Surgical management of lower urinary mesh perforation after mid-urethral polypropylene mesh sling: mesh excision, urinary tract reconstruction and concomitant pubovaginal sling with autologous rectus fascia

Introduction and hypothesis

We present our management of lower urinary tract (LUT) mesh perforation after mid-urethral polypropylene mesh sling using a novel combination of surgical techniques including total or near total mesh excision, urinary tract reconstruction, and concomitant pubovaginal sling with autologous rectus fascia in a single operation.

Methods

We retrospectively reviewed the medical records of 189 patients undergoing transvaginal removal of polypropylene mesh from the lower urinary tract or vagina. The focus of this study is 21 patients with LUT mesh perforation after mid-urethral polypropylene mesh sling. We excluded patients with LUT mesh perforation from prolapse kits (n?=?4) or sutures (n?=?11), or mesh that was removed because of isolated vaginal wall exposure without concomitant LUT perforation (n?=?164).

Results

Twenty-one patients underwent surgical removal of mesh through a transvaginal approach or combined transvaginal/abdominal approaches. The location of the perforation was the urethra in 14 and the bladder in 7. The mean follow-up was 22 months. There were no major intraoperative complications. All patients had complete resolution of the mesh complication and the primary symptom. Of the patients with urethral perforation, continence was achieved in 10 out of 14 (71.5 %). Of the patients with bladder perforation, continence was achieved in all 7.

Conclusions

Total or near total removal of lower urinary tract (LUT) mesh perforation after mid-urethral polypropylene mesh sling can completely resolve LUT mesh perforation in a single operation. A concomitant pubovaginal sling can be safely performed in efforts to treat existing SUI or avoid future surgery for SUI.     

Repair of complete urethral disruption due to synthetic sling complication

Introduction and hypothesis

Urethral complications due to synthetic midurethral slings are rare. Possible causes may include unrecognized trocar injury, mesh implantation despite recognized injury, mesh contamination leading to inflammation and delayed perforation, and excessive sling tension. There is no consensus as to the surgical management of urethral complications with regard to how much mesh should be excised, whether an interposition flap should be used, and whether a pubovaginal sling should be placed at the time of surgery. The purpose of this video is to present a technique of repairing complete urethral disruption due to a synthetic midurethral sling complication.

Methods

In this video, we demonstrate the steps to perform primary end-to-end urethral reconstruction for repairing complete urethral disruption. Any residual synthetic mesh must first be excised, after which the anastomosis may be completed.

Results

Complete urethral disruption is a rare complication of synthetic midurethral sling surgery that can be repaired primarily with good results.

Conclusions

There is no consensus regarding surgical management of urethral complications caused by synthetic midurethral slings, and thus an individualized approach should be used based on patient presentation and surgeon expertise.     

Do urodynamic parameters predict persistent postoperative stress incontinence after midurethral sling? A systematic review

Introduction and hypothesis

It is unclear whether preoperative urodynamic study (UDS) values are predictive of outcomes after midurethral sling.

Materials and methods

We systematically reviewed multiple databases from January 1989 to October 2011 for English-language studies correlating UDS data with postoperative outcomes after midurethral slings. We performed random effects model meta-analyses, as indicated. Relative risk (RR) ratios for the outcome of stress urinary incontinence (SUI) cure were calculated using high maximum urethral closure pressure (MUCP) and Valsalva leak point pressure (VLPP) values as the reference group.

Results

High preoperative MUCP was associated with cure after retropubic [RR 0.67; 95% confidence interval (CI) 0.47–0.97)] and transobturator slings (RR 0.65; 95% CI 0.49–0.90). High preoperative VLPP was also associated with cure after retropubic sling (RR 0.89; 95% CI 0.82–0.96), but this relationship did not achieve statistical significance for cure after transobturator sling (RR 0.86; 95% CI 0.74–1.00).

Conclusions

Preoperative MUCP and VLPP values may add insight into postoperative outcomes after surgical treatment for SUI.     

Treating stress urinary incontinence in female patients with neuropathic bladder: the value of the autologous fascia rectus sling

Objective/background

The aim of this study was to evaluate the efficacy of the autologous fascia rectus sling in treating stress urinary incontinence in female patients with neuropathic bladder. Furthermore, correlations between preoperative parameters and outcome were evaluated.

