Mesh Strip Research Articles

412: Lateral Suspension for Utero Vaginal Prolapse in Reproductive Age Group

Technique of prolapse repair while conserving the uterus will be shown in this video. Mesh is fixed to the pubo cervical fasica over the isthumus and is brought out over and fixed to the anterior abdominal wall. Other strip of mesh is fixed to the recto vaginal septum, utero sacral ligament and is fixed to the arcus taurineus. Good antomical and functional correction is obtained. No significant complications noted. Lateral suspension with posterior compartment repair is superior to isolated approaches of sacro hysteropexy or utero sacral suspension for marked prolapse in younger females.

411: Laparoscopic Management of Significant Utero Vaginal Prolapse

The purpose of this video is to clearly demonstrate the surgical technique of mesh augmented repair for marked utero vaginal prolapse. 22 cases of significant utero vaginal prolapse were treated by isthmic promontofixation utilizing polypropylene mesh after supra cervical hysterectomy. Two separate strips of mesh were used fixing the anterior isthmus and pubo cervical fascia and posteriorly the rectovaginal septum to the sacral promontory. Very good anatomical and functional correction obtained. No mesh erosion reported in two year follow-up.

Graft interposition colpocleisis, perineorrhaphy, and tension-free sling for pelvic organ prolapse and stress urinary incontinence in elderly patients

Study objective We sought to describe the outcome of combined colpocleisis, perineorrhaphy, and tension-free sling procedure for advanced uterovaginal prolapse and stress urinary incontinence in patients who are elderly and medically compromised. Design Prospective analysis. Setting University hospital. Patients Thirty-nine women were enrolled. Median age of patients was 82 years (76–94 years). Interventions All patients had advanced uterovaginal prolapse with perineal relaxation and incontinence and each wore a large pessary. Measurements and main results Median estimated blood loss was 42 mL (range 10–65 mL), median operating time was 58 minutes (range 45–76 minutes), and median hospital stay was 8 hours (range 0–3 days). Thirty procedures were accomplished without general anesthesia. Le Fort colpocleisis was reinforced with excessive mesh strips from the sling by placing mesh between anterior and posterior vaginal walls at the time of closure. No intraoperative complications occurred and none had postoperative voiding difficulty or significant discomfort. One patient required hospitalization for cardiac arrhythmias and 3 others for observation purposes only. Median follow-up has been 24 months. Follow-up physical examinations were performed for postoperative evaluation. One patient required reoperation for minor posterior compartment prolapse and another has started to show some apical prolapse again. Neither patient had a perineorrhaphy at the time of initial procedure. Two patients required some graft excision as a result of exposure from the side without any loss of support or discomfort. In all, 37 patients (37 of 39) are extremely pleased with the prolapse repair and 35 patients (35 of 39) report significant improvement of stress incontinence. Conclusion Concomitant severe pelvic organ relaxation and stress urinary incontinence can be surgically treated safely and rapidly using a tension-free sling and colpocleisis with perineorrhaphy under local anesthesia and sedation, thereby eliminating potential risks of general anesthesia and invasive surgery. A novel technique of graft interposition colpocleisis has been used.

Vault prolapse treated by sacrocolpopexy

Objective. To evaluate the success rate of sacrocolpopexy in 153 patients with stage 3 and 4 vault prolapse. Methods. A retrospective review was done on 153 patient records from a database in a urogynaecological unit. For the sacrocolpopexy procedure, semi-absorbable mesh was placed along the anterior and posterior vaginal walls, and attached to the anterior longitudinal ligament of the sacrum. Results. The median age was 65 years and parity 3.0; 94% of the patients were white. Previous surgery for prolapse was reported by 48% of the patients and 25% were on thyroid hormone treatment. The vault prolapse was stage 3 in 81 patients (52.9%) and stage 4 in 72 (47.1%). At surgery, the mesh extended from the vaginal vault to the sacrum in 7 patients (4.6%). In the remaining 146 patients (95.4%) the mesh was attached to the posterior vaginal wall and in 133 (86.9%) a second strip of mesh was fixed to the anterior vaginal wall. Follow-up was possible in 149 patients (97.4%), with a median of 29 months. Recurrent prolapse (any type) occurred in 22 patients (14.4%) and 12 had repeat surgery for recurrent prolapse (7.8%). In total, 25 patients (16.3%) had repeat surgery for any indication. Conclusions. Vault prolapse is difficult to treat owing to absence of support of the upper vagina, but sacrocolpopexy delivered acceptable results. South African Journal of Obstetrics and Gynaecology Vol. 13 (3) 2007: pp. 80-83

