Predicting postoperative urinary incontinence development in women undergoing operation for genitourinary prolapse

A total of 67 female patients with pelvic relaxation (cystocele beyond the vaginal orifice) and with no urinary incontinence were clinically and urodynamically evaluated before and after a reconstructive surgical procedure. Of these, 24 patients had a significant decrease in abdominal pressure transmission to the urethra once the cystocele was reduced by vaginal pessary (abdominal pressure transmission ratio to urethra: bladder of less than 1.0). All 24 had a revised Pereyra procedure in addition to the cystocele repair. The other 43 patients had adequate abdominal pressure transmission to the urethra once the cystocele was reduced by vaginal pessary (abdominal pressure transmission ratio to urethra: bladder of greater than or equal to 1.0). These 43 patients underwent cystocele repair only with no surgical repair to the urethra or urethrovesical junction. Evaluation was repeated at 3 to 6 months after the operation. No patient developed urinary incontinence after operation. All 67 patients had urodynamically good abdominal pressure transmission to the urethra while coughing. Women with significant genitourinary prolapse may be continent in spite of a weak urethral sphincter because of kinking of the poorly supported urethra. Urodynamic testing can identify those women at risk of developing postoperative urinary incontinence so that prophylactic measures can be undertaken.     

The pathophysiology of an enterocele and its management.

This paper describes 130 patients with enteroceles and their treatment. It includes analysis of all cases with enterocele over a 17-month period in a pelvic floor dysfunction database. Procedures performed included the Moschcowitz procedure with suspension of the vaginal vault to the sacrum in 13 patients (10%), colposacrosuspension (CSS) (mesh from the upper posterior half of the vagina to the sacrum with mobilisation and fixation of the rectum to the mesh) in 39 patients (30%), perineocolposacrosuspension (PCSS) (similar to CSS, but the mesh is inserted further down to the perineum) in 48 patients (37%) and perineopubo-colposacrosuspension (PPCSS) (as PCSS, but with a second mesh between the bladder and vagina extending to the sacrum) in 30 patients (23%). An additional modified Burch colposuspension was performed in 87 patients (67%). A failure was defined as a recurrent vaginal prolapse of Grade II or more, or urinary incontinence requiring surgical correction. The patients' mean age was 60.5 years, their mean parity 3.3 and 92.3% were white. Preoperatively, 33.8% of the patients complained of constipation, 33.1% of difficulty in defaecation and 77% had bladder symptoms, suggesting urinary stress incontinence or detrusor instability. In 74.6% of the patients part of the vagina protruded through the vaginal introitus. The mean period of follow-up was 7.4 months (range 1-26) with only 13 patients (10%) not followed. Only two patients (1.5%) developed Grade II vaginal prolapse (both cystoceles and both from the PCSS group). Urinary stress incontinence in need of further treatment developed in 13 patients (10%). The failure rate, therefore, was 11.5%. In six patients (4.6%) the mesh had to be removed due to mesh reaction. In all cases the mesh was unabsorbable. Vaginal suspension procedures with mobilisation of the rectum provided satisfactory results for severe enterocele over the short term.     

Cystocele and stress urinary incontinence: assessment of a total treatment by monoprosthesis

OBJECTIVES: The aim of this study is to evaluate the effectiveness and the potential complications in the short and medium terms of the transobturator and infracoccygeal hammock, a surgical technique suggested to treat in one sole operating time, by vaginal way, cystocele and stress urinary incontinence. PATIENTS AND METHODS: From February 2002 till August 2004, 45 patients aged 66+/-11 years on average, presenting a stage 3 or stage 4 cystocele associated with stress urinary incontinence (proven for 40 of them and masked by the prolapse itself for the other five) benefited from this new surgical procedure. RESULTS: With a mean follow-up of 31+/-9 months, the success rate of the technique is estimated at 98% on the anatomical aspect (one single failure) and at 91% on the urinary aspect (73% of the patients were cured, 18% improved and 9% in failure). No patient presented urinary retention except one with an infected pelvic hematoma requiring its evacuation and the partial ablation of the prosthesis. Postvoid residual volume at discharge was 83 ml. Two patients developed de novo bladder overactivity. Unfortunately we had to regret nearly 18% of exposed prosthesis. This result should be improved by the exclusive use of polypropylene monofilament prosthesis with broad meshes, weak weights and by reduced vaginal scars. DISCUSSION AND CONCLUSION: Total treatment by monoprosthesis of cystoceles with associated stress urinary incontinence constitutes an interesting prospect for some high-risk genital urinary prolapses for anatomical repetition or post-operative dysvoiding. Patients with recurrent failures of prolapse surgical cure, those with a large cystocele or by extension with a complete prolapse of the three floors, and even those with a post-hysterectomy prolapse have perhaps found a durable solution with their problem.     

