Is transvaginal mesh surgery with polytetrafluoroethylene mesh ORIHIME® feasible for anterior pelvic organ prolapse?-Randomized comparative study between ORIHIME® and Polyform™.

OBJECTIVE: Transvaginal mesh surgery for pelvic organ prolapse has been widely performed in Japan, but polypropylene mesh has not been used in Japan since the ban on TVM using polypropylene mesh in the United States. Currently, polytetrafluoroethylene mesh ORIHIME® is the only mesh available for TVM in Japan. Although polytetrafluoroethylene is a safe material, its low coefficient of friction and insufficient adhesion to the surrounding tissue make it difficult to maintain the mesh position when it is used in the transvaginal mesh surgery. The aim of this study was to evaluate the feasibility of TVM-A2 using ORIHIME®. METHODS: One hundred cases of TVM-A2 were included in the study. The patients were randomly assigned to two groups: the ORIHIME® group (Group O) and the PolyformTM group (Group P). With 50 patients in each group, the complications and recurrences up to the fourth year were compared. Surgeries were performed using the TVM-A2 method. Statistical analysis was performed using EZR. RESULTS: There were no significant differences in baseline parameters between the two groups. We observed no perioperative complications, and saw one case of postoperative abscess formation in Group O, which resolved successfully after incision and drainage. The 4-year recurrence rate was significantly higher in Group O. CONCLUSION: As the recurrence rate was significantly higher in Group O, we conclude that TVM-A2 using ORIHIME® which is the same procedure as TVM-A2 using polypropylene mesh is not feasible in repairing the pelvic organ prolapse.

Sexual and functional outcomes after prolapse surgery: a randomized prospective comparison of trocarless transvaginal mesh and pelvic organ prolapse suspension.

PURPOSE: Stress urinary incontinence (SUI) related to pelvic organ prolapse represents a common condition that negatively impacts female sexual activity. Laparoscopic pelvic organ prolapse surgery (POPs) and the anterior repair with a trocar-less trans-vaginal mesh (TTMs) represent two different surgical techniques to treat SUI secondary to POP. This study aimed to report the results of these techniques comparing the sexual and functional outcome improvement. MATERIALS AND METHODS: Fifty-nine sexually active female patients, complaining of urodynamic stress incontinence, were enrolled in this prospective study, and simply randomized in two groups: 29 POPs and 30 TTMs. All patients were studied at baseline and 6 months after surgery. Preoperative evaluation included medical history, urodynamic test, Female Sexual Function Index (FSFI), and pelvic magnetic resonance defecography. Six months after surgery, all patients completed the FSFI and the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form (ICIQ-UI SF) and were investigated with a uroflowmetry test with post-void residual volume (PVR). RESULTS: At 6 months after surgery, 87% of POPs patients and 79% of TTMs subjects resulted dry. No statistically significant results were obtained in terms of urinary outcomes between the two surgical groups. Regarding sexual function, POPs group exhibited a significant greater improvement of global FSFI (mean: 27.4; SD: 4.31) compared to TTMs group (mean FSFI: 23.56; SD: 2.28; p-value ≤ 0.0001). CONCLUSIONS: Our results indicated that POPs and TTMs lead to satisfactory and safe functional outcomes with a good recovery of urinary continence. Furthermore, POPs, when compared to TTMs, led to a greater improvement of sexual function.

Evaluation of 30-day complication rates following vaginal anterior compartment repair with and without graft augmentation in a propensity score matched cohort.

OBJECTIVE: To determine if graft augmentation with anterior colporrhaphy (AC+G) is associated with higher complication rates compared to native tissue repair (AC). MATERIALS AND METHODS: Retrospective cohort study using data from the ACS-NSQIP database between 2010 and 2017. CPT codes were used to identify women undergoing AC+G and AC. Propensity scores for the likelihood of undergoing AC+G were calculated and were used to match to women undergoing native tissue repair at a ratio of 1:2. The primary outcome was the composite complication rate. Descriptive statistics are reported as means with standard deviations for parametric data and as medians and interquartile ranges for non-parametric data. Pairwise comparisons were performed using Fisher's exact test, Wilcoxon rank-sum and Student's t test as appropriate. Multivariable logistic regression was then used to adjust for confounders to identify statistically significant factors associated with the likelihood of experiencing a complication after prolapse repair. RESULTS: 582 women met inclusion criteria for AC+G and were matched with 1164 women undergoing AC. There were no differences in preoperative characteristics between groups. There was no difference in the composite complication rate, (10.8% vs. 8.5%, p = 0.13) between groups. Dependent functional status (aOR 4.31, 95% CI 1.96-13.58) was the strongest predictor of the likelihood of a complication: other significant predictors were operating time greater than 20 min (aOR 1.68, 95% CI 1.19-2.38) and ASA class greater than 2 (aOR 1.44, 95% CI 1.01-2.05). CONCLUSION: There is no increase in 30-day complication rates in women undergoing AC+G compared to a matched cohort of those undergoing AC alone.

