Treatment of vaginal vault prolapse with abdominal sacral colpopexy using prolene mesh

BACKGROUND: We report our experience of abdominal sacral colpopexy (ASC) with a prolene mesh in women with total vaginal vault prolapse. MATERIALS AND METHODS: From 1994 to 1997, 15 patients (average age 57 years), underwent ASC. All the patients suffered from a serious vaginal vault prolapse. Eight of them also had a uterine prolapse. Seven patients had already been operated on for hysterectomy (5 vaginal, 2 abdominal), and 4 of them had already undergone an operation for urinary incontinence (3 Raz, 1 Burch). In 6 cases ASC was associated with a colposuspension in accordance with Burch. Average follow-up was 20 months. RESULTS: All the patients carried a bladder catheter for 4 to 12 days (mean 5). The 11 patients who were sexually active began having normal sexual intercourse again. Neither relapses of the treated prolapses nor infection or rejections of the prostheses occurred. In 1 patient frequent micturition unresponsive to anticholinergics persisted. Four patients presented with hypogastric "sense of heaviness," with no clinical evidence of any pathology. CONCLUSION: ASC with a prolene net is confirmed as the most valid technique, with no complications, in the treatment of total vaginal vault prolapse, above all when there is also the need for other operations via the abdomen at the same time (colposuspension, culdoplasty, and so forth), or when the vagina is too short to fix the sacrospinal ligament transvaginally.     

Magnetic resonance imaging and abdominal wall hernias in aortic surgery

BACKGROUND: The aim of this study was to evaluate the incidence of abdominal wall hernias (AWH) in patients operated on for abdominal aortic aneurysm (AAA) compared with patients treated for aortoiliac occlusive disease. The efficacy of MRI in early diagnosis of AWH also was studied. STUDY DESIGN: One hundred fourteen patients operated for either AAA (51 patients, group A) or aortoiliac occlusive disease (63 patients, group B) constitute the study. The presence of AWH onset was evaluated by clinical observation followed by ultrasonography. Data acquired by ultrasonography were compared with those obtained by MRI to determine the efficacy of this diagnostic tool in all 114 patients. The prevalence of inguinal hernias in both groups also was determined. RESULTS: A significant difference was found in the incidence of AWH. AWH developed in 31.7% (16 of 51) of group A patients and 17.4% (11 of 63) of group B patients (p < 0.03). A significant prevalence ofinguinal hernias was detected in group A (p < 0.01). The Cox hazard regression analysis revealed as independent predictors of postoperative AWH only the presence of AAA and a history of laparotomy. CONCLUSIONS: Ours and other studies recall collagen synthesis disorders to explain the statistical association observed among AAA, inguinal hernias, and AWH. MRI, especially in patients at risk, appears to be an effective diagnostic approach to early detection of AWH.     

Long-term outcomes of vaginal mesh versus native tissue repair for anterior vaginal wall prolapse

Introduction and hypothesis

To estimate the risk of repeat surgery for recurrent prolapse or mesh removal after vaginal mesh versus native tissue repair for anterior vaginal wall prolapse.

Methods

We utilized longitudinal, adjudicated, healthcare claims from 2005 to 2010 to identify women ≥18 years who underwent an anterior colporrhaphy (CPT 57420) with or without concurrent vaginal mesh (CPT 57267). The primary outcome was repeat surgery for anterior or apical prolapse or for mesh removal/revision; these outcomes were also analyzed separately. We utilized Kaplan–Meier curves to estimate the cumulative risk of each outcome after vaginal mesh versus native tissue repair. Cox proportional hazards models were used to estimate the hazard ratio (HR) for vaginal mesh versus native tissue repair, adjusted for age, concurrent hysterectomy, and concurrent or recent sling.

Results

We identified 27,809 anterior prolapse surgeries with 49,658 person-years of follow-up. Of those, 6,871 (24.7%) included vaginal mesh. The 5-year cumulative risk of any repeat surgery was significantly higher for vaginal mesh versus native tissue (15.2 % vs 9.8 %, p?<0.0001) with a 5-year risk of mesh revision/removal of 5.9%. The 5-year risk of surgery for recurrent prolapse was similar between vaginal mesh and native tissue groups (10.4 % vs 9.3 %, p?=?0.70. The results of the adjusted Cox model were similar (HR 0.93, 95%CI: 0.83, 1.05).

