Mesh For Prolapse Research Articles

POSTOPERATIVE CHRONIC PAIN FOLLOWING MESH AND NON-MESH REPAIR OF PELPIC ORGAN PROLAPSE

(Objective) A FDA alert in 2011 warned about postoperative chronic pain following transvaginal mesh (TVM) for pelvic organ prolapse (POP). We studied cases with chronic pain after TVM, natural tissue repair (NTR) and laparoscopic salcocopopexy (LSC). (Methods) We retrospectively reviewed medical charts of patients who underwent POP operations in our hospital or were referred to us after POP operations in other hospitals between 2006 and 2016. Postoperative chronic pain was defined as persistent pain for more than three months following the first three months from the time of POP operations.Patients' characteristics and treatments were analyzed. (Results) In patients who underwent POP operations in our hospital, the rates of chronic postoperative pain after TVM, NTR and LSC were 12/2,457 (0.49%), 1/402 (0.26%) and 0/29 (0%), respectively. Another 8 patients were referred to us after POP operations in other hospitals. Thus, a total of 21 patients (15: TVM, 6: NTR) had either medications, surgical treatment or were referred to other doctors due to postoperative chronic pain. All of them were parous women aged 53 to 81 years old. Preoperative chronic pelvic pain was found in seven patients (33%), and another four patients (19%) had orthopedic diseases with chronic pain. The main locations of pain were; vagina 11, vulva 2, urinary bladder 2, urethra 1, coccyx 1, buttocks 1, anus 1, perineum 1 and groin 1. Nineteen patients had pharmacological treatment using tricyclic antidepressants, Ca2+ channel α2δ ligand and/or serotonin-noradrenalin reuptake inhibitor (SNRI); 9 (47%) of the patients showed a notable improvement. Three patients following TVM had surgical treatment; one with bladder mesh exposure was resolved with TURis, one with vaginal mesh exposure was resolved with mesh trimming, but one with tenderness on the mesh arm did not improve after a partial mesh removal. Four patients were referred to pain clinics. (Conclusions) Postoperative chronic pain can occur following both TVM and NTR therefore, attentive listening and proper medication are important as initial therapies. It is mandatory to examine the presence of mesh exposure in patients after using mesh. We should be careful about preoperative chronic pain, pelvic or elsewhere, as a risk factor for postoperative chronic pain.

MP75-02 SYNTHETIC MID-URETHRAL SLING COMPLICATIONS: DO PATIENTS BENEFIT FROM SLING REVISION?

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Female Incontinence: Therapy III1 Apr 2018MP75-02 SYNTHETIC MID-URETHRAL SLING COMPLICATIONS: DO PATIENTS BENEFIT FROM SLING REVISION? Elizabeth Dray, Anne Pelletier Cameron, Erin Crosby, Ashley Grable, J Quentin Clemens, John Stoffel, Priyanka Gupta, and Paholo Barboglio-Romo Elizabeth DrayElizabeth Dray More articles by this author , Anne Pelletier CameronAnne Pelletier Cameron More articles by this author , Erin CrosbyErin Crosby More articles by this author , Ashley GrableAshley Grable More articles by this author , J Quentin ClemensJ Quentin Clemens More articles by this author , John StoffelJohn Stoffel More articles by this author , Priyanka GuptaPriyanka Gupta More articles by this author , and Paholo Barboglio-RomoPaholo Barboglio-Romo More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.2094AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Synthetic mid-urethral slings (MUS) are the most commonly performed treatment for stress urinary incontinence in women. While these procedures are typically safe and effective, complications do occur. The goal of our study was to define the presentation and outcomes of patients who underwent revision/removal of synthetic MUS at our institution. METHODS We performed a retrospective review of 432 women who underwent revision of a synthetic mid-urethral sling at our institution between 2005 and 2016. Patients with a history of vaginal mesh for pelvic organ prolapse were excluded from our analysis. The outcomes assessed were AUA SI, Michigan Incontinence Symptom Index (M-ISI), pad use and post-void residual (PVR). RESULTS Average patient age was 53 and parity was 2.5. The majority of patients had a TVT (172) followed by TOT (182) and minisling (40). The remainder of slings were MUS of unidentified type. Eighty-one patients had undergone prior mesh revisions elsewhere. Patients presented with four primary complaints: mesh exposure or erosion, pain or dyspareunia, incontinence and bladder outlet obstruction. Most patients presented with at least two categories of mesh-related complaints, with the most common presentations being incontinence/pain (84 patients) and mesh exposure/pain/incontinence (74 patients). Patients most commonly underwent partial or complete excision of the vaginal portion of their mesh (110 and 248 patients respectively). Multiple mesh revisions were performed on 43 patients. Average follow-up was 14 months. The majority of patients (302) did not require further incontinence procedures at our institution. Forty-one patients had a sling placed at the time of mesh revision and 89 patients underwent procedures for incontinence at a later date. Clinically and statistically significant improvement was demonstrated on both validated questionnaires postoperatively. The number of patients reporting pain or dyspareunia declined (p<0.001), as well as the number reporting incontinence of any kind (p=0.006). PVR improved from a preoperative average of 91 cc to 48 cc postoperatively (p=0.001) and average pad use improved from 2.1 pads per day to 1.5 pads per day(p=0.003). CONCLUSIONS Despite complex patient presentations, subjective and objective urologic symptom measures significantly improve following MUS revision. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e1008 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Elizabeth Dray More articles by this author Anne Pelletier Cameron More articles by this author Erin Crosby More articles by this author Ashley Grable More articles by this author J Quentin Clemens More articles by this author John Stoffel More articles by this author Priyanka Gupta More articles by this author Paholo Barboglio-Romo More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Place of surgery in the management of post-operative chronic pain after placement of prosthetic material based on a series of 107 cases.

