Immunochemical analysis on polypropylene mesh: does mesh size make a difference?

INTRODUCTION AND HYPOTHESIS: The aim of the study is to demonstrate the impact of the size of implanted mesh in relation to its immunohistochemical reaction implanted into animal models. METHODS: An experimental study utilizing 54 female Sprague Dawley (SD) rats was divided into five groups: control, sham, and study groups (mesh-small [M-S], mesh-medium [M-M], mesh-large [M-L]). The M-S group used a mesh size of 0.2 × 0.2 cm, the M-M group a mesh size of 0.5 × 0.5 cm, and the M-L a mesh size of 0.7 × 1.0 cm. The sham group underwent vaginal dissection with no mesh implantation. The rats were sacrificed using isoflurane overdose on days 7 and 30. The mesh with the surrounding vaginal and bladder wall tissues were removed and processed for histochemical and western blot analysis. RESULTS: There is a significant increase in IL-1 and TNF-α immunoreactivity in the M-M and M-L groups on day 7 when compared with the sham group with p values of 0.001 and < 0.001 respectively. M-L showed significantly higher immunoreactivity to TNF-α persisting until day 30. All study groups presented a significantly higher immunoreactivity to MMP-2 and NGF on day 7. However, reactivity to NGF does not persist to day 30 in all groups. Immunoreactivity to CD 31 on days 7 and 30 appears significantly greater in the M-M and M-L groups, with the reaction in the M-L group continuing until day 30. CONCLUSION: Mesh size is directly proportional to the inflammatory reaction in the host tissue. The prolonged inflammatory process leads to delayed tissue remodeling and angiogenesis, which could delay mesh-tissue integration.

Anterior-apical single-incision mesh surgery (uphold): 1-year outcomes on lower urinary tract symptoms, anatomy and ultrasonography.

INTRODUCTION AND HYPOTHESIS: Our primary objective is to determine the presence of SUI at 6-12 months after surgery. The secondary objective is to determine the objective and subjective outcomes of POP. METHODS: A retrospective study conducted between February 2015 and July 2016 at Chang Gung Memorial Hospital. The subjects had had symptomatic anterior or apical prolapse with stage III or IV and undergone pelvic reconstructive surgery using Uphold™ LITE. Patients completed a 3-day voiding diary, urodynamic study, real-time ultrasonography and validated quality-of-life questionnaires at baseline and 12-month follow-up. Primary outcome was the absence of USI. Secondary outcomes included the objective cure rate of POP, ≤ stage 1 at the anterior/apical vaginal wall, and the subjective cure rate, negative feedback to POPDI-6. RESULTS: Ninety-five women were eligible. Six were excluded because of incomplete data. The postoperative de novo USI and SUI were 22.7 and 19.7%, respectively. There was significant improvement of USI in patients who had MUS insertion (93.8%) and bladder outlet obstruction (96.7%). The objective and subjective cure rate for prolapse was 95.5 and 94.3%, respectively. POP-Q measurements pre- and postoperatively were significantly improved at all points except for Gh and Pb. There was a significant difference in the distance between the bladder neck to the distal end of the mesh during straining both at both the postoperative 3rd month and 1 year. CONCLUSIONS: Uphold™ mesh has a 20% incidence of de novo USI with acceptable objective and subjective cure rates at 1 year postoperatively. The de novo USI rate was high but not bothersome enough to require surgery.

Predictors for detrusor overactivity following extensive vaginal pelvic reconstructive surgery.

