a lightweight (24 g/m2) type I mesh anchored to the sacrospinous ligaments via two mesh arms with small self-fixating tips. The bladder neck portion of the graft is anchored to the obturator internus with similar self-fixating tips. The apical portion of the graft is adjustable to vaginal length prior to locking in place. Outcome measures included prolapse degree at last follow-up visit, intra/post-operative complications, and QOL assessments.ResultsSixty patients were implanted with average follow-up of 13.4 months (range 3–24 months). Mean pre-op Ba was +2.04 ± 1.3 and C −2.7 ± 2.9. Average blood loss was 47 cc and average hospital stay was 23 h. Sixty-two percent of patients had concomitant sling for SUI. Mean post-op Ba is −2.45 ± 0.9 and C −8.3 ± 0.9. There was no statistical difference in pre- to post-op TVL. Objective cure rate at current follow-up is 91.7% (≤stage 1). To date, there have been no mesh extrusions. No patients have reported significant buttock or leg pain. No patients have required surgical revision for any reason.ConclusionThe AES is a minimally invasive technique to treat anterior compartment and/or apical prolapse through a single vaginal incision. Initial results show the procedure to be safe and early efficacy is promising. Longer-term follow-up is ongoing.

Simultaneous Correction of Anterior and Apical Vaginal Prolapse with the Modified Placement of the Transobturator-Guided Mesh (Anterior ProliftTM) Set

Aim: Modified placement of the Anterior Prolift™ (MODAP) in patients with prolapse of the anterior and middle vaginal compartment is described. It was performed in order to achieve simultaneous tension-free correction of the anterior and middle vaginal compartment without excessive use of the mesh. Material and Methods: MODAP was performed in 32 patients. The anterior part of the mesh was placed transobturatorily. Surplus of the central part of the mesh was longitudinally divided and fixed around the cervix. Posterior mesh arms were passed through the sacrospinous ligament. All patients were analyzed regarding anatomy and symptoms 1 year after surgery. Results: Cure of pelvic organ prolapse was achieved in 28 of 32 (87.5%) patients. The position of Ba and C points was significantly corrected (p = 0.00). Deterioration of the posterior compartment occurred in 1 case. Symptoms of pelvic organ prolapse were significantly corrected (p = 0.05 up to p = 0.00) except for rectal emptying. Conclusion: MODAP makes an improvement of both anatomy support and symptoms in cases with mixed insufficiency of the anterior vaginal wall and apical vaginal support.

Novel Single Incision Vaginal Approach To Treat Cystocele and Vault Prolapse through an Anterior Approach with an Anterior Wall Mesh Anchored Apically to the Sacrospinous Ligaments (Anterior Elevate System)

Study Objective: To analyze the safety and early efficacy of a new technique to treat cystocele and concomitant vault prolapse through a single vaginal incision with a lightweight mesh anchored apically to the sacrospinous ligaments. Design: Retrospective analysis over 18 consecutive months. Setting: Large tertiary care hospital with University affiliation. Patients: Over 40 consecutive patients. Intervention: Women with cystocele and/or apical prolapse > Stage II underwent repair through a single anterior vaginal wall incision with the Anterior Elevate System (AMS). The technique utilizes a lightweight (24 g/m2) Type I mesh anchored to the sacrospinous ligaments via two mesh arms with small self-fixating tips. The bladder neck portion of the graft is anchored to the obturator internus with similar self-fixating tips. The apical portion of the graft is adjustable to vaginal length prior to locking in-place. Outcome measures included prolapse degree at last follow-up visit, intra/post-operative complications, and QOL assessments. Measurements and Main Results: Follow-up was between 3 and 18 months. Mean pre-op Ba was +1.75 (+/-1.58) and C -2.37 (+/-2.98). Average blood loss was 45cc and average hospital stay was 23 hours. There were no intra-operative complications and no bladder perforations nor any blood transfusions given. 57% of patients had concomitant mini-sling for SUI. Mean post-op Ba is -2.47 (+/-0.35) and C -8.0. There was no statistical difference in pre- to post-op TVL. Objective cure rate at current follow-up is 92.3% (</= Stage 1) and no patients have symptomatic failure or have required re-operation. To date there have been no mesh extrusions. No patients have reported significant buttock or leg pain. One patient reported vaginal pain at 6 mos that resolved with physical therapy. Conclusion: The Anterior Elevate system is a novel technique to treat cystocele and vault prolapse through a single vaginal incision. Initial results show the procedure to be safe and early efficacy is promising. Longer-term follow-up is ongoing.