Laparoscopic management of urinary incontinence, ureteric and bladder injuries.

The present review focuses on the most recently published English language literature, and addresses results and complications associated with the laparoscopic approach to urinary incontinence, anterior vaginal wall prolapse, and lower urinary tract injury. Laparoscopic Burch procedures continue to show equal efficacy, but lower morbidity as compared with conventional open techniques. Lower urinary tract injuries may also be managed effectively using the same techniques as those employed in open procedures. Laparoscopy continues to be considered a mode of surgical access, and is effective in treating urinary incontinence, anterior vaginal wall prolapse, and lower urinary tract injuries.     

Tension-free cystocele repair: an analysis after a follow-up of 24 months

AIM: The aim of the study is to verify whether tension free cystocele repair is really a good choice for the correction of moderate or severe cystocele. The surgical approach is transvaginal and involves the use of nonabsorbable prolene mesh. METHODS: We enrolled 177 women with a combined genital prolapse, characterized by second degree cystocele, first degree hysterocele and first degree rectocele or more severe conditions. All the patients underwent a complete urologic and gynecologic work-up before the surgical treatment consisting in a Y-shaped mesh placed on the prevesical fascia. This technique was implemented providing a tension free prosthesis. RESULTS: Our results on a total of 169 patients after a follow-up of 24 months are the following: 19 patients (11%) reported a recurrent cystocele (grade II) of which 9 patients at 6 months follow-up presented a vaginal wall erosion that determined a surgical explantation of the mesh; 2 patients (1%) showed a persistent dyspareunia and were treated with estrogen therapy that gave an improvement of the symptomatology although it did not disappear; 10 (6%) patients, among the women treated only for cystocele repair (cystocele III ), complained of stress urinary incontinence of 1st degree; and, finally, 150 patients (89%) didn't report any recurrence of cystocele. CONCLUSION: Given the good results obtained after a follow-up of 24 months (89% of the cure rate), we can consider this procedure simple, mini-invasive, reproducible and efficient with low morbidity and good tolerance. It is a promising approach in the management of pelvic floor dysfunctions that induces minimal foreign body reaction.     

Cystocele repair by vaginal approach with a tension-free transversal polypropylene mesh. Technique and results

OBJECTIVE: To evaluate mid term results, tolerance and efficiency of interposition of a tension-free polypropylene monofilament mesh by vaginal approach for the repair of cystoceles. PATIENTS AND METHODS: Fourty consecutive women underwent this new procedure between March 2001 and September 2002. After complete dissection of the cystocele, the polypropylene mesh (Gynemesh), Gynecare, Ethicon, Johnson & Johnson, France), proper cut-out was positioned under the bladder without any fixation. The lateral extensions of the mesh where introduced in the para-vesical spaces in contact with the arcus tendinus fascia pelvis. RESULTS: Before surgery all patients had cystocele of more or equal than grade II according to the POP-Q classification. Eight had grade II cystocele (20%) and 32 had grade III cystocele (80%). Thirty women had associated posterior or median prolapse (82.5%). Thirty women had urinary incontinence (75%). Mean age was 63.9 years (51-78). The procedure was performed without any difficulty in all cases. Duration of a cystocele cure procedure was 20 min +/- 2.2 (16-24). Mean follow-up is 16.4 months +/- 4.7 (12-24). The early complication rate was 7.5% (two vaginal erosions and one complete exposition of the mesh which requires secondary ablation). There was no mesh infection. The success rate was 95%. The satisfaction index overpasses 80% in 95% of our patients 6 months after the cystocele repair. DISCUSSION AND CONCLUSIONS: The interposition of a sub-vesical transversal tension-free polypropylene mesh by the vaginal route seems to be an excellent procedure in the definitive surgical treatment of grades II and III anterior vaginal wall prolapse. This new procedure is simple, mini-invasive, reproducible and efficient with low morbidity and good tolerance.     