Treatment of vaginal vault prolapse in The Netherlands: a clinical practice survey.

INTRODUCTION AND HYPOTHESIS: A great variety of conservative and surgical procedures to correct vaginal vault prolapse have been reported. The aim of this study was to describe practice pattern variation-the difference in care that cannot be explained by the underlying medical condition-among Dutch gynecologists regarding treatment of vaginal vault prolapse. METHODS: A clinical practice survey was conducted from March to April 2017. The questionnaire was developed to evaluate treatment of vaginal vault prolapse. All members of the Dutch Society for Urogynaecology were invited to participate in a web-based survey. RESULTS: One hundred four Dutch gynecologists with special interest in urogynecology responded to the survey (response rate, 44%). As first-choice therapy for vaginal vault prolapse, 78% of the respondents chose pessary treatment, whereas sacrospinous fixation was the second most common therapy choice according to 64% of the respondents. Preferences on how to approach vaginal vault prolapse surgically are conflicting. Overall, the most performed surgery for vaginal vault prolapse is sacrospinous fixation, followed by laparoscopic and robotic sacrocolpopexy. CONCLUSIONS: Gynecologists in The Netherlands manage vaginal vault prolapse very differently. No standardized method could be determined for the treatment of vaginal vault prolapse in The Netherlands, and we observed practice pattern variations.

Reoperations for mesh-related complications after pelvic organ prolapse repair: 8-year experience at a tertiary referral center.

INTRODUCTION AND HYPOTHESIS: The use of mesh in pelvic organ prolapse (POP) surgery has become a widespread treatment option, but carries a risk of specific complications. The objective was to report the rate and type of reoperation for mesh-related complications after pelvic organ prolapse surgery in an urogynecological referral center over a period of 8 years. METHODS: A retrospective study was carried out including all patients operated for a mesh complication after prolapse surgery between September 2006 and September 2014 in the urogynecology unit in Nîmes hospital. RESULTS: Sixty-nine mesh complications were recorded among the 67 patients included. Surgical treatment of mesh-related complications accounted for 7% of all pelvic surgeries performed in our center. Thirty-two patients (47.8%) were referred from other centers and 35 patients (52.2%) were initially operated in our unit. The global rate of reintervention for mesh-related complications after prolapse repair performed in our unit was 2.8%. Of 69 mesh complications, 48 patients (71.6%) had transvaginal mesh (TVM) and 19 patients (28.4%) sacrocolpopexy (SCP). The indication for surgery was a symptomatic or large vaginal erosion (47.8%), symptomatic mesh contraction (20.3%), and infection (11.6%). The most frequent primary symptom was pelvic/perineal pain or dyspareunia (33.3% of cases). The mean time between initial mesh surgery and the reoperation for a complication was 33.4 months (95% CI, 24.5 to 42.2). Eleven patients (15.9%) required several interventions. In total, 77.9% of patients experienced complete recovery of symptoms after surgical management. CONCLUSION: In a referral center the global rate of reinterventions for mesh-related complications after POP repair is 2.8%. The surgical treatment of mesh complications appears to be a safe and effective procedure with cure of the symptoms in most cases.

The treatment of post-hysterectomy vaginal vault prolapse: a systematic review and meta-analysis.