Oral Poster 9

OBJECTIVES: To determine the efficacy and perioperative complications in the use of Pinnacle® Pelvic Floor Repair Kit (Boston Scientific, Natick, MA) in the correction of anterior and apical pelvic floor defects. MATERIALS AND METHODS: This is a single center, retrospective study of 43 patients who underwent the Pinnacle® Anterior/Apical procedure from February 2008 through June 2009. The procedure involved transvaginal placement of Type I, monofilament, polypropylene mesh. The four mesh arms were anchored in a tension-free fashion with a Capio® Suture Capture Device to the sacrospinous ligaments and the proximal white line on each side. Preoperative assessment included a history and physical, POP-Q staging and urodynamics. At 6 weeks, 6 months and 1 year postoperatively assessment included POP-Q staging and evaluation for complications. Data are reported as proportions, means (±SD), or medians and interquartile range (IQR), as appropriate. The paired t test was used to compare pre- and post-operative measurements. RESULTS: The mean follow-up was 7.2 (range: 1.0–18.5) months. The mean age and BMI were 65.3 (±10.2) years and 28.3 (±3.8) kg/m2, respectively, while the median parity was 3.0 (IQR: 2.0). All patients had stage II (51.2%) or stage III (48.8%) prolapse with mean points Aa, Ba and C of +1.1 (±1.5), +1.7 (±2.0) and −1.8 (±2.7), respectively. Sixteen (37.2%) patients had a prior hysterectomy and 9 (20.9%) had a history of surgical prolapse repair. Concomitant procedures included 35 (81.4%) suburethral slings (28 transobturator, 3 retropubic and 4 mini-slings), 2 (4.7%) hysterectomies, 25 (58.1%) perineorrhaphies and 5 (11.6%) posterior repairs. Mean operating time was 102.5 (±37.4) minutes and median length of stay was 1.0 (IQR: 0.0) day. At the last follow-up visit, points Aa, Ba and C were −2.4 (±0.8) −2.4 (±0.8) and −6.7 (±1.7), all of which improved significantly (P < 0.0001 for each). Intra-operative complications consisted of 5 (11.6%) patients with estimated blood loss greater than 500 cc (median blood loss was 100 (IQR: 150.0) cc), two of which required embolization and blood products. Mesh exposure was noted in 12 patients (27.9%): 5 (11.6%) resolved with topical estrogen, 6 (14.0%) needed minor surgical revision and 1 (2.3%) persisted but was asymptomatic. Other post-operative complications included hematoma formation in 6 (14.0%), granulation tissue in 5 (11.6%), de novo stress urinary incontinence in 3 (7.0%), de novo overactive bladder in 3 (7.0%), buttock pain in 2 (4.7%) and urinary retention in 3 (7.0%) patients. CONCLUSION: The Pinnacle® procedure is comparable to other mesh kits; however, no blind trocar passes are needed through the transobturator or ischiorectal spaces. Excellent apical support was demonstrated in this cohort and appears to be due to improved superior mesh attachment to the sacrospinous ligaments, whereas other anterior mesh kits utilize the proximal white line for apical support. The mesh exposure rate in our patients is concerning, although the characteristics of the mesh utilized in this kit are similar to other prolapse mesh kits. Longer-term follow up and corroborative studies are needed.

Bacterial colonisation of collagen-coated polypropylene vaginal mesh: are additional intraoperative sterility procedures useful?

Introduction and hypothesisThe use of vaginally implanted polypropylene meshes in the treatment of prolapse is becoming increasingly popular. We set out to detect how often bacterial colonisation of the mesh occurs and if the intraoperative sterility procedures that are applied matter.MethodsIn 64 consecutive women, bacterial colonisation was compared between two intraoperative sterility procedures. Culture swabs of the core mesh were taken during surgery, and the mesh arms removed at the end of surgery were cultured separately.ResultsSixty-seven implants were cultured. In 56 (83.6%) implants, a positive culture with vaginal bacteria was found with very low bacterial density (<103 colony-forming units). No significant differences in bacterial species, density, clinical infection and erosion (two anterior and one posterior) were found between the two intraoperative sterility methods.ConclusionsColonisation of vaginally implanted mesh occurs frequently but in low bacterial densities, irrespective of the intraoperative sterility procedure used.

Female urology: What method will you select?

When I was a resident, my leader taught me that the gold standard forpatients with stress incontinence is the Marshall–Marchetti–Krantz(MMK) procedure. But a few years later, urologists who could performadvanced techniques showed me needle suspension as the best methodat a urological meeting. Fortunately my boss gave me a chance for ahand-to-hand lesson of the stamay procedure by the specialist. Sincethen, I have been selecting this procedure for a few years. Withoutdoubt, this needle suspension was the gold standard at that time.But now most urologists do not select this technique because of badresults. After I had mastered the technique of tension-free vaginal tape(TVT), I could see the smiling faces of patients after the operation. Atthat time I believed that TVT would be the gold standard for thiscondition. But the present status is what you know.Recently most specialists, including myself, believe that using‘mesh’ is the best operation for patients with pelvic organ prolapse. Isthis tendency good for the patients in the long run? No one can predictthe results of this procedure more than ten years from now.God knows what procedure will be the gold standard in the future.Assistant Professor Yasuyuki Suzuki

Le kit prothétique dans la cure des prolapsus génitaux: est-ce un gadget?