Trocar-assisted sling suspension for stress urinary incontinence: three-year follow-up

STUDY OBJECTIVE: To evaluate 3-year outcomes of trocar-assisted sling suspension (TASS) for genuine stress incontinence. DESIGN: Retrospective review (Canadian Task Force classification II-2). SETTING: University-based, tertiary-level center for endoscopic surgery. PATIENTS: One hundred forty women with genuine stress incontinence with bladder neck hypermobility. INTERVENTION: After standard surgery preparation and general endotracheal anesthesia, TASS was performed. The periurethral space and thicker parts of the pubocervical fascia were opened from the vagina. A 0.5-cm incision was made on both sides of the lower abdomen and was measured 4-cm lateral to the linea album and 2-3-cm above the pubic bone. A trocar was used to penetrate the incision site to the space of Retzius. A 2-cm x 30-cm folded polypropylene mesh was placed inside the vagina and was then pulled out of the trocar sheath by a laparoscopic forceps. MEASUREMENTS AND MAIN RESULTS: All patients completed the procedures without exception. The average blood loss was less than 50 mL (range 10-200 mL). The operative time ranged from 20 to 90 minutes with a mean time of 32 +/- 12 minutes. Eleven patients had voiding difficulty. Six of them voided well after intermittent self-catheterization performed 28 days postoperatively. Seven patients had poor healing of the anterior vaginal wall; therefore, removal of mesh and wound repair were performed. One patient suffered from a retroperitoneal hematoma, and one patient had an intraoperative bladder injury. The overall complication rate was 14.3%. During 12-36 months of follow-up, 134 of 140 patients (95.7%) were satisfied with the surgery. CONCLUSIONS: Based on the results of our pilot study, TASS is quite feasible as a method of treatment for stress urinary incontinence. The surgery is not difficult to perform when compared with Burch colposuspension. Moreover, it encompasses the simplicity and effectiveness of tension-free vaginal tape surgery. In addition, TASS also can correct lateral wall defects such as cystocele.     

Laparoscopic Pectopexy with Burch Colposuspension for Pelvic Prolapse Associated with Stress Urinary Incontinence