INTRODUCTION AND HYPOTHESIS: The treatment of post-hysterectomy vaginal vault prolapse (VVP) has been investigated in several randomized clinical trials (RCTs), but a systematic review of the topic is still lacking. The aim of this study is to compare the effectiveness of treatments for VVP. METHODS: We performed a systematic review and meta-analysis of the literature on the treatment of VVP found in PubMed and Embase. Reference lists of identified relevant articles were checked for additional articles. A network plot was constructed to illustrate the geometry of the network of the treatments included. Only RCTs reporting on the treatment of VVP were eligible, conditional on a minimum of 30 participants with VVP and a follow-up of at least 6 months. RESULTS: Nine RCTs reporting 846 women (ranging from 95 to 168 women) met the inclusion criteria. All surgical techniques were associated with good subjective results, and without differences between the compared technique, with the exception of the comparison of vaginal mesh (VM) vs laparoscopic sacrocolpopexy (LSC). LSC is associated with a higher satisfaction rate. The anatomical results of the sacrocolpopexy (laparoscopic, robotic [RSC]. and abdominal [ASC]) are the best (62-91%), followed by the VM. However, the ranges of the anatomical outcome of VM were wide (43-97%). The poorest results are described for the sacrospinal fixation (SSF; 35-81%), which also correlates with the higher reoperation rate for pelvic organ prolapse (POP; 5-9%). The highest percentage of complications were reported after ASC (2-19%), VM (6-29%), and RSC (54%). Mesh exposure was seen most often after VM (8-21%). The rate of reoperations carried out because of complications, recurrence prolapse, and incontinence of VM was 13-22%. Overall, sacrocolpopexy reported the best results at follow-up, with an outlier of one trial reporting the highest reoperation rate for POP (11%). The results of the RSC are too small to make any conclusion, but LSC seems to be preferable to ASC. CONCLUSIONS: A comparison of techniques was difficult because of heterogeneity; therefore, a network meta-analysis was not possible. All techniques have proved to be effective. The reported differences between the techniques were negligible. Therefore, a standard treatment for VVP could not be given according to this review.

Pressure-Volume Loop Analysis of Voiding Workload: An Application in Trans-Vaginal Mesh-Repaired Pelvic Organ Prolapse Patients.

Although trans-vaginal mesh (TVM) offers a successful anatomical reconstruction and can subjectively relieve symptoms/signs in pelvic organ prolapse (POP) patients, its objective benefits to the voiding function of the bladder have not been well established. In this study, we investigated the therapeutic advantage of TVM on bladder function by focusing on the thermodynamic workload of voiding. The histories of 31 POP patients who underwent TVM repair were retrospectively reviewed. Cystometry and pressure volume analysis (PVA) of the patients performed before and after the operation were analyzed. TVM postoperatively decreased the mean voiding resistance (mRv, p < 0.05, N = 31), reduced the mean and peak voiding pressure (mPv, p < 0.05 and pPv, p < 0.01, both N = 31), and elevated the mean flow rate (mFv, p < 0.05, N = 31) of voiding. While displaying an insignificant effect on the voided volume (Vv, p < 0.05, N = 31), TVM significantly shortened the voiding time (Tv, p < 0.05, N = 31). TVM postoperatively decreased the loop-enclosed area (Apv, p < 0.05, N = 31) in the PVA, indicating that TVM lessened the workload of voiding. Moreover, in 21 patients who displayed postvoiding urine retention before the operation, TVM decreased the residual volume (Vr, p < 0.01, N = 21). Collectively, our results reveal that TVM postoperatively lessened the workload of bladder voiding by diminishing voiding resistance, which reduced the pressure gradient required for driving urine flow.

Trans-Vaginal Mesh Revision: A Comprehensive Review on Etiologies and Management Strategies with Emphasis on Postoperative Pain Outcomes.

The use of polypropylene mesh to augment surgery aimed to correct pelvic organ prolapse and stress urinary incontinence stems largely from the high recurrence rates of native tissue repairs. While objective outcomes were improved, mesh related complications began to emerge that included mesh exposures, extrusions, dyspareunia and other pain issues. However, the indication for and benefit of surgical intervention(s) to address these complications are lacking. We aim to review to current literature regarding postoperative pain outcomes following vaginal mesh revision. Evidence based literature indicates that mesh complications are not rare and surgery that aims to address them generally have an overall benefit. However, studies available are generally small case series of a retrospective nature with short follow up. Some themes are evident: there is a long lag period from mesh insertion to removal; there is a lack of a true denominator of total mesh insertions making it hard to gauge the real scope of the problem; mesh material found not along the expected trocar path or coursing close to neurovascular structures thus raises the possibility of technical errors during insertion. Transvaginal mesh revision(s) for mesh complications generally have a positive effect on pain outcomes, but better controlled studies are needed. Additionally, since technical issues may be a factor in the development of mesh complications, rigorous training and sufficient surgical case volume should be emphasized.