Impact of polypropylene prolapse mesh on vaginal smooth muscle in rhesus macaque.

BACKGROUND: The use of polypropylene prolapse mesh to treat pelvic organ prolapse has been limited by mesh-related complications. Gynemesh PS mesh, implanted via sacrocolpopexy in rhesus macaques, had a negative impact on the vagina with thinning of vaginal muscularis and decreased vaginal smooth muscle contractility. The negative effect was attenuated when a bioscaffold derived from urinary bladder extracellular matrix was used as a composite with Gynemesh PS. OBJECTIVE: The objective of the study was to further elucidate the impact of Gynemesh PS polypropylene mesh and MatriStem extracellular matrix bioscaffolds on the vaginal smooth muscle in terms of micromorphology of vaginal smooth muscle (muscle bundles and individual myocytes), innervation, and nerve-mediated contractile function following their implantations in a rhesus macaque model via sacrocolpopexy. STUDY DESIGN: Thirty-two middle-aged rhesus macaques were randomized to undergo either a sham surgery (sham, n = 8), or the implantation of Gynemesh PS alone (n = 8) vs composite mesh comprised of Gynemesh PS plus 2-ply MatriStem (n = 8) vs 6-ply MatriStem alone (n = 8) via sacrocolpopexy. The graft-vagina complexes were harvested 3 months later. Histomorphometrics of smooth muscle bundles and myocytes were performed by immunofluorescent labeling of alpha smooth muscle actin, caveolin-3 (membrane protein), and cell nuclei followed by confocal imaging. The cross-sectional diameters of smooth muscle bundles and individual myocytes were quantified using images randomly taken in at least 5 areas of each section of sample. Contractile proteins alpha smooth muscle actin and smoothelin were quantified by Western immunoblotting. Nerve density was measured by immunohistochemical labeling of a pan-neuron marker, PGP9.5. Nerve-mediated smooth muscle contractility was quantified using electrical field stimulation. One-way analysis of variance and appropriate post hoc tests were used for statistical comparisons. RESULTS: Compared with sham, the implantation of Gynemesh PS alone resulted in a disorganized smooth muscle morphology with the number of small muscle bundles (cross-sectional diameter less than 20 µm) increased 67% (P = .004) and the myocyte diameter decreased 22% (P < .001). Levels of contractile proteins were all decreased vs sham with alpha smooth muscle actin decreased by 68% (P = .009), low-molecular-weight smoothelin by 51% (P = .014), and high-molecular-weight smoothelin by 40% (P = .015). Nerve density was decreased by 48% (P = .03 vs sham) paralleled by a 63% decrease of nerve-mediated contractility (P = .02). Following the implantation of composite mesh, the results of measurements were similar to sham (all P > .05), with a 39% increase in the myocyte diameter (P < .001) and a 2-fold increase in the level of alpha smooth muscle actin relative to Gynemesh (P = .045). Following the implantation of MatriStem alone, the number of small muscle bundles were increased 54% vs sham (P = .002), while the other parameters were not significantly different from sham (all P > .05). CONCLUSION: The implantation of Gynemesh PS had a negative impact on the structural and functional integrity of vaginal smooth muscle evidenced by atrophic macro- and microscopic muscle morphology, decreased innervation, and impaired contractile property, consistent with a maladaptive remodeling response. The extracellular matrix bioscaffold (MatriStem), when used with Gynemesh PS as a composite (2 ply), attenuated the negative impact of Gynemesh PS; when used alone (6 ply), it induced adaptive remodeling as evidenced by an increased fraction of small smooth muscle bundles with normal contractility.

Consecutive intrapartum uterine rupture following endoscopic resection of deep rectovaginal and bladder endometriosis.

