Tension-free Vaginal Mesh Procedure Research Articles

Postoperative Outcomes Following Tension-Free Vaginal Mesh Surgery for Pelvic Organ Prolapse: A Retrospective Study.

We retrospectively reviewed the postoperative outcomes of patients who underwent tension-free vaginal mesh (TVM) surgery in our institution. In total, 195 TVM surgeries were performed at the Shimane University School of Medicine from January 2010 to May 2016 in patients with Pelvic Organ Prolapse-Quantification (POP-Q) stage II or higher. Perioperative complications and problems arising following surgery were assessed from medical charts. Among the 195 patients, only 1 patient required blood transfusion due to massive intraoperative blood loss. None of the patients experienced intraoperative complications, such as injury to the bladder or rectum during surgery. Mesh exposure was observed in 10 patients (5.1%). Overall, 6 of these 10 patients were asymptomatic, and surgical treatment was required in only 1 patient. Mesh exposure occurred at significantly higher frequencies in patients aged less than 60 years. Postoperative recurrence of POP, which was defined as recurrence over POP-Q stage 2, was noted in 13 of the 195 patients (6.6%). Re-operation was performed in 1 patient in whom recurrence was observed within 3 months postoperatively. Recurrence of POP was likely to occur in patients with higher POP-Q stages. Overall, 31 of the 195 patients (15.9%) required medication for postoperative stress urinary incontinence (SUI) after surgery. Among these, 2 patients underwent surgical treatment for SUI. Outcomes following the TVM procedure were satisfactory. However, caution should be exercisedagainst mesh exposure in younger patients and recurrence of POP in patients with advanced POP-Q stage.

Severe Pelvic Organ Prolapse with Large Vaginal Mucosal Defect Underwent Laparoscopic Shull’s Uterosacral Ligament Colpo-Suspension and TVM Operation by Two Stage Surgery

A 75-year-old woman complained of anuria and a sense of discomfort with severe pelvic organ prolapse (POP). We planned tension-free vaginal mesh (TVM) surgery after curing mucosal defects and completing treatment for diabetes mellitus. Anuria and pyelonephritis relapsed repeatedly due to the failure of ring pessary therapy. Surgical treatment was required emergently. We performed a total laparoscopic hysterectomy and uterosacral ligament colpo-suspension (Shull’s method). Although the vaginal apex was supported to a good position, cystocele occurred six months after the initial surgery. A TVM procedure for recurrent cystocele was performed after curing the mucosal defects, and after the improvement of glycemic control. Transvaginal native tissue repair has the advantages of low risk of ureter injury, firm colpo-suspension, and no need for mesh usage. On the other hand, it is not good at treating cystocele. Transvaginal native tissue repair should prove to be a useful surgical option for apical support without mesh.

Predictor of de novo stress urinary incontinence following TVM procedure: a further analysis of preoperative voiding function

The purpose of this study was to evaluate the predictors of de novo stress urinary incontinence (SUI) in patients undergoing a tension-free vaginal mesh procedure (TVM) for pelvic organ prolapse (POP). Sixty-five patients without SUI were assessed with regard to voiding function by a pressure flow study and clinical characteristics. The mean age of the patients was 67 ± 8.3. Of the 65 patients, 41 (63 %) maintained urinary continence postoperatively and 24 (37 %) showed de novo SUI. In univariate analysis, the de novo SUI group included a significantly higher proportion of patients with preoperative obstruction, defined as moderate or greater obstruction according to the Blaivas nomogram (29 vs 7 %, P = 0.035). In multivariate analysis, urethral obstruction was an independent predictor of de novo SUI with an odds ratio of 12.616 (95 % confidence interval 1.580-268.731). Preoperative evaluation of urethral obstruction will contribute to prediction of de novo SUI combined with a conventional diagnosis of occult SUI.