The objective of this study was to evaluate the efficacy of surgical removal of prosthetic material, possibly combined with nerve release, on chronic postoperative pain following placement of prosthetic material. Single-tertiary-centre study on 107 patients managed between November 2004 and April 2016 for removal of prosthetic material responsible for postoperative chronic pain: retropubic suburethral sling (n = 32), transobturator suburethral sling (n = 50), prolapse mesh (n = 16), and hernia mesh (n = 9). The primary endpoint was at least 50% reduction of pain evaluated by a pain numerical rating scale (NRS). The mean interval between the initial operation involving placement of prosthetic material and reoperation for removal of prosthetic material was 41.2 ± 35.4 months. In all cases pain apperaed immediately following prosthetic material placement surgery. Pain presented neuropathic features in almost 30% of cases and was poorly systematized in more than one-half The mean follow-up of the study population was 8.4 ± 10.3 months. The mean pain NRS score for the overall population was seven preoperatively and three at last follow-up. At least 50% reduction of the pain NRS score was observed 67% of cases at last follow-up. During follow-up, 45% of patients experienced relapse of the disorder for which the prosthetic material was initially placed with, in particular, a 62% recurrence rate of urinary incontinence after removal of transobturator suburethral tape. Surgical removal of prosthetic material to treat chronic postoperative pain, achieved global improvement of pain in about two-thirds of cases, but with a risk of recurrence of the initial disorders.

The use of synthetic mesh for vaginal prolapse in the UK: a review of cases submitted to the British Society of Urogynaecology database

The use of mesh for vaginal prolapse gained popularity during the 1990s. More recently, concerns have been raised regarding the safety of mesh procedures. Mesh can be inserted vaginally, laparoscopically or via an open abdominal route, but there are few data comparing the outcomes. Most previous published data relate to small numbers of procedures. This was a review of data submitted to the British Society of Urogynaecology (BSUG) database of all cases reporting the use of mesh placed vaginally or abdominally (open or laparoscopic) between January 2006 and December 2016. The primary outcome was based on the reported patient global impression of improvement (PGI-I). A total of 6,709 cases of mesh prolapse repair were entered during the study period. Women in the laparoscopic group had a lower BMI and were younger. Significantly more patients in the open group (96.4%) described themselves as very much better or much better compared with the laparoscopic group (91%) and the vaginal mesh group (90.7%; p < 0.001). Only 0.5% of patients reported that they were worse or very much worse. This dataset suggests that the effectiveness of mesh repair might be good regardless of the route of insertion. The improvement in PGI-I seems to be greatest with open sacrocolpopexy.

Preventing Mesh Pore Collapse by Designing Mesh Pores With Auxetic Geometries: A Comprehensive Evaluation Via Computational Modeling.