OBJECTIVE: To present case report of patient with repeted endoscopic resections of deep infiltrating endometriosis (DIE) to demonstrate its possible risks for subsequent delivery. DESIGN: Case report. SETTING: Department of Obstetrics and Gynecology, Central Moravian Hospital Trust, Member of Agel holding, Prostějov, Czech Republic; Department of Obstetrics and Gynecology, Vyškov Hospital, Czech Republic; Department of Pathology, Vyškov Hospital, Czech Republic; Department of Pathology, University Hospital Brno, Medical faculty, Masaryk University Brno, Czech Republic; Department of Obstetrics and Gynecology, Palacky University, Faculty of Medicine and Dentistry, Olomouc, Czech Republic. METHODS AND RESULTS: We are presenting a case of 29 years old patient with multiple laparoscopic surgery for deep infiltrating endometriosis (DIE). At the same time, new risks are posed to the delivery process like a severe injuries of the uterine attachment aparate, vagina, parametria with the risk of developing life threatening bleeding. These case we presented here demonstrates the emergence of new risks and complications for another pregnancy with such women. CONCLUSION: Our case report demonstrates new possible obstetric risk factors as consequence of increasing radicality in surgical treatment of DIE.

The impact of prolapse mesh on vaginal smooth muscle structure and function.

OBJECTIVE: To evaluate the impact of prolapse meshes on vaginal smooth muscle structure (VaSM) and function, and to evaluate these outcomes in the context of the mechanical and textile properties of the mesh. DESIGN: Three months following the implantation of three polypropylene prolapse meshes with distinct textile and mechanical properties, mesh tissue explants were evaluated for smooth muscle contraction, innervation, receptor function, and innervation density. SETTING: Magee-Womens Research Institute at the University of Pittsburgh. POPULATION: Thirty-four parous rhesus macaques of similar age, parity, and pelvic organ prolapse quantification (POP-Q) scores. METHODS: Macaques were implanted with mesh via sacrocolpopexy. The impact of Gynemesh(™)  PS (Ethicon; n = 7), Restorelle(®) (Coloplast; n = 7), UltraPro(™) parallel and UltraPro(™) perpendicular (Ethicon; n = 6 and 7, respectively) were compared with sham-operated controls (n = 7). Outcomes were analysed by Kruskal-Wallis ANOVA, Mann-Whitney U-tests and multiple regression analysis (P < 0.05). MEAN OUTCOME MEASURES: Vaginal tissue explants were evaluated for the maximum contractile force generated following muscle, nerve, and receptor stimulation, and for peripheral nerve density. RESULTS: Muscle myofibre, nerve, and receptor-mediated contractions were negatively affected by mesh only in the grafted region (P < 0.001, P = 0.002, and P = 0.008, respectively), whereas cholinergic and adrenergic nerve densities were affected in the grafted (P = 0.090 and P = 0.008, respectively) and non-grafted (P = 0.009 and P = 0.005, respectively) regions. The impact varied by mesh property, as mesh stiffness was a significant predictor of the negative affect on muscle function and nerve density (P < 0.001 and P = 0.013, respectively), whereas mesh and weight was a predictor of receptor function (P < 0.001). CONCLUSIONS: Mesh has an overall negative impact on VaSM, and the effects are a function of mesh properties, most notably, mesh stiffness. TWEETABLE ABSTRACT: Prolapse mesh affects vaginal smooth muscle.

Anatomic and sexual outcomes after vaginoplasty using tissue-engineered biomaterial graft in patients with Mayer-Rokitansky-Küster-Hauser syndrome: a new minimally invasive and effective surgery.

INTRODUCTION: Recent years have seen continuous reports about the successful reconstruction of numerous organs with the application of tissue-engineering techniques. Thus, we assess the outcomes for vagina reconstruction using tissue-engineered biological material, which we suggested previously as an ideal graft for vaginoplasty. AIM: To evaluate the anatomic and sexual outcomes in patients undergoing vaginoplasty using tissue-engineered biomaterial mesh. METHODS: This prospective study included 53 patients with Mayer-Rokitansky-Küster-Hauser syndrome admitted to our hospital. Patients underwent vaginoplasty with tissue-engineered biological material (acellular dermal matrix). Postoperatively, a silicone vaginal dilator (length: 10 cm, diameter: 3.5 cm) was advised to be used for the first 3-6 months to prevent contraction of the neovagina. Follow-up was performed at 4 weeks, 12 weeks, 12 months, and then annually. Twenty-four age-matched women who underwent health examinations during the same time period were selected as a health control group and answered Female Sexual Function Index (FSFI) questionnaires for the purpose of comparing sexuality. MAIN OUTCOME MEASURES: Anatomic success was defined by a vaginal length ≥ 8 cm and a width allowing the easy introduction of two fingers. Sexual outcomes were assessed at the 12-month follow-up according to body image perception and FSFI questionnaires validated for the Chinese-speaking population. RESULTS: No severe intra-operative complications occurred. No graft-related infection, rejection, or detachment was recorded. The cost for tissue-engineered biomaterial graft was $1,900 (¥ 12,000) per person. Postoperatively, granulomatous polyps occurred in 6/53 patients (11.3%) at the vaginal vault and were removed in an outpatient clinic. During a mean follow-up of 21.1 months, the anatomic success rate was 100%, and all of the patients were satisfied with their body image. Postoperatively, 42 patients were followed up for more than 1 year, and 32 of them were sexually active. Among the 24/32 patients (75%) who answered the FSFI questionnaire, the mean total FSFI score was 26.7 ± 3.5, which was similar to that of the control group (25.6 ± 7.4, P = 0.46). The similarity was also observed in six separate domains of the functional aspect of female sexuality. CONCLUSIONS: Vaginoplasty with tissue-engineered biomaterial graft is a safe, effective, minimally invasive cosmetic procedure that provides near normal sexual function for patients with vaginal aplasia.