Methods and design

We retrospectively reviewed operative logs from a single surgeon (EM) of 33 female patients with neuropathic bladder treated over a 3-year period for stress urinary incontinence by implantation of an autologous fascia rectus sling. Efficacy was evaluated objectively in terms of the number of pads used per day, while subjective patient satisfaction was also recorded using a global assessment question. Possible correlations between age, obesity, preoperative Valsalva leak point pressure and incontinence severity and outcome were investigated using univariate analysis.

Outcome measures and results

The mean follow-up time was 52?months, while the mean age of the patients was 37?years. Causes of neuropathic bladder were myelomeningocele in 21 (63.63?%) and spinal cord injury in 12 patients (36.36?%). A total of 30 patients were successfully treated and satisfied with the outcome of the operation (90.9?%). Twenty-five patients (75.75?%) were totally dry, while 5 patients (15.15?%) had markedly improved but still required one pad per day. The complication rate was 15.20?%. Univariate analysis failed to show any correlation between the final outcome and the checked parameters.

Conclusion

The free autologous rectus fascia sling is a highly effective technique for the treatment of female stress incontinence in patients with neuropathic bladder, while the morbidity is mild.     

Dynamic assessment of sling function on transperineal ultrasound: does it correlate with outcomes 1 year following surgery?

Introduction and hypothesis

To correlate dynamic assessment of sling function using 2D and 3D transperineal ultrasound with outcomes following transobturator sling surgery.

Methods

This is an unmatched case–control study of 100 patients who underwent transobturator sling surgery at our center between 2009 and 2012. Group A (n?=?50) patients had successful outcomes and group B (n?=?50) patients had suboptimal outcomes 1 year following surgery. The patients underwent 2D dynamic and 3D transperineal ultrasound. The two groups were compared with regard to the deformability of the sling on Valsalva, the concordance of urethral movement with the sling, and location of the sling.

Results

When compared with group B, group A had a significantly greater number of patients in whom the sling deformed at Valsalva (flat at rest, curving into a c-shape at Valsalva), the urethral movement was concordant with the sling and the sling had a midurethral location (p?<?0.0001). In all 17 patients in group B in whom the urethra moved in a concordant manner with the sling (34%), the sling did not deform on Valsalva maneuver and was located proximally. In all 15 patients in group A in whom the sling remained either flat or curved (30%), the urethra moved concordant with the sling and the sling was in midurethral location.

Conclusions

On 2D and 3D transperineal ultrasound, the best outcomes following transobturator sling surgery are associated with concordance of urethral movement with the sling, midurethral location, and deformability of the sling on dynamic assessment.

     

A prospective study of transobturator tape as treatment for stress urinary incontinence after transvaginal mesh repair

Introduction and hypothesis

The transobturator suburethral sling is a common surgical treatment for stress urinary incontinence (SUI). In patients with incontinence after trocar-guided transvaginal mesh repair (Prolift?), data on outcome remain limited. In the present study, we hypothesized that transobturator tape in such cases is assumed to be as effective as surgery alone.

Methods

This was a prospective analysis of outcomes of transobturator slings in women who had undergone transvaginal mesh repair and in those who underwent sling surgery alone (controls). Objective cure was defined as the absence of urinary leakage during the stress test at filling cystometry and a negative cough test during pelvic examination. The success rates were evaluated 3–6 months postoperatively.

Results

One hundred women were recruited for the study. Compared to the control group, women after transvaginal mesh repair had a significantly lower objective success rate (62 vs 86 %, p?=?0.005) and poorer bladder neck mobility (0.5?±?0.8 vs 1.1?±?0.5 cm, p?=?0.001).

Conclusions

The transobturator sling has lower objective success rate in women after transvaginal mesh that may be due to decreased bladder neck mobility. Patients with post-mesh repair SUI who opt for sling surgery should be informed of these less satisfactory outcomes during preoperative counseling.     

Road to recovery after transvaginal surgery for urethral mesh perforation: evaluation of outcomes and subsequent procedures

Introduction and hypothesis

Urethral injury resulting from transvaginal mesh slings is a rare complication with an estimated incidence of <1%. Our objective was to review the surgical management and functional outcomes of women presenting with urethral mesh perforation following midurethral sling (MUS) placement.