AIM: This study aims to identify the predictors for detrusor overactivity (DO) in women following extensive vaginal pelvic reconstructive surgery (PRS) for advanced pelvic organ prolapse (POP). METHODS: We enrolled 1503 women who had prolapse POP-Q stage ≥ 3 and underwent vaginal PRS with or without MUS from January 2006 to December 2015. All subjects completed a 72-h voiding diary, IIQ-7, UDI-6, POPDI-6, and PISQ-12. Urodynamics (UDS) was performed pre- and post-operatively. RESULTS: Among 1503 women, 56 patients were excluded due to incomplete data. Women who had trans-vaginal mesh were 1083 of 1447 (74.8%) and concomitant MUS were 353 (24.4%). Pre-operative DO were 245 (16.9%) and 24.5% (60/245) of them continued to have persistent DO post-operatively. Women who had normal pre-operative stable detrusor were 1202 (83.1%) and 3.5% (30/1202) developed de novo DO post-operatively. The overall incidence of post-operative DO was 6.2% (90/1447). Patients with age ≥66 year, neurological factors like Cerebrovascular accident and Parkinsonian disease, pre-operative bladder outlet obstruction (BOO) maximum urethral closure pressure (MUCP) ≥60 cmH2 O, Maximum flow rate (MFR) <15 mL/s and detrusor at maximum flow (Dmax) ≥20 cmH2 O) and post-void residue (PVR) ≥200 mL hold a significant higher risk of developing DO either persistent or de novo following PRS. CONCLUSION: Age ≥66 year, neurological factors like CVA and Parkinsonian disease, pre-operative MUCP ≥60 cmH2 O, MFR < 15 mL, Dmax ≥ 20 cmH2 O, and PVR ≥ 200 mL are independent risk factors for developing post-operative DO following vaginal PRS for advanced POP.

Clinical outcomes of detrusor underactivity in female with advanced pelvic organ prolapse following vaginal pelvic reconstructive surgery.

AIM: To determine the impact of vaginal pelvic reconstructive surgery (PRS) on detrusor underactivity (DU) patients having advanced pelvic organ prolapse (POP). METHODS: A retrospective study of patients who underwent PRS for advanced POP (POP-Q ≥ 3) with DU. Data regarding preoperative evaluation, surgical procedure, and post-operative management were collated. Patients were considered to have DU when detrusor pressure at maximum flow (Pdet Qmax ) was ≤10 cmH2 0 and peak flow rate (Qmax ) of ≤12 mL/s. Post-operative values more than the cut-off were considered objectively cured. Subjective cure was defined as having a negative response to UDI-6 Question 5, "Do you experience difficulty emptying your bladder?" RESULTS: A total of 49 patients were evaluated. Majority of the population were post-menopausal and multiparous. Preoperatively, 38 patients (75%) had stage III prolapse and 13 patients (26%) had stage IV. Subjective cure rate of DU was 76% (37/49) and objective cure rate was 47% (23/49). Post-operative DU (P < 0.001) significantly improved together with patients having normal urodynamic diagnosis (P < 0.001). Voiding function showed significant increase in Qmax (P < 0.001) and Pdet Qmax (P < 0.001) while PVR (P < 0.001) and cystometric capacity (P < 0.001) significantly decreased. These findings were observed in 89% (43/49) of patients with post-void residual urine (PVR) of <200 mL, 63% (31/49) with Qmax > 12 mL/s, and 57% (28/49) with Pdet Qmax >10 cmH2 0. CONCLUSION: Reversal of short-term or long-term obstruction through vaginal pelvic reconstructive surgery enables bladders to regain detrusor muscle function. Although objective cure of DU was at 47%, detrusor function recovered in 57% of patients provided that mechanical obstruction was the cause.

Sacrospinous ligament fixation for hysteropexy: does concomitant anterior and posterior fixation improve surgical outcome?

INTRODUCTION AND HYPOTHESIS: Uterine preservation in uterine prolapse is an option for young patients. We hypothesized that sacrospinous hysteropexy (SSH) with anchorage to both the anterior and posterior cervix (SSH-ap) would have a better outcome than SSH with anchorage to the posterior cervix only (SSH-p). METHODS: This was a retrospective study including 75 patients who underwent SSH at Chang Gung Memorial Hospital between March 2008 and August 2013. Five were excluded due to incomplete data. Of the remaining 70 patients, 35 underwent SSH-p between March 2008 and June 2011, and 35 underwent SSH-ap between June 2010 and August 2013. The primary outcome was the objective anatomical result, and a successful outcome was considered anatomical correction (POP-Q stage 1 or less) of anterior and apical prolapse. Subjective outcome was evaluated using the POPDI-6 questionnaire, and a patient response of "No or mild abdominal organ falling out sensation" together with "No or mild heaviness" was considered to indicate a successful outcome. Anterior fornix and cervical diameter measurements were included. The secondary outcome was quality of life according to the UDI-6, IIQ-7, POPDI-6, and PISQ-12 questionnaires. The 3-year outcome was used for comparison. RESULTS: The subjective overall cure rates were significantly different between the SSH-p and SSH-ap groups (74.3% and 94.3%, respectively; p = 0.023). However, the objective overall cure rates were not significantly different (74.3% and 82.9%, respectively). CONCLUSION: Anchorage of the anterior cervix and vaginal wall together with the usual posterior anchorage yield better subjective outcomes and apical suspension at 3 years after surgery than anchorage of the posterior cervix and vaginal wall only. The cervix position affected the subjective outcome. Concurrent trachelectomy did not affect the outcome.