Fluoroscopic imaging of needle position in the tension‐free vaginal mesh procedure for pelvic organ prolapse: Two case reports

The tension-free vaginal mesh (TVM) procedure has become one of the commonly used treatments for pelvic organ prolapse (POP) due to good clinical outcome. However, there are several technical difficulties associated with this procedure. We performed fluoroscopy for imaging of the surgical procedure on the TVM to resolve the technical problems regarding needle penetration. Fluoroscopic imaging with rectogram and cystogram demonstrated the positions of the needle, pelvic organs and index finger for needle guidance in the TVM procedure. Fluoroscopic imaging may be useful to understand the movement of surgical devices in the blind space, objectively evaluate the surgeon's skill, avoid injury to the pelvic organs, and detect any such injury immediately should it occur.

Laparoscopic-assisted tension-free vaginal mesh: an innovative approach to placing synthetic mesh: transvaginally for surgical correction of pelvic organ prolapse.

Polypropylene mesh implants for the correction of pelvic organ prolapse (POP) are now available in Japan. We developed an innovative approach for correcting POP by placing polypropylene mesh transvaginally with laparoscopic assistance. From June 2007 through March 2010, sixteen consecutive patients with symptomatic stage 2 or 3 pelvic organ prolapse underwent the laparoscopic-assisted tension-free vaginal mesh procedure at Okayama University Hospital. All patients were evaluated before and at 1, 3, 6, and 12 months after surgery. Female sexual function was also evaluated with the Female Sexual Function Index (FSFI). The procedure was performed successfully without significant complications. Fifteen of 16 patients were considered anatomically cured (93.8%) at 12 months postoperatively. One patient with a recurrent stage 3 vaginal vault prolapse required sacral colpopexy six months postoperatively. Total FSFI scores improved significantly from 10.3 ± 1.3 at baseline to 18.0 ± 1.2 at 12 months after surgery. The laparoscopic-assisted trans-vaginal mesh is a safe, effective, and simple procedure for POP repairs. The procedure not only restores anatomic relationships but also improves sexual function.

Assessment of Quality of Life in Women with Tension-Free Vaginal Mesh Procedure

Assessment of Quality of Life in Women with Tension-Free Vaginal Mesh Procedure

Risk Factors for Exposure, Pain, and Dyspareunia After Tension-Free Vaginal Mesh Procedure

To identify possible risk factors for exposure, dyspareunia, and pain after insertion of tension-free vaginal mesh in pelvic organ prolapse surgery. This was a prospective observational cohort study. Consecutive women who underwent surgery with a trocar-guided tension-free vaginal mesh kit were included and evaluated at 6 weeks and at 6 and 12 months after surgery with respect to anatomy and complications. Logistic regression analysis was performed to identify risk factors for exposure, dyspareunia, and pain. Two hundred ninety-four patients were included. Exposure was found in 34 patients (12%). Smoking and total mesh were risk factors for exposure (odds ratio [OR] 3.1, 95% confidence interval [CI] 1.1-8.7 and OR 3.0, 95% CI 1.2-7.0, respectively). Clinical and surgical experience were inversely related to the risk of exposure (OR 0.5, 95% CI 0.3-0.8 per decade). Pain (OR 3.2, 95% CI 1.2-8.4) and dyspareunia (OR 4.7, 95% CI 1.7-12.8) before surgery were predictive for pain and dyspareunia after surgery, respectively. Pain after surgery was found in 35 out of 275 (13%) patients and dyspareunia was found in 77 out of 171 (45%) patients. Smoking, total tension-free vaginal mesh, and experience were predictive factors for mesh exposure.