Methods

This was a retrospective multicenter review of women who from January 2011 to March 2016 at two institutions underwent mesh sling excision for urethral perforation with Female Pelvic Medicine and Reconstructive Surgery fellowship-trained surgeons. Data comprising preoperative symptoms, operative details, and postoperative outcomes were collected by telephone (n?13) or based on their last follow-up appointment.

Results obtained

Nineteen women underwent transvaginal sling excision for urethral mesh perforation. Eight (42%) patients had undergone previous sling revision surgery. Sixty percent of women had resolution of their pelvic pain postoperatively. At follow-up, 92% reported urinary incontinence (UI), and three had undergone five additional procedures for vaginal prolapse mesh exposure (n?1), incontinence (onabotulinum toxin injection n?1, rectus fascia autologous sling n?1), prolapse (colpopexy n?1), and pain (trigger-point injection n?1). Patient global impression of improvement data was available for 13 patients, of whom seven (54%) rated their postoperative condition as Very much better or Much better.

Conclusions

The management of urethral mesh perforation is complex. Most women reported resolution of their pelvic pain and a high rate of satisfaction with their postoperative condition despite high rates of incontinence.

     

Transabdominal sacrocolpopexy with autologous rectus fascia graft

Introduction and hypothesis

Extrusion and infection are potential postoperative complications when using synthetic mesh for abdominal sacrocolpopexy. Long-term follow-up in the Colpopexy and Urinary Reduction Efforts (CARE) trial revealed an estimated 9.9 % risk of mesh extrusion. There are 26 reports of spondylodiscitis after sacrocolpopexy with synthetic mesh. These surgical risks may be decreased by using autologous fascia. To date, there have been no reports of extrusion or spondylodiscitis after using autologous fascia for sacrocolpopexy.

Methods

This video demonstrates transabdominal sacrocolpopexy with an autologous rectus fascia graft. A 76-year-old woman with symptomatic stage 3 prolapse also had a history of diverticulitis and sigmoid abscess requiring sigmoid colectomy with end colostomy and incidental left ureteral transection with subsequent left nephrostomy tube placement. She presented for colostomy reversal, ureteral reimplantation, and prolapse repair. Given the need for concomitant colon and ureteral reconstruction, the risk of infection was potentially higher if synthetic mesh were used. The patient therefore underwent transabdominal sacrocolpopexy with autologous rectus fascia graft.

Results

At 4 months’ follow-up the patient reported resolution of her symptoms and on examination she had no pelvic organ prolapse.

Conclusion

Transabdominal sacrocolpopexy using autologous rectus fascia graft is a feasible option, especially in cases in which infection and synthetic mesh extrusion risks are potentially higher.

     

Prolapse surgery in octogenarians: are we pushing the limits too far?

Purpose

To report our experience with pelvic reconstructive surgery with transobturator mesh implants in elderly women.

Materials and methods

A total of 32 women aged >75 years with pelvic organ prolapse receiving anterior and/or posterior repair using transobturator mesh implants were included. Concomitant mid-urethral sling procedure was performed in 78 % women. Postoperative outcome data and quality-of-life measurements were recorded prospectively. Patients were followed for up to 24 months.

Results

Mean age at surgery was 82.8 ± 3.1 years. A total of 15 anterior repairs, 8 posterior repairs, and 9 posterior and anterior repairs were performed using transobturator mesh implants. Concomitant synthetic mid-urethral transobturator sling procedure was performed in 25 women (78 %). Mean operating time was 47.2 ± 22.3 min, and the mean hospitalization period was 5.9 ± 1.6 days. There were no systemic complications related to anesthesia or surgery. Two patients required intraoperative bladder suturing due to iatrogenic bladder lesion. There were no rectal injuries, no bleeding necessitating transfusion, voiding dysfunction, or erosions of synthetic implants. Pelvic floor testing at 24 months postoperatively showed 15 % of the patients presenting with stage II vaginal wall prolapse. Further, quality-of-life parameters, as measured by SF-36 questionnaire, were improved compared to baseline values.