Five-Year Outcome of MiniArc Single-Incision Sling Used in the Treatment of Primary Urodynamic Stress Incontinence.

STUDY OBJECTIVE: To evaluate the effectiveness and safety of the MiniArc single-incision sling in the treatment of urodynamic stress incontinence (USI) through 5 years. DESIGN: Retrospective observational study (Canadian Task Force classification II-2). SETTING: Tertiary referral center. PATIENTS: Eighty-five patients with USI without needing concurrent procedures who underwent anti-incontinence surgery using the MiniArc SIMS from February 2010 to December 2011. INTERVENTIONS: Anti-incontinence surgery. MEASUREMENTS AND MAIN RESULTS: Objective cure was defined as no demonstrable leakage of urine on the cough stress test and 1-hour pad test weight <2 g. Subjective cure was based on negative response to Urinary Distress Inventory question 3, no leakage on coughing, sneezing, or laughing. Most patients were postmenopausal, overweight, and multiparous. Postoperative USI significantly improved (p < .001) through 3 years, and the 1-hour pad test showed significant improvement through 5 years (p < .001). Although 13 patients had recurrence of USI, no repeat surgery was done. The cumulative cure rates may show a declining trend of cure, yet subjective cure was 80.0% and objective cure 84.7%, with age as a significant risk factor for sling failure. CONCLUSION: MiniArc maintains its effectiveness and safety in treatment of USI through 5 years with high objective and subjective cure rates and low incidence of complications.

Predictors of voiding dysfunction following extensive vaginal pelvic reconstructive surgery.

INTRODUCTION AND HYPOTHESIS: The objective of this study was to identify the predictors of postoperative voiding dysfunction in women following extensive vaginal pelvic reconstructive surgery. METHODS: We enrolled 1,425 women who had pelvic organ prolapse of POP-Q stage III or IV and had undergone vaginal pelvic reconstructive surgery with or without transvaginal mesh insertion from January 2006 to December 2014. All subjects were required to complete a 72-h voiding diary, and the IIQ-7, UDI-6, POPDI-6 and PISQ-12 questionnaires. Urodynamic study was performed preoperatively and postoperatively. RESULTS: Of the 1,425 women, 54 were excluded due to incomplete data, and 1,017 of the remaining 1,371 (74.2 %) had transvaginal mesh surgery and 247 (18 %) had concurrent midurethral sling insertion. Of 380 women (27.7 %) with preoperative voiding dysfunction, 37 (9.7 %) continued to have voiding dysfunction postoperatively. Of the remaining 991 women (72.3 %) with normal preoperative voiding function, 11 (1.1 %) developed de novo voiding dysfunction postoperatively. The overall incidence of postoperative voiding dysfunction was 3.5 % (48/1,371). Those with concurrent midurethral sling insertion were at higher risk of developing voiding dysfunction postoperatively (OR 3.12, 95 % CI 1.79 - 5.46, p < 0.001). Diabetes mellitus, preoperative detrusor pressure at maximal flow (Dmax) <10 cm H2O and postvoid residual volume ≥200 ml were significant risk factors for the development of postoperative voiding dysfunction (OR 3.07, 1.84 and 2.15, respectively; 95 % CI 1.69 - 5.60, 1.39 - 2.91 and 1.10 - 3.21, respectively). CONCLUSIONS: Diabetes mellitus, concurrent midurethral sling insertion, preoperative Dmax <10 cm H2O and postvoid residual volume ≥200 ml in patients with advanced pelvic organ prolapse were risk factors for the development of postoperative voiding dysfunction after vaginal pelvic reconstructive surgery. Therefore, counseling is worthwhile before considering vaginal pelvic reconstructive surgery.