Basic procedures in tension‐free vaginal mesh operation for pelvic organ prolapse

A variety of tension-free vaginal mesh (TVM) systems are available for surgical treatment of pelvic organ prolapse (POP). These include Prolift, Apogee/Perigee and Avaulta, all of which vary in terms of mesh size, shape and surgical technique to such an extent that they cannot truly be considered the same operation for the purpose of evaluating results. I began carrying out self-made mesh cut out from Gynemesh PS in 2005. This system has four main characteristics: (i) the mesh is intended as a replacement for defective visceral pelvic fascia; (ii) it bridges between the left and right arcus tendineus fascia pelvis (white line, or ATFP); (iii) large-size mesh is held in place by passing cannulas through the obturator fascia (anterior wall) or the sacrospinous ligament (SSL) to attach the arms of the mesh graft; and (iv) the bladder neck is preserved. The mesh that I have used since then has been essentially similar to the Prolift System, developed by a French TVM group, in terms of size and shape of its central portion. Mesh grafts used for the anterior wall are quite large, so skillful execution will provide sufficient room between the left and right ATFP in almost all cases. This video discusses the fundamental techniques necessary for skillful execution of the tension-free vaginal mesh (TVM) procedure using the Prolift System, focusing on the following points: (i) surgical separation of the correct layers of the vaginal wall, and the area separated, and effective hemostasis; (ii) precise puncture technique, especially the second puncture for the anterior TVM (TVM-A) procedure and the sacrospinous ligament (SSL) puncture in the posterior TVM (TVM-P) procedure; (iii) firmly securing the mesh to the vaginal wall or cervical canal; and (iv) careful mesh placement and formation of a bridge between the left and right arcus tendineus fascia pelvis (ATFP). Proper separation of the vaginal wall layers, in particular, is crucial for preventing unnecessary blood loss and mesh erosion. The second puncture in the TVM-A is the most important of the puncture maneuvers for the procedure. Penetrating the tough tissue near the ischial spine represents a significant challenge, and the SSL penetration in the TVM-P procedure is unexpectedly difficult for those without sufficient experience. In order to become proficient, the surgeon must have hands-on experience under the supervision of experts. Finally, TVM is a relatively new procedure, so one must master the fundamentals before gaining true proficiency. The technique does not call for virtuosity on the part of the surgeon, but key points must be mastered to reduce the risk of complications and recurrences. With repeated hands-on training, surgical skills will gradually improve to the requisite level. This is a translated section of a video article originally published in Japanese as a DVD in the Audio-Visual Journal Vol.15 No.15. 2009 by The Japanese Urological Association.

Postoperative voiding function in patients undergoing tension-free vaginal mesh procedure for pelvic organ prolapse

We compared pre- and postoperative voiding function in patients with POP and assessed the efficacy of urodynamic studies in these cases. Forty-six patients treated with the tension-free vaginal mesh (TVM) procedure between January 2009 and February 2010 underwent pressure flow study pre- and postoperatively. Pre- and postoperative voiding functions were assessed according to Schäfer nomograms. The mean postoperative detrusor pressure at maximal flow was decreased significantly compared with that preoperatively. The mean maximum flow rate was also improved significantly and the proportion of normal contractility was increased significantly after the operation, as was the proportion of non-obstructive patients. The TVM procedure for pelvic organ prolapse improved both detrusor contractility and urethral obstruction.