Megavoltage x-ray skin dose variation with an angle using grid carbon fibre couch tops

It is well known that a skin dose from high-energy x-ray radiation varies with the angle of beam incidence or the presence of a radiotherapy linear accelerator couch top material. This note investigates changes produced to the skin dose from a Varian carbon fibre grid couch top at differing angles of incidence for 6 MV x-rays as is often the case clinically. Results have shown that the skin dose can easily be measured using an EBT Gafchromic film whereby the delivered skin dose can be quantified to a high level of spatial resolution, not easily achieved with other skin dose detectors. Results have shown a significant increase in the skin dose specifically at the point of a cross-sectional carbon fibre grid. Values in % of the skin dose increased from approximately 27% (an open area within a 10 cm × 10 cm field) up to 55% (same field size) at the centre of the carbon fibre mesh strip (0° incidence). This is compared to 19% of the skin dose for an open field of a 10 cm × 10 cm beam without the couch material present. At larger angles similar effects occur with values changing from 52% to 75% (60°, 10 cm × 10 cm) in the open area and under the grid, respectively. This produces a wave effect for the skin dose. The average skin dose magnitude increases with the angle of incidence of the beam, ranging from 37.5% to 66% from 0° to 60° (10 × 10 cm), respectively. The symmetric wave nature of the skin dose profile skews to deliver an increased dose on the posterior side of the carbon fibre grid as the angle of incidence increases. Simulated fractional dose delivery on a phantom has shown that over 30 fractions the wave nature of the delivered skin dose is minimized due to the random nature of most patient positioning on the treatment couch. However, some variations are still present as the ratio of the open to grid area is approximately 4:1 and the dose spread is not necessarily completely averaged during a typical fractionated radiotherapy treatment. As such, if the treatment type results in a more rigorously positioned patient on the treatment couch, the wave nature of skin dose delivery may need to be taken into account.

A new technique of polypropylene mesh-reinforced pancreaticojejunostomy

Anastomotic leakage of pancreaticojejunostomy is a common problem and a significant cause of morbidity and mortality after pancreatic resection. An appropriate technique to minimize pancreatic leakage is very important. Recently we have performed a safe and simple mesh-reinforced pancreaticojejunostomy, by which a strip of polypropylene mesh is wrapped around the pancreatic stump in order to secure the end-to-end pancreaticojejunal anastomosis. No leakage developed in all 10 patients who received this procedure.

Centrifuge Model Studies of the Seismic Response of Reinforced Soil Slopes

Centrifuge tests were used to study the dynamic behavior of soil slopes reinforced with geosynthetics and metal grids. The main objectives were to determine the failure mechanism and amount of deformations under seismic loading and to identify the main parameters controlling seismically induced deformations. Geosynthetically reinforced soil slopes (2V:1H) and vertical walls reinforced with metallic mesh strips were subjected to earthquake motions with maximum foundation accelerations of up to 1.08g. The experimental results show that slope movement can occur under relatively small base accelerations, and significant lateral and vertical deformations can occur within the reinforced soil mass under strong shaking. However, no distinct failure surfaces were observed, and the magnitude of deformations is related to the backfill density, reinforcement stiffness and spacing, and slope inclination.

TISSUE REACTIONS OF 5 SLING MATERIALS AND TISSUE MATERIAL DETACHMENT STRENGTH OF 4 SYNTHETIC MESH MATERIALS IN A RABBIT MODEL