Conclusions

The use of mesh for anterior prolapse was associated with an increased risk of any repeat surgery, which was driven by surgery for mesh removal. Native tissue and vaginal mesh surgery had similar 5-year risks for surgery for recurrent prolapse.     

Magnetic resonance imaging of abdominal aortic grafts

The widespread use of abdominal aortic grafting procedures and increasing awareness of related complications suggests the need for a reliable and non-invasive diagnostic technique which will allow early detection of both occlusive and non-occlusive complications. Ultrasound is generally used with satisfactory results, but has several limitations, whereas MRI has shown great promise in the study of cardiovascular disease, being non-invasive, multiplanar and multiparametric. The present research aims to evaluate MRI in the follow-up of abdominal aortic grafts, attempting to define its significance as a screening procedure in non-selected patients. MRI is reliable in ascertaining the normality of the graft as well as the complications, these being partial or total thrombosis, pseudoaneurysms and perigraft collections. The data obtained are highly satisfactory and are almost always superior to those achieved with ultrasound and CT.     

Magnetic resonance imaging versus angiography in the preoperative assessment of abdominal aortic aneurysms

Magnetic resonance is a cost-effective imaging tool in the preoperative evaluation of abdominal aortic aneurysm, and yields more clinically relevant information than ultrasonography and computerized tomography. Magnetic resonance imaging has advantages over angiography in that is costs substantially less, is noninvasive, and reconstructs images in multiple planes. By utilizing multiplanar imaging, magnetic resonance imaging yields more information than angiography. The position of the left renal vein is imaged only by magnetic resonance, as is the origin of the superior mesenteric artery. Angiography remains important in patients with associated occlusive disease and claudication. The use of magnetic resonance in the emergent setting is limited at this time.     

Tension-free vaginal mesh repair for anterior vaginal wall prolapse

OBJECTIVES: We determined the efficacy of the use of a tension free prolene mesh to correct a grade III anterior vaginal wall prolapse recurrence. METHODS: Twelve women (mean age 65.6 years) with stress urinary incontinence (SUI) (4 type II and 1 type III) and bladder prolapse entered the study. After vaginal incision a pretailored polypropylene mesh was fixed to its four angles by absorbable sutures to the urethropelvic ligaments and pubocervical fascia anteriorly and to the cardinal ligaments and pubocervical fascia posteriorly. When present, a posterior descensus was corrected during the same procedure. SUI was treated with the tension-free vaginal tape procedure (TVT) through a separate vaginal incision over the mid-urethra. RESULTS: All patients were available for postoperative pelvic examination at 3-month intervals, for a mean follow-up of 20.5 months (range 15-32). Nine patients were considered cured (no cystocele recurrence) while in 3 patients a grade 1 asymptomatic cystocele was present postoperatively (asymptomatic). No significant postoperative pain was reported by the patients. CONCLUSIONS: This study confirms that in patients with moderate cystocele a tension-free mesh to support bladder base and neck effectively treats the cystocele. It is particularly recommended in the treatment of previous failure with traditional techniques and when the quality of suspending tissue is poor or defective. A long-term study on a large number of patients is still warranted to confirm and validate its clinical use.     

Changes in prolapse surgery trends relative to FDA notifications regarding vaginal mesh

Introduction and hypothesis

In 2008 and 2011, the US Food and Drug Administration (FDA) released notifications regarding vaginal mesh. In describing prolapse surgery trends over time, we predicted vaginal mesh use would decrease and native tissue repairs would increase.

Methods

Operative reports were reviewed for all prolapse repairs performed from 2008 to 2011 at our large regional hospital system. The number of each type of prolapse repair was determined per quarter year and expressed as a percentage of all repairs. Surgical trends were examined focusing on changes with respect to the release of two FDA notifications. We used linear regression to analyze surgical trends and chi-square for demographic comparisons.