1703 CHANGES IN CLITORIAL BLOOD FLOW FOLLOWING SURGERY WITH TENSION-FREE VAGINAL MESH FOR PELVIC ORGAN PROLAPSE

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Female Urology1 Apr 20111703 CHANGES IN CLITORIAL BLOOD FLOW FOLLOWING SURGERY WITH TENSION-FREE VAGINAL MESH FOR PELVIC ORGAN PROLAPSE Toyohiko Watanabe, Miyabi Inoue, Ayano Ishii, Toyoko Yamato, Motoo Araki, Shinya Uehara, Takashi Saika, Yasutomo Nasu, and Hiromi Kumon Toyohiko WatanabeToyohiko Watanabe Okayama, Japan More articles by this author , Miyabi InoueMiyabi Inoue Okayama, Japan More articles by this author , Ayano IshiiAyano Ishii Okayama, Japan More articles by this author , Toyoko YamatoToyoko Yamato Okayama, Japan More articles by this author , Motoo ArakiMotoo Araki Okayama, Japan More articles by this author , Shinya UeharaShinya Uehara Okayama, Japan More articles by this author , Takashi SaikaTakashi Saika Okayama, Japan More articles by this author , Yasutomo NasuYasutomo Nasu Okayama, Japan More articles by this author , and Hiromi KumonHiromi Kumon Okayama, Japan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.1894AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In the previous study, we reported a significant improvement in sexual function outcome following the surgery with tension-free vaginal mesh (TVM) for pelvic organ prolapse (POP). We evaluated the effect of TVM procedure on clitorial blood flow and sexual function in women with POP. METHODS The study was conducted with 30 patients who underwent TVM for surgical correction of pelvic organ prolapse. Doppler ultrasonography was performed using a commercially available color Doppler scanner (prosound α-7, ALOKA, Tokyo, JAPAN) with a 12 mHz linear array transducer. The Doppler translabial probe was placed sagittally on the clitoris at an angle of less than 20°, without exerting any significant pressure on the tissues. After identifying the clitoral artery using color flow mapping, the Doppler probe was positioned over the vessel and at least three sequential Doppler waveforms were obtained. We measured the resistance index (RI), pulsatility index (PI), peak systolic velocity (PSV), and end-diastolic velocity (EDV) of the clitoral arteries, before and 1, 3, 6 months postoperatively. Female sexual function was also investigated with the Female Sexual Function Index (FSFI) which was a 19-question, self-report measure, organized in a 6-domain structure, including desire, subjective arousal, lubrication, orgasm, satisfaction, and pain. RESULTS One month after surgery, the mean PI and RI, which reflect blood flow impedance, increased and both parameters significantly decreased 6 months after surgery. (P<0.05). On the other hand, the mean PSV and EDV decreased one month after surgery, and then increased at 6 months after surgery. These 4 parameters recovered at 6 months after surgery. Total FSFI scores were deteriorated from 10.2±7.9 at baseline to 7.0±4.3 at 3 months, and then improved significantly to 18.2±8.9 at 6 months after surgery. As the PI and RI decreased, FSFI scores tended to increase; and they also tended to increase as the PSV and EDV increased. CONCLUSIONS Color Doppler ultrasonography appears to be feasible and useful in measuring both baseline and post-treatment condition of clitorial blood flow in patients treated with TVM for POP. Further studies are necessary to investigate the effect of clitorial blood flow changes on female sexual function in various clinical settings. Parameter Baseline 1 M after TVM 3 M after TVM 6 M after TVM PI 1.20±0.31 1.50±042* 1.18±0.23 1.06±0.39 RI 0.72±0.08 0.84±0.14* 0.70±0.05 0.64±0.08 PSV (cm/sec.) 10.9±6.2 7.7±2.5* 9.3±2.0 9.7±2.5 EDV (cm/sec.) 3.1±2.2 1.7±1.4* 2.8±0.6 3.2±0.8 FSFI 10.2±7.9 (-) 7.0±4.3 18.2±8.9* * P<0.05 © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e685 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Toyohiko Watanabe Okayama, Japan More articles by this author Miyabi Inoue Okayama, Japan More articles by this author Ayano Ishii Okayama, Japan More articles by this author Toyoko Yamato Okayama, Japan More articles by this author Motoo Araki Okayama, Japan More articles by this author Shinya Uehara Okayama, Japan More articles by this author Takashi Saika Okayama, Japan More articles by this author Yasutomo Nasu Okayama, Japan More articles by this author Hiromi Kumon Okayama, Japan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