We evaluated tissue reactions to 5 sling materials used in tension-free vaginal tape (TVT), intravaginal slingplasty (IVS), polypropylene mesh hernia repair, the suprapubic approach to suburethral polypropylene tape (SPARC) and cadaveric fascia lata procedures. We also compared the mesh-to-tissue attachment strength of 4 sling mesh materials (TVT, IVS, surgical polypropylene mesh and SPARC) at on days 2, 7, 15 and 30 after implantation. A total of 20 female New Zealand White rabbits were randomized to group 1-2 days, group 2-7 days, group 3-15 days and group 4-30 days. After the rabbits were anesthetized an 8 cm midline incision was made for rectus muscle access, and 0.5 x 1 cm pieces of TVT, IVS, SPARC, surgical polypropylene mesh and cadaveric fascia lata were sewn to the rectus muscle with direct contact. At the same time 4 subfascial tunnels in the medial surface of the upper extremities were prepared, and 1.0 x 0.5 cm strips of TVT, IVS, SPARC and polypropylene mesh were implanted in each tunnel. On days 2, 7, 15 and 30 after implantation mechanical testing was performed to define tissue detachment strength. The strips of 5 sling materials were then harvested with the surrounding tissue. Specimens were studied by light microscopy. Mean detachment strength, that is the minimum weight needed to move the mesh, of the synthetic meshes from days 2 to 30 were 291.6 to 2,390.0 gm for TVT, 178.4 to 2,160.0 gm for SPARC, 188.4 to 1,850.0 gm for hernia mesh and 92.8 to 1,510.0 gm for IVS (at all data points TVT vs IVS p < 0.05). Light microscopy revealed a quite uniform tissue reaction with a sign of marked acute inflammation in and around the mesh fibers on days 2 and 7 after implantation. All meshes showed stable fibrosis and muscle infiltration on day 30. All 5 synthetic sling materials produce similar tissue reactions beginning soon after implantation. Cadaveric fascia lata persisted in tissue with remarkable perifascial fibrosis at day 30. When comparing the 4 polypropylene mesh materials; the attachment capacity of TVT was superior and that of IVS was the least of the 4. TVT was statistically better than IVS at all data points. SPARC and hernia mesh provided results similar to those of TVT.

Laparoscopic sacrocolpopexy for severe vaginal vault prolapse: Five-year outcome

Study objective To assess the efficacy of the laparoscopic sacrocolpopexy in the treatment of severe vaginal prolapse. Design (Canadian Task Force classification II-1). Setting Private clinic. Patients Fifty-one consecutive posthysterectomy patients with severe vaginal prolapse (Baden-Walker Grade 3 or 4). Interventions The patients were treated by laparoscopic sacrocolpopexy in conjunction with other laparoscopic and/or vaginal procedures, as indicated. Measurements and main results Of the 43 patients seen at 5-year follow-up, 3 had recurrent vaginal prolapse (objective cure rate 93%). In the patients with recurrence, the polypropylene mesh had torn partially or completely from the vaginal apex. When the posterior strip of mesh was extended to the perineal body, there were fewer recurrences of posterior compartment defects. Postoperatively, two patients had a partial small bowel obstruction secondary to bowel adherence to the mesh. Four patients had mesh erosion at the vaginal apex: two responded to local treatment, and two required vaginal flaps to cover the defect. Conclusion Laparoscopic sacrocolpopexy can be used safely with cure rates similar to abdominal sacrocolpopexy. Extending the mesh to the perineum appears to decrease posterior vault defects. There is a protracted learning curve. Patient recovery is greatly enhanced, in most cases requiring only an overnight hospitalization.

Sling may hasten return of continence after radical prostatectomy

Objectives To place absorbable slings in 15 men at radical retropubic prostatectomy in an attempt to hasten recovery of continence. Methods Fifteen men underwent placement of a sling immediately after prostatectomy by a single surgeon . A strip of either porcine small intestine submucosa (SIS) or polyglactin mesh was placed beneath the anastomosis. The initial five slings were tension free. The last 10 were tightened just to the point they began to elevate the anastomosis. A comparison was made with the same number of men who underwent radical retropubic prostatectomy immediately before beginning this project. The average follow-up was 28.9 months. Results The first 5 sling patients (no tension) recovered complete bladder control in an average of 5.8 weeks. The 10 men with slings placed under slight tension were dry an average of 2.6 weeks after catheter removal, including 4 within 24 hours. One month later, 10 sling patients (67%) were continent, including 8 (80%) who had had the sling placed under slight tension. Six (40%) of 15 control patients were completely dry in that interval. Three months later, all but 1 sling patient (93%) was dry, but only 7 (47%) of 15 controls. All, except 1 control, were dry at 12 and 24 months. No complications were attributed to this maneuver, specifically no bladder neck contracture or retention occurred. No one in either group received incontinence treatment, although 2 control patients had either stricture or bladder neck contracture. Conclusions The early results have been encouraging, but must be confirmed. Slight tension on the sling may be beneficial.