Pelvic organ prolapse (POP) meshes are exposed to predominately tensile loading conditions in vivo that can lead to pore collapse by 70-90%, decreasing overall porosity and providing a plausible mechanism for the contraction/shrinkage of mesh observed following implantation. To prevent pore collapse, we proposed to design synthetic meshes with a macrostructure that results in auxetic behavior, the pores expand laterally, instead of contracting when loaded. Such behavior can be achieved with a range of auxetic structures/geometries. This study utilized finite element analysis (FEA) to assess the behavior of mesh models with eight auxetic pore geometries subjected to uniaxial loading to evaluate their potential to allow for pore expansion while simultaneously providing resistance to tensile loading. Overall, substituting auxetic geometries for standard pore geometries yielded more pore expansion, but often at the expense of increased model elongation, with two of the eight auxetics not able to maintain pore expansion at higher levels of tension. Meshes with stable pore geometries that remain open with loading will afford the ingrowth of host tissue into the pores and improved integration of the mesh. Given the demonstrated ability of auxetic geometries to allow for pore size maintenance (and pore expansion), auxetically designed meshes have the potential to significantly impact surgical outcomes and decrease the likelihood of major mesh-related complications.

32: Reoperation rates for stress urinary incontinence and pelvic organ prolapse in women undergoing a mid-urethral sling in academic centers within the United States

The aim of this study was to look at reoperation rates for stress urinary incontinence (SUI) and pelvic organ prolapse (POP) in women who underwent a primary mid-urethral sling with or without concurrent POP repair. We hypothesized that women undergoing an SUI procedure with concurrent prolapse repairs would have decreased rates of reoperation for both prolapse and stress urinary incontinence. We also theorized that concurrent hysterectomy would be associated with lower rates of reoperation for POP and SUI, while prolapse repair with mesh would be associated with higher complication rates but lower rates of reoperation. The Faculty Practice Solutions Center (FPSC) is an academic hospital consortium database with information from over 60,000 physicians. This database was used to identify a cohort of patients who were treated surgically for SUI with a mid-urethral sling, with or without concurrent prolapse repair between 2009 and 2011. These patients were followed until 2014 for any subsequent SUI or POP surgeries and for any mesh complications that occurred during this time period. Patient variables (age, region, insurance) as well as surgeon volume were analyzed. Concurrent prolapse repair was analyzed based on anatomic involvement (anterior, apical, posterior, or “complete”). Sub-analyses were performed to evaluate the differences in secondary procedures. Of the 20,484 patients who underwent an SUI repair with or without concurrent POP repair, 7.2% required reoperation within the follow up period. There was a significantly higher rate of reoperation in those women who underwent concurrent prolapse repair (8.6 vs 6.3%). Women who had a concurrent prolapse repair had a 2-to-5-fold higher hazard of undergoing a repeat prolapse repair. Concurrent hysterectomy was performed in 15% of patients. While its addition did not lower the hazard of requiring any secondary surgery, it lowered the rate of repeat prolapse surgery in patients who received a concurrent ‘complete’ repair (HR = 0.48). Prolapse mesh was placed in 5% of patients. Its use resulted in a higher hazard of requiring any additional surgery (HR = 1.4), and specifically, increased the hazard of requiring repeat prolapse repair (HR = 1.5). Post-operative fistula, although rare (0.4%), had a significant association with older patients (HR = 2.1) and prolapse mesh (HR = 2.7) placement. Medicaid insurance was associated with higher risk of requiring secondary surgery (HR = 1.3). With over 20,000 patients and up to a 5 year follow-up, this is one of the largest cohort studies performed on the surgical outcomes of mid-urethral slings with or without prolapse repair surgery. While the overall reoperation rate was low, the addition of prolapse repair surgery with the initial sling procedure was associated with higher reoperation rates. In contrast, the addition of a hysterectomy lowered the risk of secondary surgery in some patients. This data allows for a clearer understanding of reoperative rates for patients undergoing mid-urethral sling placement with or without prolapse repair.

Road to recovery after transvaginal surgery for urethral mesh perforation: evaluation of outcomes and subsequent procedures.