Study ObjectiveTo present a case of pelvic organ prolapse associated with stress urinary incontinence treated by laparoscopic pectopexy followed by Burch colposuspension.DesignCase report.SettingUniversity Gynecology Clinic of the Emergency Clinical City Hospital Timișoara, Romania.PatientsWe present the case of a 41-year-old woman, gravida 1 para 1, with no notable medical or surgical history, with a body mass index of 40 kg/m², who presented in our service with heavy menstrual bleeding, dysmenorrhea, pelvic pressure, dyspareunia, stress urinary incontinence, and voiding difficulties. Local examination revealed a cervix descended 2 cm below the hymenal ring, cystocele, urethrocele, and a positive cough stress test. The pelvic prolapse was classified as pelvic organ prolapse quantification stage 3. Ultrasound exam revealed a uterus with diffuse adenomyosis of the posterior uterine wall and normal adnexa. Because of the patient's obesity, the treatment plan was laparoscopic supracervical hysterectomy for the treatment of adenomyosis, laparoscopic pectopexy for the correction of the apical defect, and Burch colposuspension for the cure of stress incontinence.InterventionsThe patient was placed in the standard dorsal lithotomy position with the hips in extension and the knees flexed and the table in 45° Trendelenburg position. One 10-mm umbilical optical trocar and three 5-mm trocars were used—2 inserted 2 cm above and medial to the anterior superior iliac crests, and the third, 5 cm below the umbilical trocar. The dissection started on the left side of the pelvis. The peritoneum was incised in the center of a V-shaped area bordered by the left round ligament and the obliterated umbilical artery (the medial umbilical ligament). The soft tissue was dissected, and the left iliopectineal ligament (also known as the inguinal ligament of Cooper) was identified right under the external iliac vein and prepared. The same steps were repeated on the right side of the pelvis. The procedure continued with the dissection of the vesicovaginal space. The anterior vaginal wall was exposed with the help of a retractor placed inside the vagina and held by an assistant. A supracervical hysterectomy was performed. An 8 × 15-cm polypropylene mesh, cut in a T shape, was introduced in the abdomen. First, the short arm of the T was fixed on the anterior vaginal wall using multiple absorbable tacks (AbsorbaTack fixation device; Medtronic, Dublin, Ireland). To use a type of nonabsorbable fixation, we decided to also fix the mesh to the cervix stump with 3 isolated stitches (Silk Suture 2-0; Ethicon, Somerville, NJ). Second, with the purpose of ensuring a permanent fixation, the lateral arms of the mesh were attached to the iliopectineal ligaments with multiple nonabsorbable tacks on both sides (ProTack fixation device; Medtronic, Dublin, Ireland). The procedure continued with the complete closure of the peritoneum with VICRYL 2-0 sutures (Ethicon). Because the patient also had stress urinary incontinence, a Burch colposuspension was performed. To expose its limits, the urinary bladder was filled with 200 mL of saline. After the incision of the peritoneum, the avascular space of Retzius was opened. The dissection continued until the Cooper's ligaments were exposed bilaterally. The proper suture placement points on the vaginal wall were facilitated by an assistant's intravaginal finger. Two isolated nonabsorbable silk stitches (Silk Suture 2-0) were placed through the Cooper's ligament and through the anterior vaginal wall on each side. The knots were tied just enough to properly lift the vaginal wall in the normal position, assessed by the assistant by vaginal route, but not too tight to avoid urethral obstruction.Measurements and Main ResultsThe duration of the surgery was 95 minutes, with minimal blood loss of about 60 mL. The patient recovered well, with the Foley catheter being removed after 12 hours. The patient was discharged after 48 hours. The 6-month follow-up examination revealed a correct anatomical position of the anterior vaginal wall and of the cervix at 6 cm above the hymenal ring and no urinary incontinence.ConclusionLaparoscopic pectopexy represents a new option for the treatment of pelvic organ prolapse. In the case we reported, no intraoperative or postoperative complications were present, and the follow-up assessment revealed an effective correction of the prolapse. Further studies are needed to conclude the efficiency and safety of this new procedure.     

Physiology of stress urinary incontinence: a new theory based on the physical analysis of forces and anatomy

We developed a theoretical model to understand the extrinsic factors of the bladder-urethral system involved in stress urinary incontinence and their relationships with cystocele or the protective effect of dorsal decubitus and with overfilled-bladder-related dysuria. The model is based on known physical rules (elasticity, pressure-volume relationships in a closed cavity - vagina and its supportive tissue, Retzius space) applied to anatomy. The anterior vaginal wall, divided in two parts, plays a major role in stress urinary incontinence by moderating the rise in the abdominal pressure on the bladder and also by increasing the pressure in the Retzius space that increases the resistance to flow in the urethra. The tent canvas hypothesis applied to the anterior portion of the vaginal wall under the urethra explains the relationship between defective vaginal wall resistance and mobility of the urethra-bladder junction.     

Dyspareunia and recurrent stress urinary incontinence after laparoscopic colposuspension with mesh and staples. A case report

BACKGROUND: A laparoscopic colposuspension technique using hernia staples and polypropylene mesh has been introduced for the treatment of stress urinary incontinence but is not without hazards. CASE: A 32-year-old woman developed recurrent stress urinary incontinence and dyspareunia approximately one year after undergoing laparoscopic colposuspension with hernia staples and polypropylene mesh. Metal staples palpated vaginally corresponded with the area of maximal tenderness, and the bladder neck was hypermobile. Upon surgical exploration of the space of Retzius, four staples were found in the bladder wall, and polypropylene mesh densely adherent to the bladder wall had eroded into the muscularis. CONCLUSION: Laparoscopic colposuspension with hernia staples and polypropylene mesh may be associated with early recurrence of incontinence and dyspareunia.     