52 CHANGES IN CLITORIAL BLOOD FLOW FOLLOWING SURGERY WITH TENSION-FREE VAGINAL MESH FOR PELVIC ORGAN PROLAPSE

INTRODUCTION AND OBJECTIVES: In the previous study, we reported a significant improvement in sexual function outcome following the surgery with tension-free vaginal mesh (TVM) for pelvic organ prolapse (POP). We evaluated the effect of TVM procedure on clitorial blood flow and sexual function in women with POP. METHODS: The study was conducted with 30 patients who underwent TVM for surgical correction of pelvic organ prolapse. Doppler ultrasonography was performed using a commercially available color Doppler scanner (prosound -7, ALOKA, Tokyo, JAPAN) with a 12 mHz linear array transducer. The Doppler translabial probe was placed sagittally on the clitoris at an angle of less than 20°, without exerting any significant pressure on the tissues. After identifying the clitoral artery using color flow mapping, the Doppler probe was positioned over the vessel and at least three sequential Doppler waveforms were obtained. We measured the resistance index (RI), pulsatility index (PI), peak systolic velocity (PSV), and end-diastolic velocity (EDV) of the clitoral arteries, before and 1, 3, 6 months postoperatively. Female sexual function was also investigated with the Female Sexual Function Index (FSFI) which was a 19-question, self-report measure, organized in a 6-domain structure, including desire, subjective arousal, lubrication, orgasm, satisfaction, and pain. RESULTS: One month after surgery, the mean PI and RI, which reflect blood flow impedance, increased and both parameters significantly decreased 6 months after surgery. (P 0.05). On the other hand, the mean PSV and EDV decreased one month after surgery, and then increased at 6 months after surgery. These 4 parameters recovered at 6 months after surgery. Total FSFI scores were deteriorated from 10.2 7.9 at baseline to 7.0 4.3 at 3 months, and then improved significantly to 18.2 8.9 at 6 months after surgery. As the PI and RI decreased, FSFI scores tended to increase; and they also tended to increase as the PSV and EDV increased. CONCLUSIONS: Color Doppler ultrasonography appears to be feasible and useful in measuring both baseline and post-treatment condition of clitorial blood flow in patients treated with TVM for POP. Further studies are necessary to investigate the effect of clitorial blood flow changes on female sexual function in various clinical settings.

Surgery for vaginal valt prolapse ,TVM(tension free vaginal mesh)procedure and sacral colpopexy

Surgery for vaginal valt prolapse ,TVM(tension free vaginal mesh)procedure and sacral colpopexy