Urethral injury resulting from transvaginal mesh slings is a rare complication with an estimated incidence of <1%. Our objective was to review the surgical management and functional outcomes of women presenting with urethral mesh perforation following midurethral sling (MUS) placement. This was a retrospective multicenter review of women who from January 2011 to March 2016 at two institutions underwent mesh sling excision for urethral perforation with Female Pelvic Medicine and Reconstructive Surgery fellowship-trained surgeons. Data comprising preoperative symptoms, operative details, and postoperative outcomes were collected by telephone (n 13) or based on their last follow-up appointment. Nineteen women underwent transvaginal sling excision for urethral mesh perforation. Eight (42%) patients had undergone previous sling revision surgery. Sixty percent of women had resolution of their pelvic pain postoperatively. At follow-up, 92% reported urinary incontinence (UI), and three had undergone five additional procedures for vaginal prolapse mesh exposure (n 1), incontinence (onabotulinum toxin injection n 1, rectus fascia autologous sling n 1), prolapse (colpopexy n 1), and pain (trigger-point injection n 1). Patient global impression of improvement data was available for 13 patients, of whom seven (54%) rated their postoperative condition as Very much better or Much better. The management of urethral mesh perforation is complex. Most women reported resolution of their pelvic pain and a high rate of satisfaction with their postoperative condition despite high rates of incontinence.

Uterine Preserving Laparoscopic Lateral Mesh Suspension for Uterovaginal Prolapse

Objective: To evaluate the technique of laparoscopic lateral colpo-uterine suspension using a mesh for uterovaginal prolapse; to specify its indications, advantages and complications and to assess its success rate. Patients and methods: This retrospective cohort study included all women treated by uterus preserving laparoscopic lateral suspension with mesh for symptomatic uterovaginal prolapse between January 2008 and June 2016 in tertiary referral hospital Farhat Hached Sousse (Tunisia). The data collected were: preoperatively and postoperatively functional symptoms and prolapse grade (POP-Q) grading system, the degree of preoperative discomfort and postoperative satisfaction, complications rate classified according to the Clavien grading system for surgical morbidity. Results: One hundred and twelve patients were included. Twenty nine women were lost to follow up and were, therefore, excluded from the study. The mean age of the patients was 49.02 ± 6.92 years (29-69). After a mean follow-up of 21 months, the success rate of anatomical reduction with this technique was about 94.8% and 4 cases of recurrent vaginal prolapse was noted, 2 were partially improved. A grade 0 was found in 58.4% and 70.1% of cases respectively at the anterior and middle floor. The rate of success for the anterior and middle floor was respectively 94.8% and 97.4%. Seventy patients (84.3%) were satisfied by the functional outcome and the degree of postoperative satisfaction was 8.1 ± 1.38 (4-10) out of 10. No laparoconversion was necessary. One bladder perforation occurred during dissection requiring preoperative sutures. Three delayed complications were observed (3.6%): two cases of parietal mesh erosions, one case of bladder granulomas. There were no cases of vaginal mesh erosions. Conclusions: The results of this study demonstrate that laparoscopic lateral colpo-uterine suspension in the treatment of genital prolapse has good anatomical and functional results, and is simple, reproducible and safe. But, we need level 1 data comparing this technique to other established surgical procedures for uterovaginal prolapse.

Anatomical and Functional Results of Pelvic Organ Prolapse Mesh Repair: A Prospective Study of 105 Cases

Objective: We assess the anatomical and functional results of pelvic organ prolapse (POP) repair with application of transvaginal synthetic meshes. Keywords: pelvic organ prolapse, vaginal repair, urogynecology. Methods: We analyzed a cohort of 105 women who underwent transvaginal pelvic floor repair using mesh (Elevate Prolapse Repair System). A gynecological examination, cough test, uroflowmetry and an administration of the overactive bladder Awareness Tool were done. Parametric and nonparametric methods of descriptive statistics, as well as logistic regression were used for data analysis. Results: Prolapse recurrence after vaginal repair was noted in 3.81% (n=4) of patients. The proportion of patients with de novo onset of incontinence after surgery was 8.57% (n=9). In 26.7% (n=28) of women with stress urinary incontinence (SUI), SUI symptoms persisted after surgery. The mean Qmax in the patient group was 19.5 ml/s. The mean Qmax in patients reporting bladder-emptying problems was 14 ml/s, and the mean post-void residual (PVR) was 50±15.0 ml. After surgery, the mean Qmax increased to 27.6 ml/s. The PVR after surgery decreased to 30±5.0 ml. The number of patients with bladder outlet obstruction symptoms decreased to 17 (16.19%). Conclusion: The management of genital prolapse with synthetic prostheses interposed through vaginal approach is an efficient method with good midterm outcomes.

Outcomes and Characteristics of Patients Undergoing Surgical Management for Mesh Related Complications.