Correction of cystocele and stress incontinence with anterior transobturator mesh

OBJECTIVE: To evaluate the effectiveness and safety of anterior transobturator mesh for treating cystocele with or without urinary stress incontinence. STUDY DESIGN: Eighty-five women with cystocele, with or without USI, underwent anterior transobturator vaginal mesh operation. All patients were examined after 4 months. Seventy-two of them were evaluated via questionnaire after 7 months with respect to complications, the effectiveness of the operation and its influence on their quality of life. Women with urinary stress incontinence in addition to cystocele (62.5%) underwent suburethral mesh placement with the anterior mesh-arms used like a transobturator sling. RESULTS: Recurrence of stage 1 cystoceles were seen in 9.6% of patients but no recurrence of symptomatic cystocele was observed. Mesh erosion of the central anterior vaginal wall appeared in 5.9%. Three revisions but no mesh explantation became necessary. Urinary stress incontinence was cured in 83.3%, while it improved in 9.3%. Urge incontinence was cured in 28.6% of patients and improved in 17.5%. De novo urge incontinence occurred four times and de novo urinary stress incontinence was found in three patients. Among sexually active women, 27% reported improved intercourse, while 24.3% reported a change for the worse. Quality of life improved in 81.9%, and 95.8% would undergo the procedure again. CONCLUSION: Anterior transobturator mesh is a safe method to treat cystocele with or without stress urinary incontinence and yields good initial results.     

Repair of recurrent vaginal vault prolapse using sacrospinous ligament fixation with mesh interposition and reinforcement

OBJECTIVE: Our goal was to study the efficacy of performing the repeated sacrospinous ligament fixation with mesh interposition and reinforcement in women with recurrent vaginal vault prolapse. MATERIALS AND METHODS: Fifteen consecutive patients with symptomatic severe vaginal vault or uterus prolapse after previous sacrospinous ligament fixation were enrolled. The sacrospinous ligament fixation was performed with a mesh interposition between sacrospinous ligament complex and vaginal apex. The mesh was extended to anterior and posterior vaginal wall for the repair of concurrent cystocele and rectocele, if indicated. The surgical results and complications were evaluated. The prolapse evaluation was performed according to International Continence Society (ICS) ordinal stages of pelvic organ prolapse. RESULTS: The mean age was 55 years. The mean follow-up was 2.9 years (range 1.0-5.5 years). Repeated sacrospinous ligament fixation was performed for all patients. Eleven were performed unilaterally to the right and four to the left. The average time for sacrospinous fixation was 20 min. The average blood loss for sacrospinous fixation was 75 ml. No major complication except one accidental rectotomy was observed. It was repaired intraoperatively without sequel. The concurrent pelvic surgeries included vaginal total hysterectomies, anterior colporrhaphies, posterior colporrhaphies, and tension-free vaginal tape procedures. No recurrence of apical prolapse was observed. However, two patients developed stage I prolapse on anterior vaginal wall (cystocele) and required no further repair. Minor postoperative complications were observed. CONCLUSION: Repeated sacrospinous ligament fixation with mesh interposition and reinforcement is a safe and effective procedure for the correction of recurrent vault prolapse. The extended implanted mesh can be used for the repair of concurrent cystorectocele effectively. A long-term follow-up is necessary to detect any late complication.     