LONG-TERM EFFICACY OF A VAGINAL SLING PROCEDURE IN A RAT MODEL OF STRESS URINARY INCONTINENCE

We examined the long-term efficacy of a newly created vaginal sling procedure for the restoration of leak point pressure (LPP) in a rat model of stress urinary incontinence (SUI). A total of 20 female Sprague-Dawley rats were randomly assigned to 1 of 4 groups, namely normal control, SUI plus vaginal sling, SUI plus sham sling and SUI only. SUI was created in the latter 3 groups by bilateral pudendal nerve transection (PNT). In the sling procedure a 2 x 0.3 cm strip of polypropylene mesh was placed at the mid urethral level. Animals in the SUI plus sham sling group underwent vaginal dissection only. After 5 weeks LPP was measured 4 or 5 times in each rat and the mean was determined. The Kruskal-Wallis and Wilcoxon rank sum tests were used to evaluate whether levels of measurements differed across and between groups. Mean LPP +/- SD in control rats was 48.8 +/- 10.2 cm H2O. PNT decreased LPP to 23.5 +/- 7.4 cm H2O. Sling placement improved LPP at 5 weeks to 35.5 +/- 2.3 cm H2O, whereas LPP in the sham sling group was 29.1 +/- 4.9 cm H2O. LPP recovery in the sling group was significantly above levels for PNT (p = 0.037). LPP in the sling group did not differ statistically from that in the control group (p = 0.11). The newly created vaginal sling model restores the LPP in the rat model of SUI in the long term (5 weeks). This model could be used to address research questions related to the sling procedure.

A simple and reliable hemostatic technique during partial nephrectomy

Introduction To report our experience with a refined technique for hemostasis that obviates the need for vascular control and closure of the collecting system in partial nephrectomy. Technical considerations Four to five sutures, 2 cm apart, are placed 0.5 cm from the anticipated parenchymal incision border, using a specially designed, blunt-tip, straight needle with folded 2-0 Vicryl thread. The needle is removed, leaving the Vicryl thread with the loop on one side of the kidney and two free ends on the other side. A 1.0-cm-wide Vicryl mesh strip is passed circumferentially through the loops and between the free ends on each side, tension is applied on the strip during knotting of the free ends of the thread, and the tissue is incised. No additional hemostatic sutures are necessary. No attempt is made to identify and close the open collecting system. Vascular clamping and surface cooling are avoided. Sixty-one patients have undergone this technique since 1987: initially, for complicated nephrolithiasis (n = 15), localized purulent kidney disease (n = 4), trauma (n = 3), congenital anomalies (n = 2), and resection of horseshoe kidney (n = 6) and, recently, for peripherally located renal tumor (n = 31). Upper pole resection was performed in 11 patients, lower pole resection in 45, and middle segment resection in 5. The blood loss was minimal, with only 1 patient developing gross hematuria that resolved after conservative treatment. No other complications occurred. Conclusions A simple and easily performed hemostatic method suitable for peripherally located and, particularly, polar renal tumors is described. The Vicryl mesh strip prevents tears of the parenchymal sutures and ensures good hemostasis without closing the collecting system separately.

THE ROSTI SLING: A NEW, MINIMALLY INVASIVE, TENSION-FREE TECHNIQUE FOR THE SURGICAL TREATMENT OF FEMALE URINARY INCONTINENCE—THE FIRST 217 PATIENTS