The aims of this study were to describe the characteristics of women presenting with mesh-related complications and evaluate postoperative quality of life, sexual functioning, and patient-perceived outcomes. This institutional review board-approved study included a retrospective chart review and a cross-sectional follow-up with validated questionnaires. Demographics and medical histories were collected from charts of women treated for mesh-related complaints between 2010 and 2014. Subjects completed follow-up validated questionnaires regarding health, sexual functioning, postoperative symptom improvement/severity, satisfaction, and regret with the decision to pursue treatment. Ninety-three charts were analyzed. Mean subject age was 55 years, median body mass index was 28.7 kg/m, and median time from mesh placement to presentation was 2.7 years. Forty-nine had midurethral sling mesh only, 30 had prolapse-related mesh, and 14 had both. Forty-two subjects (48.9%) had mesh exposures, 19 involving prolapse-related mesh (52.4% transvaginal and 47.4% sacrocolpopexy). Surgical revisions were most often for exposure and pain. Seventy-five women were reached for follow-up; 71 agreed to participate, 53 (75%) returned the questionnaires. Thirty had sling revision, 22 had prolapse mesh revision, and 1 had both. Questionnaire results revealed no changes in health or sexual function after treatment. Postoperatively, subjects reported symptom improvement, low symptom severity, as well as high satisfaction and low regret with the decision to pursue surgical intervention. Women with mesh complications presented 2 years after initial placement, most often complaining of exposure or pain/dyspareunia. Although no changes in health or sexual functioning were noted postoperatively, participants reported symptom improvement after revision and satisfaction with the decision to pursue treatment.

Sacrocolpopexy with polyvinylidene fluoride mesh for pelvic organ prolapse: Mid term comparative outcomes with polypropylene mesh

ObjectiveThe aim of this study was to compare the surgical, anatomical, and functional outcomes of sacrocolpopexy (SCP) using polyvinylidene fluoride (PVDF) mesh versus SCP using the standard polypropylene (PP) mesh. Study designThis was a retrospective single centre case-control study including female patients who underwent laparoscopic or abdominal SCP for POP with either PP (Cousin Biotech®) or PVDF (DynaMesh®-PRS) mesh between March 2005 and May 2015. Anatomical outcomes were assessed by the Pelvic Organ Prolapse Quantification (POP-Q) system. Functional outcomes included voiding and storage urinary symptoms (VS and SS, respectively), urgency and stress urinary incontinence (UUI and SUI) and sexual dysfunction (SD). Symptoms and their impact on patients’ quality of life (QoL) were assessed using validated questionnaires as Incontinence Impact Questionnaire (IIQ-7), Urinary Distress Inventory (UDI-6) and Female Sexual Function Index (FSFI). Global patient perception of improvement (PGI-I questionnaire) and mesh erosion rates were also recorded. ResultsOf the 166 patients enrolled, 136 could be included in the analysis: 73 in the PP group and 63 in the PVDF group. The mean follow-up was 94± 17.31 months for the PP and 25.6± 13.8 months for the PVDF group. There were no statistically significant differences in patient demographics and preoperative clinical characteristics. Postoperative anatomical correction were not significantly different between the two groups. The PVDF group showed superior results in term of storage symptoms (PVDF=0% versus PP=8.2%; p=0.02) and lower rate of sexual dysfunction (PVDF=0% versus PP=16,4%; p=0.001). Only 1 patient in PP group and 2 in PVDF group (p=0.47) presented a mesh exposure. There was no statistical difference in PGI-I scores (PP=1.5±1.0 vs PVDF=1.8±0.5; p=0.40). ConclusionsOur findings suggest that both meshes can be safely and effectively used with good anatomical outcomes. Interestingly, PVDF use was associated with significantly less storage symptoms and sexual dysfunction.

300 - Laparoscopic Excision of Anterior Vaginal Wall Prolapse Mesh Kit

This video presents the technique of laparoscopic excision of an anterior vaginal wall prolapse mesh kit. A 67-year-old female underwent repair of anterior compartment defect using transvaginal synthetic mesh in 2009. She complained of persistent vaginal pain and dyspareunia. We removed the central portion of the mesh vaginally, followed by laparoscopic excision of remaining 4 arms of the mesh. This video will demonstrate the anatomical relations of the mesh and the key surgical principles followed during mesh dissection from the underlying tissue. Mesh was extracted successfully from both sides and resulted in resolution of patient's symptoms on the follow up.