Conclusions

Pelvic reconstructive surgery in elderly women is safe and enhances the quality of life. However, special caution should be paid to risks and benefits of such surgery in this patient population.     

Indications and risk factors for midurethral sling revision

Introduction and hypothesis

To determine the indications and risk factors for needing midurethral sling revision in a cohort of women undergoing midurethral sling placement.

Methods

This was a case–control study of all women undergoing midurethral sling placement for stress urinary incontinence (SUI) between January 2003 and December 2013. Cases were patients who underwent midurethral sling placement followed by sling revision (incision, partial or complete excision). Controls were patients who underwent sling placement only. Once all subjects had been identified, the electronic medical record was queried for demographic and perioperative and postoperative data.

Results

Of 3,307 women who underwent sling placement, 89 (2.7 %, 95 % CI 1.9 – 3.4) underwent sling revision for one or more of the following indications: urinary retention (43.8 %), voiding dysfunction (42.7 %), recurrent urinary tract infection (20.2 %), mesh erosion (21.3 %), vaginal pain/dyspareunia (7.9 %), and groin pain (3.4 %). The median time from the index to the revision surgery was 7.8 months (2.3 – 17.9 months), but was significantly shorter in patients with urinary retention. The type of sling placed (retropubic or transobturator) was not associated with indication for revision. Patients who underwent revision surgery were more likely to have had previous SUI surgery (adjusted odds ratio 4.4, 95 % CI 1.7 – 6.5) and to have undergone concomitant vaginal apical suspension (adjusted odds ratio 2.4, 95 % CI 1.4 – 4.5).

Conclusions

The rate of sling revision after midurethral sling placement was 2.7 %. Urinary retention and voiding dysfunction were the most common indications. Patients with a history of previous SUI surgery and concomitant apical suspension at the time of sling placement may be at higher risk of requiring revision surgery.

     

Traitement de l’incontinence urinaire post-opératoire de l’homme par bandelette sous urétrale: A propos de 16 cas

Objective

To evaluate our preliminary results of the male sling procedure for treatment of urinary stress incontinence following prostate surgery using the modified Comiter procedure (without bony fixation).

Material and Methods

Between January 2005 and December 2006, 16 patients underwent a male sling procedure for treatment of urinary stress incontinence developing after prostate surgery. A polypropylene mesh was placed over the bulbar portion of the urethra and tied with nylon sutures to the periosteum of the ischio-pubic rami. The evaluation of the severity of the incontinence was based on physical examination and the number of pads used per day. The patients were followed up one month after the intervention and then in three-month intervals.

Results

After a mean follow-up of 18 months 11 patients were dry and did not require any protection, while a significant improvement was noted in 3 patients. The procedure had failed in one patient who was suffering from severe incontinence at presentation. In one patient the sling caused an infection and had to be removed. This patient was excluded from the evaluation of the study. No cases of pubic pain, osteitis or urethral erosion were encountered.

Conclusion

Our modification of the male sling procedure according to Comiter seems to provide satisfactory results which are comparable to the original technique. At the same time it is cheaper compared to other kits in the market.     

Bone-anchored suburethral sling: Surgical technique and outcomes

The gold standard treatment for stress urinary incontinence (SUI) is the autologous rectus fascia pubovaginal sling. Although successful, it is associated with increased morbidity related to the graft harvest. Because of this, less invasive techniques were developed, including the retropubic and transobturator midurethral sling and the bone-anchored sling (BAS). Early reported outcome failures and concern for bone-anchored-related complications caused BAS to fall out of favor. However, technique modifications and use of a more durable graft or mesh have proven that the transvaginal placement of BAS is actually safe and effective in treating patients with SUI. Further, recent evidence suggests that the bone-anchored sling may be a reasonable option for treatment of patients with moderate to severe and/or recurrent SUI.     

Predictors of vaginal mesh exposure after midurethral sling placement: a case–control study

Introduction and hypothesis

Female stress urinary incontinence is highly prevalent, and synthetic midurethral sling placement is the most common type of anti-incontinence surgery performed in the USA. We aimed to identify risk factors associated with surgery used to treated vaginal mesh exposure after midurethral sling placement for stress urinary incontinence.