Transvaginal management of severe pelvic organ prolapse in nulliparous women.

AIM: The aim of this study was to evaluate the management outcomes of advanced pelvic organ prolapse (POP) in nulliparous women. METHODS: Eight nulliparous women diagnosed with POP ≥ stage 3 between January 2005 and August 2013, according to the Pelvic Organ Quantification System (POPQ), were reviewed. Seven were managed surgically and one was managed with pessary. Primary outcome was surgical objective cure (POP-Q ≤ 1) and subjective cure, defined as negative response to questions 2 and 3 on Pelvic Organ Prolapse Distress Inventory 6. Secondary outcomes were complications, symptoms' severity and quality of life according to validated questionnaires. RESULTS: A total of 1275 prolapse patients with POP-Q ≥ stage 3 were managed surgically, among whom seven (0.55%) were nulliparous. Each woman had at least one risk factor associated with POP. Risk factors identified were history of pelvic trauma, obesity, menopause, chronic cough, hard physical labor and constipation. Five patients underwent surgical correction (vaginal hysterectomy with sacrospinous fixation) with mesh (Perigee, n = 3; Avaulta, n = 2). Two patients had uterine preservation without mesh (hysteropexy with sacrospinous ligament fixation). One patient preferred treatment with pessary. The total cure rate (objective and subjective cure rates) was 86% after surgical reconstructive surgery. CONCLUSION: Management of nulliparous advanced POP poses significant challenges with regard to uterine preservation, future pregnancy and childbirth. Conservative management with pessary insertion should be offered followed by surgical correction. Reconstructive surgery with mesh may improve prolapse symptoms objectively and subjectively.

Association of urodynamics and lower urogenital tract nerve growth factor after synthetic vaginal mesh implantation on a rat model.

AIM: By investigating the association of urodynamics and urogenital nerve growth factor (NGF) levels in vaginal mesh surgery, we may be able to associate the likelihood of postoperative lower urinary tract symptoms developing as a result of synthetic mesh implanted for pelvic floor reconstructive surgery. METHODS: Thirty-eight female Sprague-Dawley rats were divided into three groups: mesh, sham (no mesh), and control. Urodynamic study and NGF analysis of the urogenital tissues were done and results were compared among all groups. The urodynamic studies of the mesh and sham groups were further divided into the 4th and 10th days. A P-value < 0.05 was considered statistically significant. RESULTS: All rats survived and no complications were observed during the post-implantation period. Histological evaluation showed intense acute inflammatory reaction on days 4 and 7 in the mesh and sham groups when compared to the control. The mesh group showed a larger area of inflammation as compared to the sham. The NGF levels increased significantly in the mesh and sham groups on the 4th and 10th days when compared to the control (P < 0.001, P < 0.001, respectively). Both the mesh and sham groups had shorter voiding interval and lower voiding volume on days 4 and 10 when compared to the control group (P < 0.001, P < 0.001, respectively). The magnitude on increasing NGF level and decreasing voiding interval and voiding volume was significantly more on the mesh group than the sham group. CONCLUSION: A higher level of NGF in the early days post-transvaginal mesh implantation is associated with a shorter voiding interval and a smaller bladder capacity, which represents abnormal lower urinary tract symptoms following transvaginal mesh implantation.

Rectovaginal fistula: Twenty years of rectovaginal repair.