Deterioration in biomechanical properties of the vagina following implantation of a high-stiffness prolapse mesh.

OBJECTIVE: To define the impact of prolapse mesh on the biomechanical properties of the vagina by comparing the prototype Gynemesh PS (Ethicon) to two new-generation lower stiffness meshes, SmartMesh (Coloplast) and UltraPro (Ethicon). DESIGN: A study employing a nonhuman primate model. SETTING: University of Pittsburgh, PA, USA. POPULATION: Forty-five parous rhesus macaques. METHODS: Meshes were implanted via sacrocolpopexy after hysterectomy and compared with sham. Because its stiffness is highly directional, UltraPro was implanted in two directions: UltraPro Perpendicular (less stiff) and UltraPro Parallel (more stiff), with the indicated direction referring to the position of the blue orientation lines relative to the longitudinal axis of the vagina. The mesh-vaginal complex (MVC) was excised in toto after 3 months. MAIN OUTCOME MEASURES: Active mechanical properties were quantified as the contractile force generated in the presence of 120 mmol/l KCl. Passive mechanical properties (a tissue's ability to resist an applied force) were measured using a multiaxial protocol. RESULTS: Vaginal contractility decreased by 80% following implantation with the Gynemesh PS (P = 0.001), 48% after SmartMesh (P = 0.001), 68% after UltraPro Parallel (P = 0.001) and was highly variable after UltraPro Perpendicular (P = 0.16). The tissue contribution to the passive mechanical behaviour of the MVC was drastically reduced for Gynemesh PS (P = 0.003), but not for SmartMesh (P = 0.9) or UltraPro independent of the direction of implantation (P = 0.68 and P = 0.66, respectively). CONCLUSIONS: Deterioration of the mechanical properties of the vagina was highest following implantation with the stiffest mesh, Gynemesh PS. Such a decrease associated with implantation of a device of increased stiffness is consistent with findings from other systems employing prostheses for support.

The physiology, medical management and oral implications of menopause.

BACKGROUND: Approximately 36 million women in the United States are in the postmenopausal phase of life. The vast majority of these women experienced spontaneous cessation of menses between the ages of 47 and 55 years when the production of estrogen decreased because of an inadequate number of functioning follicles within their ovaries. Fewer women entered menopause after surgical removal of both ovaries. This procedure usually is performed prophylactically to prevent ovarian cancer in conjunction with a hysterectomy, which is required to treat abnormal bleeding, endometriosis or pelvic inflammatory disease. The physiological changes associated with spontaneous or surgical menopause cause some women to experience uncomfortable symptoms such as hot flashes, night sweats and vaginal dryness. In addition, estrogen deprivation arising from menopause in association with age-related factors disproportionately increases the risk of developing cardiovascular disease (that is, myocardial infarct, stroke), osteoporosis, Alzheimer's disease and oral disease. Hormone replacement therapy, or HRT (estrogen or estrogen and progestin), often is prescribed on a short-term basis to alleviate the uncomfortable symptoms associated with estrogen deficiency and on a long-term basis to prevent some of the chronic illnesses common to postmenopausal women. CONCLUSIONS: Dentists who treat women entering menopause need to consider the stressful phase of life their patients are experiencing. Clinical findings of postmenopausal problems on dental examination may include a paucity of saliva, increased dental caries, dysesthesia, taste alterations, atrophic gingivitis, periodontitis and osteoporotic jaws unsuitable for conventional prosthetic devices or dental implants. Panoramic dental radiographs may reveal calcified carotid artery atheromas. CLINICAL IMPLICATIONS: Dentists have an opportunity to refer women who are not under the care of a gynecologist for an evaluation to determine the appropriateness of HRT for its systemic and oral health benefits.