The UK National Prolapse Survey: 10\xa0years on

Introduction and hypothesisTo assess trends in the surgical management of pelvic organ prolapse (POP) amongst UK practitioners and changes in practice since a previous similar survey.MethodsAn online questionnaire survey (Typeform Pro) was emailed to British Society of Urogynaecology (BSUG) members. They included urogynaecologists working in tertiary centres, gynaecologists with a designated special interest in urogynaecology and general gynaecologists. The questionnaire included case scenarios encompassing contentious issues in the surgical management of POP and was a revised version of the questionnaire used in the previous surveys. The revised questionnaire included additional questions relating to the use of vaginal mesh and laparoscopic urogynaecology procedures.ResultsOf 516 BSUG members emailed, 212 provided completed responses.. For anterior vaginal wall prolapse the procedure of choice was anterior colporrhaphy (92% of respondents). For uterovaginal prolapse the procedure of choice was still vaginal hysterectomy and repair (75%). For posterior vaginal wall prolapse the procedure of choice was posterior colporrhaphy with midline fascial plication (97%). For vault prolapse the procedure of choice was sacrocolpopexy (54%) followed by vaginal wall repair and sacrospinous fixation (41%). The laparoscopic route was preferred for sacrocolpopexy (62% versus 38% for the open procedure). For primary prolapse, vaginal mesh was used by only 1% of respondents in the anterior compartment and by 3% in the posterior compartment.ConclusionBasic trends in the use of native tissue prolapse surgery remain unchanged. There has been a significant decrease in the use of vaginal mesh for both primary and recurrent prolapse, with increasing use of laparoscopic procedures for prolapse.

Recurrent Urinary Tract Infections in the Setting of Mesh Implants

Mid-urethral polypropylene mesh slings are widely accepted as a standard for surgical management of stress urinary incontinence due to a low complication rate and superior efficacy. Synthetic mesh implants used to augment female pelvic prolapse repairs gained popularity following introduction of these slings. Mesh implants for prolapse have been under increased scrutiny after the FDA safety notification was published in 2008 due to a higher than anticipated complication rate. While the complication rate of mesh slings used for incontinence is low, both incontinence mesh and prolapse mesh are associated with similar types of complications. These include mesh exposure, pain, voiding dysfunction, and infections. The majority of available literature describes the incidence of acute urinary tract infections in the immediate postoperative period, specifically after mid-urethral sling procedures for incontinence. The rates of de novo recurrent urinary tract infections and risk factors for these infections after polypropylene mesh placement are not well-characterized. The incidence of recurrent urinary tract infections after polypropylene mesh-augmented surgery for stress urinary incontinence and for pelvic organ prolapse is low. Risk factors for recurrent urinary tract infections after surgery include urinary retention, need for indwelling or intermittent catheterization, and preoperative history of recurrent urinary tract infections. While multiple theories exist, the current literature has not been able to determine risk factors for de novo recurrent urinary tract infections after mesh-augmented surgery in women without urinary retention or prior history of recurrent urinary tract infections. While some have suggested that the implant is coated with a bacterial biofilm resulting in chronic low levels of bacterial shedding, and thus predisposing certain individuals to chronic recurrent urinary tract infections, this theory remains unproven. It is also not known if revision of the mid-urethral slings or if removal of the mesh implant in women in this subgroup will result in the resolution of recurrent infections.

Anterior six arms prolene mesh for high stage vaginal prolapse: five years follow-up.

ABSTRACTIntroduction In high stage vaginal prolapse, recurrence risk patients, anterior and apical defects need to be addressed in the same procedure. The pre-molded commercial mesh kits are expensive and not always available. Alternative effective and safe treatment ways, with lower costs are desirable.Objective To present long term follow-up of patients treated with a homemade mesh shape to correct high stage prolapses.Materials and Methods We describe prospectively 18 patients with anterior and apical vaginal prolapses, stages III and IV, repaired using this specific design of mesh. All patients were submitted to pre-operative clinical evaluation and urodynamics. Prolapse was classified using the pelvic organ prolapse quantification (POP-Q). Intervention Prolapse surgery, using a six arms prolene mesh, through a single anterior vaginal incision. Outcome Measurements: POP-Q, patients satisfaction, descriptive statistical analysis.Results Between February 2009 and Oct 2010, 18 consecutive women underwent the above-mentioned surgery. Mean age was 68 years. At a mean follow-up of .,4 years (5 to 5.8 years), 16 (89%) patients were continent, mean Ba point came from +4.7cm to - 2.5cm, mean C point from +2.8cm to -6.6cm and mean Bp point from +1.3 to -1.7cm. There were two (11%) objective failures, but all the patients were considered success subjectively. There were two cases of mesh vaginal extrusion.Conclusions The homemade six arms prolene mesh allows concomitant correction of anterior and apical prolapses, through a single anterior vaginal incision, being an effective, safe and affordable treatment option when mesh is needed.