AIM: To identify the favorable factors in rectovaginal fistula (RVF) management. METHODS: After Institutional Review Board approval (99-0793B), we retrospectively studied all patients diagnosed, treated and followed up with RVF at Chang Gung Memorial Hospital, Taiwan between January 1990 and December 2009. All female patients with International Classification of Diseases RVF were included. We reviewed demographic data, socioeconomic status, clinical presentation, comorbidities, method of treatment, duration of hospitalization and clinical outcome at 12 months postoperatively. RESULTS: A total of 397 patients were included in the study. Fifty-six patients (14.1%) had conservative treatment and 341 patients (85.9%) underwent surgical intervention. A total of 125 patients underwent simple repair while 216 patients underwent reconstruction. Three hundred and forty-four patients (86.7%) had improved outcome at 12-month follow up. Age (P = 0.003), education level (P = 0.033), ability to pay insurance (P < 0.001), and choice of treatment (P < 0.0001) were identified as significant favorable factors. An etiological factor associated with favorable outcome was RVF from obstetric complication, while that resulting from malignancy had a less favorable outcome. CONCLUSIONS: Age, education level and ability to pay insurance significantly affect 12-month outcome of RVF. Surgery is the preferred option, while medical treatment should be used only for small rectovaginal fistulas or for patients not suitable for surgery and anesthesia. More support and assistance should be offered to those patients with unfavorable factors, such as old age, low education level and inability to afford insurance. All RVF secondary to obstetrical injury had a 100% favorable outcome compared with those secondary to surgery or malignancy. Women with suspected RVF should receive prompt and extensive evaluation to ensure immediate effective management and prevention of further serious complications.

Dissecting of the paravesical space associated with lower urinary tract dysfunction - a rat model.

To determine the association of opening the paravesical space in relation to its occurrence of de novo SUI in an animal model. Thirty five female Sprague Dawley rats were divided into 5 groups of 7 rats each: Control group, Sham groups(F, H), and Study groups(MF, MH). Groups labeled with "F" had the paravesical space opened, "H" had tissue dissection with no opening of the space, and "M" had mesh implanted inside the vaginal wall. Urodynamic studies, immunohistochemical analysis, and western blot were done at day 40. The mean weight and age of 35 rats were 302.1 ± 25.1 grams and 12.8 ± 1.2 weeks old. No significant differences were noted among the control, Sham F, Sham H, Study MF, and Study MH on the voiding pressure and voided volume. The Sham F and Study MF (opened paravesical space) groups had significantly lower values on leak point pressures (LPP) (p = 0.026; p < 0.001) and shorter voiding intervals (p = 0.032; p = 0.005) when compared to other groups. Immunohistochemical analysis showed IL-1 and TNF-α to be intensely increased for the Study MF group (p = 0.003; p = <0.001). MMP-2 and CD 31 markers were also significantly higher in the Study MH and MF group. NGF expression was significantly increased in the Study MF and Sham F groups. Thus, opening of the paravesical space causes an increased inflammatory reaction, which leads to tissue destruction and lower urinary tract dysfunction, exemplified in the study with low leak point pressure and shortened voiding intervals.

Urodynamics mixed type urinary incontinence with advanced pelvic organ prolapse, management and outcomes.

Patients with pelvic organ prolapse (POP) often have accompanying lower urinary tract symptoms. Symptoms such as stress urinary incontinence(SUI-UD) and detrusor overactivty(DO) would co-exist in a number of patients. Management entails relieving the obstructive element. To determine the clinical outcome of patients with urodynamics mixed type urinary incontinence(MUI-U) after vaginal pelvic reconstructive surgery(PRS), a retrospective study was conducted. MUI-U was defined as having urodynamic findings of both of DO/DOI (derusor overactivity incontinence) and SUI-UD. Main outcome measures: Objective cure- absence of involuntary detrusor contraction on filling cystometry and no demonstrable leakage of urine during increased abdominal pressure; Subjective cure- assessment index score of <1 on UDI-6 question #2 and #3. Of the 82 patients evaluated, 14 underwent vaginal PRS with concomitant mid-urethral sling(MUS) insertion while 68 had vaginal PRS alone. Pre-operatively, 49(60%) patients had stage III and 33(40%) had stage IV prolapse. Post-operatively, 1-year data shows an objective cure of 56% (46/82) and subjective cure of 54% (44/82). MUI-U was significantly improved. Improvement of SUIUD and results of the 1-hour pad test were more pronounced in patients with concomitant MUS insertion. Ergo, vaginal PRS cures symptoms of MUI-U in >50% of patients and concomitant MUS can be offered to SUI predominant MUI.

Clinical relevance and treatment outcomes of vesicovaginal fistula (VVF) after obstetric and gynecologic surgery.