The preliminary evaluation of surgical treatment of pelvic organ prolapse with polypropylene mesh by double transobturator approch technique (double TOT)

OBJECTIVES: The aim of this study was to evaluate preliminary results of a new, simple surgical technique with the use of polypropylene mesh (double TOT) used for the treatment of cystocele associated / not associated with urinary incontinence in females. MATERIAL AND METHODS: 19 women, aged 49-76, BMI 24-40, with cystocele associated or not with urinary incontinence, were operated on at the 1st Department of Obstetrics and Gynaecology in Warsaw, using double TOT technique. In this technique, described by Theobald, the trapezoidal polypropylene four-arm vaginal mesh is inserted through the obturator foramens from the outside to the inside and is positioned without tension under the urethra. RESULTS: 9 patients qualified for the operation were grade III in POPQA, 5--grade IV, 4--grade II and one patient grade I. 16 women had additional operations performed beside double TOT. The duration of operations varied from 30 to 135 minutes. No intra-operative complications were observed. There were no complications in short 6 weeks follow-up. CONCLUSIONS: Double Transobturator technique is simple, easy to learn, safe and, at the same time, efficient surgical procedure for the treatment of pelvic organ prolapse and female urinary stress incontinence. The results of longer follow-up on a larger group of operated patients will be more accurate.     

Transabdominal partial vaginal resection and infundibulopelvic colpopexy for posthysterectomy vaginal vault prolapse

OBJECTIVE: To assess abdominal partial resection of the vagina and infundibulopelvic colpopexy in women with posthysterectomy vaginal vault prolapse. STUDY DESIGN: After laparotomy, the elongated vaginal wall was resected, and sutures with absorbable surgical suture material were used to close the vagina, which was suspended by the sutures placed into the infundibulopelvic, sacrouterine and round ligaments. The surgical site was covered and elevated by the overlapping peritoneum. Over 15 years (July 1990-July 2005), the procedure was performed on 74 women (aged 28-84 years; mean age at the time of surgery, 58.5 years) due to vaginal eversion developing after abdominal (24 cases) or vaginal (39) hysterectomy, supravaginal amputation (4) or abdominal colpopexy (7). RESULTS: Perioperative complications included entry into the bladder (2.6%) and transitory voiding difficulty (6.7%). There was no bowel injury. Patients were followed annually by pelvic examination; in 1 of 74 patients, vaginal eversion partly recurred, and a repeat colpopexy was performed. All the patients have a functional vagina without urinary incontinence, pelvic pain or other pelvic discomfort. CONCLUSION: This safe and reliable intervention should be performed only by gynecologists trained in surgery on the pelvic retroperitoneum and parametrium.     

Laparoscopic promontal fixation: assessment of 100 cases

AIM: Aim of the study is to evaluate long term results of 100 patients treated laparoscopically to repair genital prolapse and urinary incontinence. METHODS: A retrospective review analysis of 100 women, who underwent laparoscopic genital prolapse repair at Primary Referral University Hospital in Clermont-Ferrand. Patients characteristics, preoperatory exams, intraoperative, postoperative and outpatient clinic data were collected and analyzed. RESULTS: The mean operative time was 172 minutes. One laparotomy conversion was required, due to a technical problem. The mean hospitalization stay was 4.7 days. Two patients required a reintervention during their hospitalization stay, due to a complication. All the patients were reviewed during the 6 months later the intervention. The follow-up is between 6 months and 3 years. The average degree of cystocele and hysterocele was ameliorated from stage 3 to stage 0, the average stage of rectocele was ameliorated from stage 2 to stage 0, finally the average stage of vault prolapse was ameliorated from stage 1 to stage 0. The incidence of genuine stress incontinence was 47% in the preoperative time and only 4% at the long follow-up. We had a total 4% rate of mesh vaginal erosion. CONCLUSIONS: The laparoscopic sacrocolpopexy is an effective and safe technique to repair the major pelvic prolapses.     