Birds of a feather?

The complications of using vaginal mesh for pelvic organ prolapse are well known. SCENIHR (Scientific Committee on Emerging and Newly Identified Health Risks), NHS England Mesh working Group and the Scottish Independent Review of the Use, Safety and Efficacy of Transvaginal Mesh Implants in the Treatment of Stress Urinary Incontinence and Pelvic Organ Prolapse in Women all published reports in 2016. Their conclusions have overlapping themes, with an emphasis on the need for robust clinical governance, multi-disciplinary team working, thorough audit, and recording and reporting of adverse events. Adequate patient information and informed consent is a fundamental principle underlying all healthcare management. The midurethral synthetic sling is made of the same type 1 macroporous material as vaginal prolapse mesh and so slings have been included with mesh in adverse publicity with a consequent decline in their use, with resurgence of fascial slings and more complex surgery such as colposuspension. The impact of this has been particularly evident in Scotland, where patients have been refusing to have a synthetic sling. As recently as 2011, it was common practice to inform patients that a synthetic sling was the procedure of choice and it was acceptable to give this as the sole option. This is now in violation of the Montgomery ruling of the UK Supreme Court (Montgomery v Lanarkshire Health Board [2015] UKSC 11), which requires a thorough discussion of pros and cons and alternatives. However, complete cessation of use, as has been the case with vaginal mesh, would equate to throwing the baby out with the bathwater. The price would be paid by the patient, who would end up with more complex surgery, with greater overall risks (apart from the risks of any synthetic material, i.e. extrusion and erosion, which are low in the case of sub-urethral slings). Some patients would likely be denied treatment altogether on the grounds of obesity or other comorbidities which make them unsuitable for an abdominal procedure. The midurethral sling is no longer a ‘new’ device and has reassuring 17-year follow-up data with a 90% objective continence rate and no serious long-term tape-induced adverse effects (Nilsson et al. Int Urogynecol J 2013;24:1265-9). So at what point is a prosthesis considered well established in clinical practice? In the history of implantable devices, defective/faulty ones will usually be identified within 10 years of market launch. Examples include trocar-guided meshes for prolapse, PIP breast implants, and Pinnacle Hip implants. On the other hand, the full extent of complications with synthetic slings such as extrusion and erosion may not yet be apparent. In the UK, we need to centralise the management of mesh-related complications in specialist units to allow the development of the expertise needed for successful remediation. With patient groups such as TVT MUM clamouring for a total ban on the product, there is an urgent need for the development of agreed clinical decision-making tools to enable patients to make fully informed choices in the management of their urinary incontinence. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Challenging the Myth: Transvaginal Mesh is Not Associated with Carcinogenesis

We sought to determine if there was a potential link between synthetic polypropylene mesh implantation for transvaginal pelvic organ prolapse and stress urinary incontinence, and carcinogenesis using statewide administrative data. Women who underwent transvaginal surgery for pelvic organ prolapse or stress urinary incontinence with mesh between January 2008 and December 2009 in New York State were identified using ICD-9-CM procedure codes and CPT-4 codes. Patients in the mesh cohort were individually matched to 2 control cohorts based on comorbidities and procedure date. Carcinogenesis was determined before and after matching at 1, 2 and 3 years, and during the entire followup time. A total of 2,229 patients who underwent mesh based pelvic organ prolapse surgery and 10,401 who underwent sling surgery for stress urinary incontinence between January 2008 and December 2009 were included in the study. Mean followup was 6 years (range 5 to 7). Exact matching between the mesh and control cohorts resulted in 1,870 pairs for pelvic organ prolapse mesh and cholecystectomy (1:2), 1,278 pairs for pelvic organ prolapse mesh and hysterectomy (1:1), 7,986 pairs for sling and cholecystectomy (1:1) and 3,810 pairs for sling and hysterectomy (1:1). Transvaginal mesh implantation was not associated with an increased risk of a cancer diagnosis (pelvic/local cancers or any cancer) at 1 year and during the entire followup of up to 7 years. Transvaginal surgery with implantation of mesh was not associated with the development of malignancy at a mean followup of 6 years.