OBJECTIVE: Vesicovaginal fistulas (VVF) are consequences from obstetric and gynecologic surgery. Treatment approach from either abdominal or vaginal route have its own pros and cons. The study aims to present the anatomical, clinical and lower urinary tract symptom outcomes of women with VVF. MATERIALS AND METHODS: A retrospective case series conducted patients with VVF. Data regarding pre-operative evaluation, surgical treatment, and post-operative follow-ups were collected. Surgical approach depended on the cause, type, number, size, location, and time of onset of the fistula. Post-operatively, foley catheter was maintained for at least 1 week with cystoscopy performed prior to removal. Follow-up evaluation included cystoscopy, bladder diary, UDI-6 and IIQ-7 questionnaires and multi-channel urodynamic study. RESULTS: Of the 15 patients that were evaluated, 1 had spontaneous closure, 8 were repaired vaginally and 6 abdominally. Patients repaired vaginally were significantly noted to have a mean age of 50.3 ± 7.1 years with VVFs located adjacent the supra-trigone area having a mean distance of 1.7 ± 0.5 cm from the ureteric orifice. Its operative time and hospital stay were significantly shorter. In contrast, abdominally repaired patients had mean age of 38.0 ± 8.2 years and VVFs with mean distance of 0.4 ± 0.4 cm from the ureteric orifice. Post-operatively, 2 cases (14.2%, 2/14) of VVF recurrence and de novo urodynamic stress incontinence (USI) (25%, 2/8) were noted after vaginal repair and 3 cases (50%, 3/6) of concurrent ureteric injury and overactive bladder after abdominal repair. CONCLUSION: Treatment outcomes for vaginal and abdominal repair yielded good results. Though the vaginal route had higher incidence of recurrence and de novo USI, its less invasiveness, faster recovery period, and no association with post-op overactive bladder made it more preferable than the abdominal approach.

Ureterovaginal fistula: A complication of a vaginal foreign body.

OBJECTIVE: To know the diagnostic tools and proper management of ureterovaginal fistula following neglected vaginal foreign body in order to achieve optimal outcome. CASE REPORT: A case of ureterovaginal fistula associated with a neglected vaginal foreign body. The patient was complaining of a foul-smelling vaginal discharge and lower abdominal pain. On vaginal examination, a hard and large foreign body was found. Examination under anesthesia was performed, and an aerosol cap was removed from her vagina. The patient developed urinary incontinence after removal of the foreign body. Subsequent work-up demonstrated the presence of a right ureterovaginal fistula. The patient underwent an abdominal ureteroneocystostomy. At one year follow up, the patient had fully recovered. CONCLUSION: Ureterovaginal fistula following neglected vaginal foreign body is a serious condition. Early diagnosis, treatment of infection and proper surgical management can improve the outcome and decrease complications.

Trans-vaginal mesh surgery for management of recurrent pelvic organ prolapse following abdominal sacrocolpopexy.

OBJECTIVE: To evaluate the outcome of transvaginal mesh surgery as a management of recurrent pelvic organ prolapse, in patients previously treated with sacrocolpopexy. CASE REPORT: A series of three patients who developed recurrent pelvic organ prolapse more than 9 years after sacrocolpopexy. A 50-year-old and two 77-year-old patients who presented with recurrent pelvic organ prolapse at 9, 15 and 17 years, respectively after the primary abdominal sacrocolpopexy were managed by transvaginal mesh surgery. CONCLUSION: Management of recurrent pelvic organ prolapse using transvaginal mesh would be an option for patients treated previously by sacrocolpopexy.

Single incision anterior apical mesh and sacrospinous ligament fixation in pelvic prolapse surgery at 36 months follow-up.