1512 CLITORIAL BLOOD FLOW CHANGES AFTER SURGERY WITH TENSION-FREE VAGINAL MESH FOR PELVIC ORGAN PROLAPSE

You have accessJournal of UrologyUrodynamics/Incontinence/Female Urology: Female Urology I1 Apr 20101512 CLITORIAL BLOOD FLOW CHANGES AFTER SURGERY WITH TENSION-FREE VAGINAL MESH FOR PELVIC ORGAN PROLAPSE Toyohiko Watanabe, Miyabi Inoue, Ayano Ishii, Toyoko Yamato, Hiroyuki Nose, Katsutoshi Uematsu, Katsumi Sasaki, Motoo Araki, Shinya Uehara, Takashi Saika, Yasutomo Nasu, and Hiromi Kumon Toyohiko WatanabeToyohiko Watanabe More articles by this author , Miyabi InoueMiyabi Inoue More articles by this author , Ayano IshiiAyano Ishii More articles by this author , Toyoko YamatoToyoko Yamato More articles by this author , Hiroyuki NoseHiroyuki Nose More articles by this author , Katsutoshi UematsuKatsutoshi Uematsu More articles by this author , Katsumi SasakiKatsumi Sasaki More articles by this author , Motoo ArakiMotoo Araki More articles by this author , Shinya UeharaShinya Uehara More articles by this author , Takashi SaikaTakashi Saika More articles by this author , Yasutomo NasuYasutomo Nasu More articles by this author , and Hiromi KumonHiromi Kumon More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1250AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES In the previous study, we reported a significant improvement in sexual function outcome following the surgery with tension-free vaginal mesh (TVM) for pelvic organ prolapse (POP). We evaluated the effect of TVM procedure on clitorial blood flow and sexual function in women with POP. METHODS A total of 39 underwent TVM for surgical correction of POP. Seventeen of 39 patients underwent tranlabial color Doppler ultrasonography. The Doppler translabial probe was placed sagittally on the clitoris at an angle of less than 20°, without exerting any significant pressure on the tissues. After identifying the clitoral artery using color flow mapping, the Doppler probe was positioned over the vessel and at least three sequential Doppler waveforms were obtained. We measured the resistance index (RI), pulsatility index (PI), peak systolic velocity (PSV), and end-diastolic velocity (EDV) of the clitoral arteries, before and 1, 3, 12 months postoperatively. Female sexual function was also investigated with the Female Sexual Function Index (FSFI) which was a 19-question, self-report measure, organized in a 6-domain structure, including desire, subjective arousal, lubrication, orgasm, satisfaction, and pain. RESULTS One month after surgery, the mean PI was significantly greater and the mean PSV of the clitoral arteries was significantly lower compared with baseline. (P<0.05). However, the mean PI and mean PSV recovered at 12 months postoperatively. Total FSFI scores was deteriorated from 10.2±7.9 at baseline to 7.0±4.3 at 3 months. However, FSFI scores improved significantly from 10.2±7.9 at baseline to 18.2±8.1 at 6months, 21.4±7.3 at 12 months after surgery. As the resistance index values decreased, FSFI scores tended to increase; and they also tended to increase as flow velocity increased. CONCLUSIONS Color Doppler ultrasonography appears to be feasible and useful in measuring both baseline and post-treatment condition of clitorial blood flow in patients treated with TVM for POP. Further studies are necessary to investigate the effect of clitorial blood flow changes on female sexual function in various clinical settings. Parameter Baseline 1 M after TVM 3 M after TVM 12 M after TVM RI 0.77±0.11 0.86±0.12 0.71±0.06 0.75±0.08 PI 1.37±0.43 1.55±0.34⁎ 1.33±0.19 1.26±0.30 PSV (cm/sec.) 12.38±7.10 8.85±3.10⁎ 8.03±0.76 10.59±2.55 EDV (cm/sec.) 2.89±2.54 1.48±1.13 2.30±0.27 2.59±0.76 FSFI 10.2±7.9 (-) 18.2±8.1⁎⁎ 21.4±7.3⁎ ⁎⁎ 6M after TVM ⁎ P<0.05 Okayama, Japan© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e583 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Toyohiko Watanabe More articles by this author Miyabi Inoue More articles by this author Ayano Ishii More articles by this author Toyoko Yamato More articles by this author Hiroyuki Nose More articles by this author Katsutoshi Uematsu More articles by this author Katsumi Sasaki More articles by this author Motoo Araki More articles by this author Shinya Uehara More articles by this author Takashi Saika More articles by this author Yasutomo Nasu More articles by this author Hiromi Kumon More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Tension‐free vaginal mesh procedure for pelvic organ prolapse: A single‐center experience of 310 cases with 1‐year follow up

To prospectively evaluate the efficacy of a tension-free vaginal mesh (TVM) procedure for pelvic organ prolapse (POP). Between December 2005 and April 2008, 310 female patients (mean age 67.2 years, range 42-84) with POP underwent TVM procedures at our institute. Fifty-six individuals were qualified as stage 2 according to the POP quantification system and 162 and 92 were stage 3 and 4, respectively. One hundred ninety-one patients underwent anterior TVM, and seven underwent posterior TVM. One hundred twelve cases underwent both anterior and posterior TVM procedures. Each patient was systematically assessed at 1, 3, 6 and 12 months after surgery. Quality of life (QOL) was also assessed by using the Short Form-36 and the prolapse-QOL questionnaires. Perioperative complications were the following: five bladder injuries (1.6%), no rectal injuries and three hemorrhages greater than 400 mL (1.0%). The anatomical cure rate (% stage 0 cases) at 3, 6 and 12 months after surgery were 94.1%, 93.5%, and 92.3%, respectively. Short Form-36 and prolapse-QOL parameters were significantly improved, and maintained during the follow-up period. Postoperative complications were the following: five pelvic hematomas (1.6%), one wound infection (0.3%), 10 vaginal mesh extrusions (3.2%), and three cases of pelvic pain (1.0%). Complications concerning lower urinary tract function were: eight cases of postoperative stress urinary incontinence (2.6%), three cases of transient urinary retention (1.0%), and two cases of de novo overactive bladder (0.6%). The TVM procedure provides a good outcome at 1 year with a low incidence of surgical complications and recurrence. Further evaluation with a longer follow up is needed.