Analysis of Complications of Pelvic Mesh Excision Surgery Using the Clavien-Dindo Classification System

We describe and categorize complications using the Clavien-Dindo classification system in patients who underwent vaginal mesh excision surgery. With institutional review board approval we retrospectively reviewed the records of 277 patients who underwent vaginal mesh extraction between 2007 and 2015 at a single institution. Surgical complications were stratified using the Clavien-Dindo classification system. Complications were perioperative (prior to discharge) or postoperative (within 90 days). Indications for initial mesh placement, mesh revision procedure, time to resolution and medical comorbidities were assessed. Of the 277 patients 47.3% had at least 1 surgical complication, including multiple complications in 7.2%. A total of 155 complications were identified, which were grade II in 49.0% of cases, grade I in 25.8%, grade IIIb in 18.7%, grade IIIa in 5.2% and grade IVa in 1.3%. No grade IVb or V complications were identified. The indication for initial mesh placement did not significantly affect complication frequency. Patients who underwent combined stress urinary incontinence and pelvic organ prolapse mesh revision surgeries had an increased frequency of complications compared to those treated with mesh revision surgery for pelvic organ prolapse or stress urinary incontinence alone (p = 0.045). Most complications occurred postoperatively and resolved by 90 days. Age, body mass index, smoking status and diabetes were not associated with increased complications. Despite the complexity of mesh revision surgery most complications are minor. Serious complications may develop, emphasizing the need for proper patient counseling and surgical experience when performing these procedures.

Patient satisfaction after laparoscopic lateral suspension with mesh for pelvic organ prolapse: outcome report of a continuous series of 417 patients.

Sacropexy is considered the gold standard for the treatment of pelvic organ prolapse (POP) although dissection of the promontory may be challenging, particularly in obese women. Laparoscopic lateral suspension with mesh (LLS) could be an alternative. LLS provides lateral attachment by fibrosis of a vesicovaginal mesh. Clinical evaluation was performed at 1year using the simplified POP quantification system (POP-Q). Primary outcomes were objective and subjective cure at 1year. After a mean of 7.2years the rates of reoperation and complications were assessed as secondary outcomes. Patient satisfaction was evaluated by telephone interview using a ten-point-scale and the PGI-I scale. Factors predicting satisfaction were determined by logistic regression analysis. A total of 417 patients were treated between 2003 and 2011. At 1year 78.4% of patients were asymptomatic and anatomic success rates were 91.6% for the anterior compartment, 93.6% for the apical compartment and 85.3% for the posterior compartment. The complication rate of Clavien-Dindo grade III or higher was 2.2%. The mesh exposure rate was 4.3% and the reoperation rate was 7.3%. Of the 417 patients, 214 participated in the telephone interview. Over 85% rated their situation as improved and satisfaction was associated with the absence of concomitant hysterectomy. LLS is a safe technique with promising results in terms of a composite outcome, low complication rates and high long-term patient satisfaction. However, a randomized controlled trial is needed to establish the technique as an alternative to sacropexy in the treatment of POP in obese and high morbidity patients.

Fabrication and evaluation of a warp knitted polypropylene/polylactic acid composite mesh for pelvic floor repair

Surgical mesh for repairing pelvic defects is expected to be stiff to improve surgical convenience, as well as be soft and flexible to relieve foreign body sensation. This paper aims to develop a new composite mesh (PA) consisted of polypropylene (PP) monofilaments and polylactic acid (PLA) monofilaments according to this expectation. The PA mesh was designed by the two-bar warp knitting technique to have a knitted structure with light weight (19.9 g/m2) and high porosity (porosity). A commercial lightweight PP mesh—Surgimesh® Prolapse mesh—was used as the control group. The mechanical property, in vitro degradation, and in vivo biocompatibility were then measured. The results revealed that the addition of stiffer, stronger PLA monofilaments did not significantly strengthen PA mesh, but made the mesh stiff. The warp knitted structure, porosity and pore size are vital factors affecting mesh mechanical properties. PLA monofilaments in PA mesh were degraded in 74 weeks, with a maximum weight loss reaching 62.4%. PA mesh was demonstrated to have better biocompatibility with evidences of lower shrinkage (13.1%) and faster tissue growth speed.