OBJECTIVE: To compare the clinical efficacy, recurrence, complications and quality of life changes 3 years after Elevate-A/single incision mesh surgery anterior apical (SIM A) and sacrospinous ligament fixation (SSF) in the management of pelvic organ prolapse (POP). MATERIALS AND METHODS: A prospective cohort study, 139 women, underwent transvaginal surgery for anterior and/or apical POP > stage 2, 69 patients had SIM A and 70 patients had SSF. The objective cure was defined as POP ≤ stage 1 anterior, apical according to POP-Q. Subjective cure is patient's negative feedback to question 2 and 3 of pelvic organ prolapse distress inventory 6 (POPDI-6). Patient's satisfaction was reported using validated quality of life questionnaires. Multi-channel urodynamic study was used to report any voiding problems related to the prolapse surgery 6 months after surgery. RESULTS: 119 patients completed a minimum of 3 years follow-up. 89.8% is the overall prolapse correction success rate for SIM A and 73.3% for SSF group (p = 0.020), and 96.6% versus 73.4% at the anterior vaginal compartment respectively (p ≤ 0.001). Statistically significant difference was noticed in apical compartment with 98.3% with SIM A and 85.0% with SSF (p = 0.009). The subjective success rate, 86.4% in the SIM A and 70.0% in the SSF arm (p = 0.030) was significantly noted. Only, Pelvic Organ Prolapse Distress Inventory-6 (POPDI-6) showed significant improvement. Operation time and intra-operative blood loss tend to be more with SIM A. CONCLUSION: SIM A has better 3 years objective and subjective cure rate than SSF in the anterior and/or apical compartment prolapse.

A 52-month follow-up on the transvaginal mesh surgery in vaginal cuff eversion.

OBJECTIVE: Transvaginal mesh anterior-posterior (TVM-AP) provides better cure rates in the surgical treatment of vaginal cuff eversion than anterior transvaginal mesh combined with sacrospinous ligament fixation (TVM-A). We determine the outcomes after TVM-A and TVM-AP surgeries in advanced vaginal cuff prolapse. MATERIALS AND METHODS: The charts of 796 women who underwent pelvic organ prolapse (POP) surgery from July 2006 to January 2012 in Chang Gung Memorial Hospitals were reviewed. We included women who presented with advanced cuff eversion and treated with TVM surgery. Data were analysed after three years post-surgery. Descriptive statistics were used for demographic and perioperative data. The paired-samples t test was used for comparison of preoperative and postoperative continuous data. The outcomes measured were objective cure (POP-Q stage ≤ 1) and subjective cure (negative response to question 2 and 3 on POPDI-6). RESULTS: A total of 97 patients was analysed. 61 patients had TVM-A and 36 patients had TVM-AP insertion. Mean follow-up was 52 months. The objective cure rate for TVM-AP was significantly higher than TVM-A, 94.4% versus 80.3%. TVM-AP also showed a higher subjective cure rate (91.7%) though there was no significant difference from TVM-A (p = 0.260). The mesh extrusion rate was low at 3.1% with no major complications seen. In TVM-A the blood loss was lesser and the operation time was shorter. CONCLUSION: TVM-AP showed better objective cure rate than TVM-A at 52 months. However, TVM-A is less invasive in comparison with an acceptably good cure rates.

The immunohistochemical and urodynamic evaluation towards the collagen-coated and non-coated polypropylene meshes implanted in the pelvic wall of the rats.

Our aim is to study the inflammatory response towards the collagen-coated and non-coated polypropylene meshes in rats and the urodynamic investigation post-operatively. Forty-two female Sprague Dawley were divided into 7 groups of 6 rats; Control, Day 7 and 30 for Sham, Avaulta Plus (MPC), Perigee (MP). UDS were taken at days 7 and 30. Mesh with the vagina and bladder wall was removed and sent for immunohistochemical examination. Results showed intense inflammatory reaction on day 7 in the study groups which decreased on day 30. IL-1, TNF-α, MMP-2 and CD31 were observed to decrease from day 7 to day 30. NGF was almost normal on day 30 in all groups. UDS showed no difference in voiding pressure. Both Study and Sham groups had shorter voiding interval (VI) on day 7 but significantly lower in MPC. VI had significantly increased on day 30 in all groups. Voided volume was significantly lower in the mesh groups even when an increase was seen on day 30. In conclusion, the higher levels of IL-1, TNF-α and MMP-2 in collagen-coated polypropylene mesh imply greater inflammation than the non-coated polypropylene mesh. Mesh implantation can lead to shorter voiding interval and smaller bladder capacity.