Results

One thousand two hundred and eleven women underwent 1,385 prolapse procedures. Mean age was 64?±?12, and 70 % had stage III prolapse. Vaginal mesh procedures declined over time (p?=?0.001), comprising 27 % of repairs in early 2008, 15 % at the first FDA notification, 5 % by the second FDA notification, and 2 % at the end of 2011. The percentage of native tissue anterior/posterior repairs (p?<?0.001) and apical suspensions (p?=?0.007) increased, whereas colpocleisis remained constant (p?=?0.475). Despite an overall decrease in open sacral colpopexies (p?<?0.001), an initial increase was seen around the first FDA notification. We adopted laparoscopic/robotic techniques around this time, and the percentage of minimally invasive sacral colpopexies steadily increased thereafter (p?<?0.001). All sacral colpopexies combined as a group declined over time (p?=?0.011).

Conclusions

Surgical treatment of prolapse continues to evolve. Over a 4-year period encompassing two FDA notifications regarding vaginal mesh and the introduction of laparoscopic/robotic techniques, we performed fewer vaginal mesh procedures and more native tissue repairs and minimally invasive sacral colpopexies.     

Magnetic resonance imaging before chemonucleolysis for lumbar disc prolapse

Summary Chemonucleolysis is an established non-operative treatment of a prolapsed symptomatic lumbar disc. It was introduced as a form of treatment in the early 1960s by Smith [18]. One of the main causes of failure is the difficulty in pre-operative assessment of a contained disc prolapse. Reducing failure rates is very important for the morale of surgeon and patient alike. We investigated 58 patients with magnetic resonance imaging (MRI) to select those with a contained protrusion prior to chemonucleolysis. Per-operative discography confirmed contained protrusion in 96.5% (56/58) of cases, increasing the specificity of selection. At 6 months post chemonucleolysis 86% of our patients were asymptomatic. We would commend MRI as the investigation method of choice prior to chemonucleolysis for a prolapsed symptomatic lumbar disc, thus avoiding separate diagnostic discography, thereby reducing inconvenience to the patient and wastage of prepared chymopapain.     

Trocar-guided total tension-free vaginal mesh repair of post-hysterectomy vaginal vault prolapse

Introduction and hypothesis  

The objective of this study was to report 1 year anatomical and functional outcomes of trocar-guided total tension-free vaginal mesh (Prolift™) repair for post-hysterectomy vaginal vault prolapse with one continuous piece of polypropylene mesh.     

Perioperative outcomes after robotic versus vaginal surgery for pelvic organ prolapse

Journal of Robotic Surgery - The objectives of the study were to compare post-anesthesia care unit opioid use and pain scores, surgical and hospitalization times, and perioperative adverse events...     

Marlex mesh prosthesis for massive vaginal vault prolapse

A case of repeatedly recurrent massive vaginal vault prolapse is presented. Representative articles on various ingenious modalities for the repair of this condition are reviewed. An additional safe and simple procedure is described. Criteria for the ideal prosthetic material are listed. Marlex mesh prosthesis, which appears to fulfil all the criteria required for use in vaginal surgery, is recommended not only as an onlay graft to support the soft tissues approximated, but also to cover wide gaps, as was presented in this case.     

Patient goal attainment in vaginal prolapse repair with and without mesh

Introduction and hypothesis

The objective of this study was to describe patient-centered goals and their attainment in vaginal prolapse repair, with and without mesh.

Methods

A secondary analysis of a multicenter randomized controlled trial of prolapse repair with or without vaginal mesh was performed. Participants (n?=?65) selected three preoperative goals ranked by importance. At 3 and 12?months postoperatively, patients graded their goal attainment on a scale of 1 (not at all) to 5 (100?% attainment). Goal attainment was compared with anatomical outcome, symptoms, quality of life, and satisfaction scores. Nonparametric tests and the log-rank test were used to determine statistical significance (p?<?0.05).