We evaluated the outcome of a new, innovative, inexpensive tension-free technique, the Rosti sling (RS), for female urinary incontinence. RS was performed in 217 patients under local (45%), spinal (52%) or general (3%) anesthesia. A 1.5 x 33 cm strip of polypropylene mesh was inserted under the mid urethra from above through small suprapubic stabs down and out through a 1.5 cm midline vaginal incision using the Stamey needle. Of the women 76% had stress urinary incontinence and 24% had mixed incontinence. Patient age was 24 to 90 years (mean 56) and parity was 0 to 6 (mean 2). The diagnosis of incontinence was based on history and physical examinations with a cough stress test. Mean followup was 23 months. Mean operative time was 25 minutes (range 15 to 45) and mean hospital stay was 3 days (range 1 to 12). Perioperative complications were bladder and urethral perforations in 2 and 1 cases, respectively (1.4%), and hematoma in 3 (1.4%). There was postoperative retention with a variable duration in 49 patients (23%), of whom 41 underwent Hegar dilation. Altogether 186 of 215 patients (86.5%) were cured of incontinence. Two patients were lost to followup and 14 (16.3%) had de novo urge incontinence. The cure rates were 87% for stress urinary incontinence and 91% for mixed incontinence. The cure rate in patients treated under local and spinal anesthesia were 82% and 91%, respectively (p = 0.1084). The rates for RS with recurrent vs primary incontinence were 84% vs 87% (p = 0.5800) and for RS with vs without Hegar dilation 80% vs 88% (p = 0.2094). The technique described is simple, safe and inexpensive. The cure rates are comparable to those of tension-free vaginal tape. However, because of the relatively high rate of postoperative voiding difficulties compared to tension-free vaginal tape, this technique can be criticized. To avoid these problems special attention should be focused on applying the mesh without tension and with precision.

Colposacrosuspension for severe genital prolapse

Objective: A descriptive study of 140 patients with severe genital prolapse managed by colposacrosuspension with mesh interposition and a modified Burch colposuspension. Methods: A laparotomy was performed with mobilization of the rectum and exploration of the rectovaginal septum. Vaginally, a longitudinal incision was made in the posterior vaginal wall which was completely separated from the rectum. A perineal repair was done, whereafter a strip of Vypro ® (Johnson & Johnson, Brussels, Belgium) mesh was inserted from the perineum to the sacrum at S1. It was fixated to the perineum and vagina while the rectum was elevated and attached to the mesh. Where a perineal repair was deemed not necessary, the mesh extended from the mid-vagina to the sacrum. A second mesh strip was placed anteriorly of the vagina, covering the upper third of the vagina and extending to the sacrum. After closure of the pelvic peritoneum, covering the mesh, a modified Burch colposuspension was performed. Follow-up was done at 6 weeks, 6 months and yearly thereafter. Results: The median age was 61 years with a median parity of 3. All patients presented with grade 2 (extending to the vaginal introitus) or 3 (outside the vaginal introitus) prolapse. Approximately one-third had urinary incontinence and a similar proportion complained of difficulty in defecation. All the patients underwent colposacrosuspension with the mesh extending to the perineum in 67% of the patients. A Burch colposuspension was performed in 79% of the women. Postoperatively, 97% of the patients were followed for 1–29 months with a median of 8.5 months (mean 10.2 months). Recurrent prolapse, grade 2 or 3, developed in 11 patients (8%) and 17 patients (12%) developed urinary incontinence, needing a transvaginal tape procedure. Removal of the mesh was necessary in one patient (0.7%). Conclusion: Colposacrosuspension for severe genital prolapse delivered satisfactory short-term results. It is, however, a major surgical procedure and elderly or compromised patients may require less invasive procedures.

Laparoscopic Two-Team Slings for Women with Stress Urinary Incontinence

Study Objective To review long-term success and complication rates of laparoscopic two-team sling procedures in women with stress urinary incontinence or mixed incontinence confirmed by urodynamic testing and cystoscopy. Design Prospective study (Canadian Task Force classification II-2). Setting Tertiary urogynecology unit at a university-affiliated teaching hospital. Patients One hundred seventy-five women. Interventions Laparoscopic two-team sling procedure. Measurements and Main Results The extraperitoneal approach to the space of Retzius was accomplished using a balloon device, and the intraperitoneal approach involved a transverse incision through the anterior parietal peritoneum 6 cm above the symphysis. A 1.5- to 2.0-cm wide strip of polypropylene mesh was inserted through a vertical incision along the anterior vaginal wall, perforating the urogenital diaphragm under laparoscopic guidance. The mesh was sutured to Cooper's ligaments bilaterally with 0 polypropylene sutures. Mean operating time was 80.1 ± 30.0 minutes, mean estimated blood loss was 160 ± 146 ml, and mean hospital stay was 2.4 ± 1.2 days. Patients were followed at 6 weeks, 6 months, 1 year, and yearly (mean 17.8 mo, range 1–5 yrs). Conclusion Laparoscopic two-team sling procedures can be performed safely in women with recurrent stress incontinence and those with risk factors for failure of retropubic urethropexy. Long-term success rates are excellent (91.1%) with few complications.