Methods

We identified women who underwent anti-incontinence procedures from January 2002 through December 2012. Patients with vaginal mesh exposure undergoing surgical repair after midurethral sling placement were compared with a control group without mesh exposure in a 1:3 ratio. Patients with ObTape sling placement (Mentor Corporation) were excluded. Logistic regression models were used to evaluate associations between clinical risk factors and vaginal mesh exposure.

Results

Overall, 2,123 patients underwent primary sling placement, with 27 (1.3 %) having vaginal mesh exposure necessitating surgical repair. Patients with mesh exposure were more likely to have undergone previous bariatric surgery (P?=?0.008), hemoglobin <13 g/dL (P?=?0.006), premenopausal status (P?=?0.008), age <50 years (P?=?0.001), and the retropubic approach to sling placement (P?=?0.03). Multivariate analysis identified these risk factors: previous bariatric surgery (odds ratio [OR], 7.0; 95 % CI, 1.1–61.4), retropubic approach (OR, 5.7; 95 % CI, 1.1–107.0), preoperative hemoglobin <13 g/dL (OR, 2.8; 95 % CI, 1.1–7.5), and premenopausal status (OR, 2.6; 95 % CI, 1.0–7.3). Among postmenopausal patients, those with mesh exposure were significantly more likely to receive preoperative estrogen therapy (OR, 12.4; 95 % CI, 2.7–57.8).

Conclusions

Previous bariatric surgery, retropubic approach, premenopausal status, and lower preoperative hemoglobin were associated with a significantly increased risk of surgery for vaginal mesh exposure after midurethral sling placement. Recognizing these factors can improve preoperative patient counseling.

     

De novo overactive bladder following midurethral sling procedures: a systematic review of the literature and meta-analysis

Introduction and hypothesis

De novo overactive bladder (OAB) is a known complication of midurethral sling surgery for the treatment of stress urinary incontinence. To date, differences in the incidence of de novo OAB following the use of different types of midurethral sling remain relatively unknown. The purpose of the present systematic review was to evaluate this incidence and summarize current evidence.

Methods

We systematically searched the literature using the MEDLINE, Embase, Scopus, ClinicalTrials.gov, LILACS and Cochrane Central Register of Controlled Trials databases as well as the grey literature and references from the electronically retrieved articles. For comparisons of proportions, we used the chi-squared test. All reported analyses were designed as two-tailed. Statistical significance was set at p < 0.05.

Results

Finally, 32 studies were included in this systematic review, with a total of 3,139 patients who had undergone midurethral sling procedures that included transobturator tapes (TOT), retropubic tapes (TVT) or single-incision tapes (mini-slings). The overall incidence of de novo OAB was 11.5% in nonrandomized studies (280 women) and 6.4% in randomized studies (50 women). In relation to the type of midurethral sling, the incidence of de novo OAB was 9.7% for mini-slings, 11.2% for TVT-O, 8.7% for TOT and 9.8% for TVTs. The chi-squared test did not reveal significant differences (p = 0.58).

Conclusions

Current evidence suggests that the overall incidence of de novo OAB following midurethral sling procedures is approximately 9%. There is not enough evidence to support differences in the effects of the different types of sling with regard to this particular postoperative complication.

     

A comparative study of a single-incision sling and a transobturator sling: clinical efficacy and urodynamic changes

Introduction

In this retrospective study, a comparison is made of the clinical efficacy of two stress urinary incontinence treatment apparatuses, a single-incision sling and a transobturator sling.

Methods

Eighty-five (single-incision n?=?43, transobturator n?=?42) consecutive patients were included in this study. Clinical outcomes were assessed by the cough stress test (CST), the pad test, the Impact Questionnaire-Short Form (IIQ-7), the Urogenital Distress Inventory six-item questionnaire (UDI-6), the Sexual Questionnaire-SF (PIS-Q), the pain score, and the postoperative changes in urodynamic parameters. A comparison of the 1-year follow-up data is presented.

Results

Three months post-surgery, 81.8% of the single-incision sling group and 74.4% of the transobturator sling group had a negative cough test and a dry pad test. One year after surgery, significantly decreasing UDI-6, IIQ-7, and increasing PIS-Q scores were observed in both groups, while the complication rates remained similar. Postoperatively, the single-incision sling group seems to show a greater improvement in UDI-6 score, require less operation time, and experience less blood loss, less postoperative pain, and a smaller decrease in maximal urethral closure pressure (MUCP).