To search if the prosthetic kits bring an interest, other that financier. Authors have counted 5 firms presenting the varied kits. The Prolift kit with synthetic pre- cut mesh made of polypropylene, standardized needle, cannulas and protective devices of recovery of mesh arms in 3 versions, anterior, posterior and total. Perigee and Apogee systems in a synthetic version (IntePro) and a biological version (InteXen ++LP) matched of specific needles for the different obturator passages and infra coccygeus. The Avaulta kit declines in a biosynthetic version and a hybrid version with a specific needle for its anterior kit and an other for its posterior kit. The Biomesh Soft system presents a polypropylène mesh posed on a multi pattern sheet to carve following dots with a share of 3 needles according to the type of arm passage ended by a recuperator thread. The Nazca POP Repair System, in its anterior version claims to be able to correct in the same time a urinary incontinence by pre-pubic arms. The polypropylene mesh is perforated and is had with the help a needle for its anterior and posterior kit. Authors have been interested in the research of studies on prosthesis with and without kit. The Prolift kit contains the alone prosthesis having been evaluated without (TVM) and with kit. Authors remind results of two studies, understanding 684 cases without kit and 110 cases with kit. The rate of early per and postoperative complications has been decreased half, the rate of mesh exposure decreased from 11,3 to 4,7%. Studies on Perigee and Apogee IntePro kits, whose meshe and the procedure are similar to the Prolift seem to obtain from results equal. The Biological version has not made the object of study. For the Avauta kit, alone the mesh in plate not pre-cut has been well studied as for its tolerance for the biosynthetic version. Nothing on the hybrid version. No study is found for the Biomesh Soft kit and Nazca POP repair system. The cost of these kits, varying 1 to 4, is to take in consideration and to put in scale with the returned service. Alone TVM/Prolift allows to advance in a reply. The utilization of needles, presents in all the kits, but especially devices facilitating the passage and the recovery of prosthesis arms, presents solely in the Prolift kit, reduce the utilization of valves and the risk of tear tissues during their job. The improvement of techniques by elements of the kit make that the surgical procedure become mini invasive. The full kits allow a best security of procedures, facilitate the surgical gesture and limit complications. It is necessary to remain vigilant in the evaluation of these new materials "ready to wear" and to require pre clinic and clinic studies before their distribution.

Prevention of Parastomal Hernia by Placement of a Polypropylene Mesh at the Primary Operation

Parastomal hernias occur frequently after placement of a permanent colostomy. Preliminary reports have shown a beneficial effect of placing a mesh at the primary operation to prevent the formation of a parastomal hernia. We studied the safety and prophylactic effect of placing a newly designed polypropylene mesh in an onlay position at the primary operation. This was a prospective study that included 25 patients scheduled for elective colorectal surgery. Risk factors for development of parastomal hernia were recorded before surgery. A prepared lasercut polypropylene mesh with six "arms" was placed in an onlay position. Immediate and long-term complications were evaluated by an experienced stoma nurse and a surgeon. Abdominal ultrasound was performed at 6 and 12 months follow-up. Parastomal hernia was defined as both clinical and ultrasonographic signs of protrusion in the vicinity of the stoma. The median follow-up time was 12 (range, 2-26) months. One patient died eight days after surgery. Of the 24 patients included, none had infections or immediate complications after surgery. Two patients had minor complications necessitating a local revision of one of the mesh arms. No other long-term complication was found. Two patients had signs of parastomal hernia at 6 and 12 months follow-up, respectively. Placement of a polypropylene mesh in an onlay position at the primary operation is a safe procedure and probably results in a low risk of parastomal hernia occurrence.

Chunking by Proximal Arm Cues Facilitates Rats′ Performance in the Radial Maze

Three experiments showed that training rats to chunk a 16-arm radial maze into striped and wire mesh (gridded) arms facilitates their spatial working memory for arm locations. Rats were trained to visit eight unblocked baited arms of a 16-arm radial maze (half-maze run) and then were exposed to the complete maze to sample the remaining eight baited arms (whole-maze run). The initially exposed eight arms were either all striped or all gridded on alternating trials for half the rats (Arm Cue Relevant, ACR group). The remaining rats (Arm Cue Irrelevant, ACI group) received a mixture of striped and gridded arms on their half-maze runs. Following this phase of segmented trials, all rats were exposed only to all 16 arms over a series of trials in the first two experiments. In the third experiment, the initial eight arms were either all striped or all gridded on alternating trials for all rats. During some second, whole-maze runs, however, all arms contained the same proximal cue. ACR rats made fewer reentries than ACI rats in all phases of all experiments. This difference was maintained over increasing delays between half- and whole-maze runs in the first experiment, changes in arm cue and blocking configurations in the second experiment, and removal of differential arm cues in the third experiment.