Classification of turbulent flow patterns with fuzzy clustering

A pattern recognition technique for the identification of critical points in turbulent flows based on fuzzy C-means clustering is presented. The technique deals with, in particular, the problem that experimental data is normally obtained with coarsely spaced sensors making the identification of critical points uncertain. The technique was applied to hot-wire data from two different turbulent flows; one is the highly ordered wake of a mesh strip, while the second is the wake of a circular cylinder, which has a higher level of disorder. Foci and saddle points in the velocity fields were accurately detected and classified.

The open tension-free mesh repair of inguinal hernia Analysis of 1,235 cases

1235 outpatient repairs of inguinal hernias under local anesthesia with IV sedation were performed between September 1993 and June 1997. The average age was 63. Twelve percent were recurrent repairs. All indirect hernias and all focal diverticular type V direct defects were treated with a cone-shaped polypropylene plug plus an overlay mesh strip. All broad fusiform type IV direct defects were repaired either by the same plug method or in the manner of a Lichtenstein repair. Mortality was zero. There were 3 recurrences, 5 superficial hematomas, 5 seromas, 1 questionable neuralgia, 1 dysejaculation, 1 ischemie orchitis, 1 flare-up of gout and 1 TIA, for a complication rate of 1.46%. Infection rate was zero. Recurrence rate thus far is only 0.24%, 0.16% for primary repair and 0.67% for recurrent repair.

Development of structure within the turbulent wake of a porous body. Part 1. The initial formation region

This paper deals with the initial region (x/d = 1 to 20) of a turbulent wake generated by a mesh strip. The purpose of the study is to identify the formation mechanism of the large-scale vortices which have developed by the end of this zone. The region is characterized by the evolution and interaction of two parallel shear layers generated at the edges of the mesh. Multi-point hot-wire velocity measurements establish that the merging and interaction of the small-scale eddies account for the formation of the large-scale vortices. A numerical simulation based on a discrete vortex method was carried out to gain further insight into the interaction between the two shear layers. Both the experimental and numerical results suggest that low-frequency perturbation plays an important role in the communication between the two shear layers.

Development of structure within the turbulent wake of a porous body. Part 2. Evolution of the three-dimensional features

The present investigation deals with the development stage (x/d = 20–100) of the porous-body wake, generated by a mesh strip. Pattern-recognition analysis was applied to the velocity signals from hot-wire measurements in the vertical centreplane and various horizontal planes in the flow field. Spanwise coherent structures (with ωz) and lateral coherent structures (ωy) have been identified. An examination of the fine-scale turbulence is used to show that the two kinds of structures are indeed connected. In the near region of the wake, the lateral structures are ‘ribs’ attached to the spanwise vortices. In the intermediate region, the interaction of the two structures changes the original spanwise vortices into three-dimensional structures. Beyond this zone, in the far region, the’ legs’ of the original spanwise structure merge with the’ ribs’, and it can be inferred that the coherent structures within the flow are essentially randomly distributed hairpin-like vortices.

The near wake region of a high solidity mesh strip

A pattern‐recognition analysis of the near region of a plane turbulent wake generated by a high solidity mesh strip reveals a markedly regular vortex street. In fact, the ratio of the ‘‘coherent’’ to ‘‘incoherent’’ (or ‘‘random’’) fluctuations is significantly larger than for many other plane turbulent wakes of similar Reynolds number. Since these incoherent fluctuations are so weak, the vortex street persists. This is in contrast to what is observed to happen in many other wakes, where secondary vortices, which are associated with the incoherent fluctuations, act to deform the main vortices of the vortex street into horseshoe‐like vortices very early in the development. Here, the secondary structures must be too weak in the near region to influence the vortex street to any significant effect.