Caring for women living with Sjögren's syndrome.

T his article advises nurses about providing care to women who are living with Sjögren's syndrome. A chronic, autoimmune condition, Sjögren's syndrome affects mostly women and leads to visual, vocal, and vaginal problems related to dryness. A review of the literature indicates that not many women are aware of Sjögren's, and when diagnosed, are not informed about the possibility that they will have the vaginal dryness associated with the condition. Nursing implications include interventions that involve pharmacologic and nonpharmacologic methods to moisturize women's eyes, mouth, and vagina, increasing the comfort of those with Sjögren's syndrome.

[The treatment of urinary stress incontinence with the sling and Pereyra's suspension]. / Lechenie na pikochnata stres-inkontinentsiia sus "Sling" i okachvane po Pereira.

Patients with proven stress incontinence were subjected to surgical treatment which combined both sling and Stamey-Pereyra techniques. A 3-4 cm long and 1,5-2 cm wide sling of Bulgarian polyamide mesh was placed under the urethrovesical junction using a small vaginal incision. Two long polyamide sutures were tied to either end of the mesh and were retrieved from the vagina to the abdomen by Pereyra needle inserted through two small suprapubic incisions and guided by the vaginal forefinger. The technique of the procedure is described. A total number of 27 patients were operated on. Two of them has their suspending sutures cut postoperatively because of prolonged urinary retention. The remaining 25 were continent. The technique proposed combines the advantages of the sling procedures (high efficiency especially in cases of severe and recurrent incontinence) and the simplicity of Stamey-Pereyra suspension technique. On the other hand the Bulgarian polyamide mesh showed very good qualities. No infection, rejection or sling erosion were observed.

A review of the tension-free vaginal tape procedure: outcomes, complications, and theories.

In the last century, the pathophysiology of stress urinary incontinence (SUI) has been investigated and several surgical techniques have been utilized for cure. The most recent evolution in the study of SUI is the minimally invasive tension-free vaginal tape (TVT) procedure, which can be done under local anesthesia and intravenous sedation and is individualized for each patient. The procedure recreates the "hammock" of the anterior vaginal wall and endopelvic fascia with a mesh tape of polypropylene. The cure rates of the initial studies are equal to or better than other anti-incontinence procedures, and the permanent supportive mesh is very well tolerated. The TVT creates a backboard on which the urethra compresses itself when it rotates posteriorly during cough or stress. The procedure accomplishes subjective and objective cure without elevating the bladder neck or altering urethral mobility.

The tampon: investigated and challenged.

Tampons have been associated with toxic shock syndrome, a newly-recognized disease which attacks women of menstrual age and has caused at least 84 deaths so far. A study of the medical literature since 1933, when tampons were first put on the market, reveals warning of possible dangers as a foreign body, as an irritant, as a carrier of bacteria. Today more health professionals are aware of the dangers of tampon use, but they have not yet applied this knowledge to diseases other than TSS. We believe this should be done. Tampons, now considered a Class II Medical Device, should be re-classified into Class III, where pre-market testing is mandatory.

Abdominal sacral colpopexy with Mersilene mesh in the retroperitoneal position in the management of posthysterectomy vaginal vault prolapse and enterocele.

During a 12-year study period from 1972 to 1984, 56 patients underwent abdominal sacral colpopexy with retroperitoneal interposition of a suspensory hammock between a prolapsed vaginal vault and the anterior surface of the sacrum. They were followed from 6 months to 12 1/2 years, and constitute the basis of this report. In most patients, a synthetic mesh was the material interposed. Hysterectomy had previously been performed on 53 patients, and in two patients there was congenital absence of the uterus. Indications for abdominal sacral colpopexy, surgical technique, complications, and results of operation are discussed. Seven additional patients underwent this operation after termination of the defined study period.