Clinical pathway for tension‐free vaginal mesh procedure: Evaluation in 300 patients with pelvic organ prolapse

To evaluate a clinical pathway of discharge on postoperative day 3 for the tension-free vaginal mesh (TVM) procedure in patients with pelvic organ prolapse (POP). Between May 2006 and December 2007, 305 consecutive women with POP quantification stage 3 or 4 were planned to undergo the TVM procedure in a single general hospital. Excluding five patients with concomitant hysterectomy, a pathway (removal of the indwelling urethral catheter on the next morning, discharge on postoperative day 3) was applied to the remaining 300 patients. The perioperative complications and postoperative hospitalization were prospectively evaluated in this case series. Perioperative complications were: bladder injury (11 cases, 3.7%), vaginal wall hematoma (two cases, 0.7%), rectal injury (one case, 0.3%) and temporary hydronephrosis (one case, 0.3%). None needed blood transfusion. The indwelling urethral catheters were removed on the next morning as in the pathway in 287 cases (95.6%), and none required clean intermittent catheterization at home. Postoperative hospitalization was within 3 days in 280 cases (93.3%). The six cases (2.0%) with longer hospitalization were due to complications (two cases of bladder injury, one of rectal injury, one of blood loss over 200 mL, one of temporary urinary retention, and one of hydronephrosis). Two patients were re-hospitalized within one month due to vaginal bleeding or gluteal pain. Patients generally accepted the pathway of discharge on postoperative day 3 in spite of the Japanese culture preferring a longer hospital stay.

Nerve preservation in tension-free vaginal mesh procedures for pelvic organ prolapse: a cadaveric study using fresh and fixed cadavers

The aims of this study were, using fixed and fresh cadavers, to clarify how closely the pelvic splanchnic nerve, levator ani nerve (LAN), and sacrospinous ligament (SSL) are located and to examine how to avoid nerve injury during the posterior tension-free vaginal mesh procedure (TVMP), in which mesh is applied through the SSL. Macroscopic dissection of fixed cadavers demonstrated that the LAN crossed the inside of the SSL at a point 0-18 mm medial to the ischial spine and entered the muscle at a point 12-26 mm inferior to the ischial spine and 40-55 mm anterolateral to the coccyx. Dissection after TVMP of fresh cadavers revealed that the point of penetration of mesh through the SSL was close to the LAN. To preserve the LAN, penetration of the SSL should be within 5 mm of the lower margin at a point 20-25 mm medial to the ischial spine.

Prosthetic reinforcements: how to manage bladder injuries?

The aim of this study was to describe our experience in the management of bladder injuries occurring at intervesicovaginal dissection during the tension-free vaginal mesh (TVM) procedure. Seven hundred four patients were treated for prolapse by vaginal route using the TVM procedure. Bladder injury was diagnosed during the procedure in five patients. Polypropylene mesh was placed in the intervesicovaginal space after a careful repair of the bladder injury. Major postoperative complications were not diagnosed during the short-term follow up. We describe the occurrence and treatment of bladder injuries during the dissection phase in the TVM procedure. Such injuries can occur during the dissection. Placing an intervesicovaginal mesh is acceptable if cautious bladder repair is performed.