Results

A total of 176 goals were selected. The first goal in 37 women (57?%) was improving prolapse symptoms, in 15 (23?%) urinary symptoms, in 7 (11?%) appearance, activity, and self-image, in 2 (3.1?%) bowel symptoms, and in 2 (3.1?%) sexual function. At 3 and 12?months postoperatively, goal achievement for prolapse symptoms was 96.1 and 93.6?%, for urinary symptoms 75.6 and 70.0?%, and for appearance, activity, and self-image 90.5 and 94.7?%, respectively. The effect of anatomical outcome, mesh use, or the presence of mesh erosion on goal attainment could not be demonstrated. Women who achieved their first goal had significantly better symptoms, quality of life, and satisfaction scores than women who did not.

Conclusions

Patient goal attainment after vaginal prolapse repair was high and not consistently related to objective anatomical outcome or mesh use. It persisted between 3 and 12?months postoperatively and was associated with better satisfaction, quality of life, and symptom scores.     

Comparison of vaginal mesh extrusion rates between a lightweight type I polypropylene mesh versus heavier mesh in the treatment of pelvic organ prolapse

Introduction and hypothesis

The objective of the study was to compare extrusion (vaginal mesh exposure) rates in patients undergoing transvaginal prolapse repair with the trocar-based Apogee and/or Perigee devices (American Medical Systems, Minnetonka, MN, USA) using either the original type I polypropylene mesh (IntePro, American Medical Systems, Minnetonka, MN, USA) or a newer generation lightweight type I mesh (IntePro Lite, American Medical Systems, Minnetonka, MN, USA).

Methods

Data were pooled from three similarly designed prospective multicenter studies evaluating the safety and efficacy of Perigee for correction of the anterior (AC) and/or Apogee to repair the posterior/apical (PC/A) compartments. The first two studies utilized IntePro (mesh density 50 g/m²) and the third utilized IntePro Lite (mesh density 25.2 g/m²). Data were pooled to form IntePro and IntePro Lite groups for comparison. Patient demographics were recorded. Risk factors for vaginal mesh exposure were also considered.

Results

Two hundred and sixty-three patients were implanted with Perigee and/or Apogee with IntePro for a total of 371 heavier mesh implants (174 Perigee, 197 Apogee) compared to 86 patients who underwent Perigee and/or Apogee with IntePro Lite for a total of 116 lightweight mesh implants (60 Perigee, 56 Apogee). Demographics and potential risk factors for extrusion were compared between the two groups. Mean follow-up was 2.0?years and similar between the two groups. In the AC, there were 234 implants, with mesh extrusion occurring in 8.0?% following IntePro compared to 5.0?% following IntePro Lite (p?=?0.57). In the PA/C, there were 253 implants, with mesh extrusion occurring in 13.7?% following IntePro compared to 7.1?% following IntePro Lite (p?=?0.25). Overall mesh extrusion rates in 487 implants in all compartments were found to be 11.1?% with IntePro versus 6.0?% with IntePro Lite with an estimated odds ratio of 1.93 (95?% confidence interval 0.84–4.44, p?=?0.12).

Conclusions

No statistically significant difference in extrusion rates were seen following use of IntePro versus IntePro Lite; however, the 46?% reduction in rate of mesh exposure observed in those receiving the lighter weight mesh may represent clinical importance.     

Magnetic resonance imaging in the localization of undescended abdominal testes

In children with nonpalpable undescended testes, preoperative localization is very helpful prior to surgical investigation both to reduce the time required for complete exploration and to plan the correct surgical procedure. Magnetic resonance imaging (MRI) was accomplished in 23 patients with a clinical diagnosis of cryptorchidism after ultrasonographic studies were inconclusive in identifying the undescended testis. An abdominal testis was correctly located in 16 cases. No structures resembling testicular parenchyma were detected in 4 instances. The surgical findings confirmed the absence of testes in 2 patients but showed 2 abdominal testes not seen by MRI. The movements of 5 patients caused inadequate MRI examinations, so these patients were not considered in the results. In our experience MRI proved to be effective in locating undescended abdominal testes with a diagnostic accuracy of 90%. Therefore MRI should be performed before any invasive diagnostic procedure. Lack of cooperation in young patients could reduce the accuracy of the procedure, so we think that sedation should be performed in children under 6 years of age.