The vaginal patch plastron for vaginal cure of cystocele. Preliminary results for 47 patients

OBJECTIVE: We describe a new surgical technique (the vaginal plastron) for the treatment of cystocele by the vaginal route. The technique is based on bladder support by a vaginal strip (6-8cm in length and 4cm in width), isolated from the anterior colpocele, left attached to the bladder, associated with a suspension of this strip by its fixation to the tendinous arch of the pelvic fascia by six lateral sutures (three on each side of the plastron). The vaginal plastron is then covered by tucking it under the anterior colporraphy. STUDY DESIGN: We evaluated the short-term functional and anatomical results of the first 47 patients to have undergone this treatment between October 1997 and June 1998. The average age of the patients was 69 years. Cystoceles were associated with urinary stress incontinence in 38.3% of cases, with hysterocele or prolapse of the vaginal dome in 87.2% of cases, with an elytrocele in 19.1% of cases and a rectocele in 70.2% of cases. Of the 45 patients having had a hysterectomy combined with the vaginal plastron or in their past history, 44 (99.77%) had a Richter sacro-spino-fixation and 17 (38%) had a Campbell procedure combined with the vaginal plastron. All patients underwent a posterior perineorraphy with myorraphy of the elevators. RESULTS: Average follow-up was 16.4 months with extremes of 6-26 months and concerned 46 patients (one patient was unavailable). Ninety-three percent of the cystoceles were considered treated. One case of imperfect anatomical outcome was noted (persistence of stage 1 cystocele in one patient) together with two other cases of failure of the treatment of cystocele (relapse to stage 2 cystocele). CONCLUSION: Proposed as a curative treatment of cystocele and combined with the Richter fixation, the plastron provides a surgical solution to the problem of cystocele relapse arising after vaginal treatment of prolapse by sacro-spino-fixation alone (10-20% according to Richter). Short-term results are encouraging, however, medium- to long-term results (36-60 months) are necessary in order confirm the usefulness of this surgical technique.     

Management of complications of mesh surgery

Polypropylene mesh (PPM) has been used in abdominal sacrocoplopexies since the 1990's however following a patient led campaign controversy surrounds its use incontinence procedures, midurethral slings (MUS) and vaginal mesh prolapse repairs. The complication rates following mesh surgery may be as high as 10%. NHS England paused the vaginal insertion of polypropylene mesh in July 2018 pending a review by Baroness Cumberledge. This review will outline the assessment and basic management of complications of polypropylene mesh. This is a relatively new area of urogynaecological practice which non-specialist obstetric and gynaecology clinicians and GPs need to be aware of. Symptoms which could be due to mesh complications are vaginal discharge or bleeding, recurrent urinary tract infection, haematuria, dyspareunia and pelvic pain. Women presenting with any of the above symptoms should be asked if they have had previous surgery for stress incontinence or prolapse. The women may not recall having mesh inserted and may use different terms “sling” “net” or “tape”. They should be examined to both look and feel for PPM. Mesh complications should be managed by the designated mesh centres which are listed on the BAUS and BSUG websites. All mesh complications should be reported to the Medicines & Healthcare products Regulatory Agency (MHRA) by the yellow card system. All mesh complications requiring further surgical intervention should be recorded on the British Society of Urogynaecology (BSUG) national database.     

Laparoscopic Burch colposuspension and the tension-free vaginal tape procedure

PURPOSE OF REVIEW: Minimally invasive procedures for urinary incontinence and pelvic organ prolapse have gained increasing popularity in the past decade. The advantages of minimal access through laparoscopic and vaginal routes include smaller incisions, shortened hospital stay, decreased analgesia, rapid recovery and rapid return to work. The laparoscopic Burch colposuspension and the tension-free vaginal tape procedure were at the forefront of minimal access antiincontinence procedures. The most recent and significant publications regarding laparoscopic Burch colposuspension and tension-free vaginal tape procedure are highlighted in this article. RECENT FINDINGS: The laparoscopic Burch is time-consuming and requires a steep learning curve in laparoscopic suturing, thwarting its adoption and staying power. The advantages and success of the retropubic midurethral sling procedures such as tension-free vaginal tape have largely replaced all other antiincontinence procedures and have ignited the development and adoption of transobturator midurethral sling procedures and vaginal 'kit' procedures for pelvic organ prolapse. SUMMARY: Clinical trials show that laparoscopic Burch cure rates are equal or inferior to tension-free vaginal tape cure rates. Publications regarding laparoscopic Burch colposuspension have tapered significantly in the past year, which may represent the ebb of its utilization. Tension-free vaginal tape and other midurethral sling procedures may become the new 'gold standard' antiincontinence therapy.