Conclusions

These results suggest that the single-incision sling and the transobturator sling are equally as effective and safe for the treatment of stress incontinence, as evaluated during the 1-year follow-up. The insertion of a single-incision sling seems to be less painful than that of a conventional sling. One year after surgery, the MUCP and mean flow rate of the transobturator sling group had significantly decreased compared with that of the single-incision sling group.     

Evaluation of the local carcinogenic potential of mesh used in the treatment of female stress urinary incontinence

Introduction and hypothesis

To evaluate the carcinogenic potential of implanted synthetic mesh midurethral slings in the treatment of female stress urinary incontinence.

Methods

We identified female patients undergoing implantation of mesh materials for stress urinary incontinence at our institution from 1 January 2002 to 31 December 2012. This was accomplished by querying the medical records for CPT code 57288 (“sling operation for stress incontinence”) and a subsequent chart review to identify patients who underwent synthetic mesh sling placement. Medical records were then evaluated for the documentation of bladder, urethral, vaginal, cervical, uterine or ovarian cancers via the International Classification of Disease (ninth edition) coding. A chart review of patients with a cancer diagnosis was performed for verification of the diagnosis and evaluation of the temporal relationship with sling placement.

Results

During the study period, 2,474 patients underwent polypropylene midurethral sling placement. The median age was 57 years (IQR 47, 69) and the median follow-up was 60 months (IQR 23.3, 94.9). Overall, 51 patients also had a cancer diagnosis (8 bladder cancers, 7 vaginal malignancies, 8 ovarian carcinomas, 26 endometrial cancers, 2 cervical malignancies); however, only 2 cancers (0.08 %, 2 out of 2,474) developed following sling placement (a vaginal melanoma 3 years after sling placement and an ovarian tumor 1 year after sling placement). No cases of sarcoma formation, bladder, urethral or squamous cell carcinomas were identified.

Conclusions

With a median follow-up of 5 years after synthetic midurethral sling placement, development of pelvic malignancy was rare (0.08 %) and unlikely to be secondary to foreign body reaction from the implanted material.

     

Carcinogenic potential of polypropylene mid-urethral slings: what do we know so far?

Introduction and hypothesis

Polypropylene (PP) mesh has come under increased scrutiny owing to previous FDA safety communications regarding the risks of mesh in trans-vaginal surgery and ensuing class action litigation for post-operative complications. Additional concerns have been raised regarding a possible link between implanted PP mesh and the long-term development of malignancy. Until recently, no research was specifically committed to the exploration of such a link. Our objective was to provide an overview of the recent literature focusing on any association between the use of PP mesh for midurethral sling procedures and the development of malignancy.

Methods

Multiple online research databases were searched for information related to any possible carcinogenic potential of PP mesh.

Results

There was no increased incidence in the development of malignancy after midurethral sling procedures using PP mesh in any of the studies.

Conclusion

Given the scarcity of evidence suggesting otherwise, the likelihood of PP mesh causing malignancy is exceptionally low. However, with few studies and an unknown latency period between exposure and diagnosis, more observational data would prove useful to exclude causality.

     

Comparison between the retropubic and transobturator approaches in the treatment of female stress urinary incontinence: a systematic review and meta-analysis of effectiveness and complications

Objective

This study aimed to compare the effectiveness and complications between the retropubic and transobturator approaches for the treatment of female stress urinary incontinence (SUI) by conducting a systematic review.

Materials and Methods

We selected all randomized controlled trials (RCTs) that compared retropubic and transobturator sling placements for treatment of SUI. We estimated pooled odds ratios and 95% confidence intervals for intraoperative and postoperative outcomes and complications.

Results

Six hundred twelve studies that compared retropubic and transobturator approaches to midurethral sling placement were identified, of which 16 were included in our research. Our study was based on results from 2646 women. We performed a subgroup analysis to compare outcomes and complications between the two approaches. The evidence to support the superior approach that leads to better objective/subjective cure rate was insufficient. The transobturator approach was associated with lower risks of bladder perforation (odds ratio (OR) 0.17, 95% confidence interval (CI) 0.09-0.32), retropubic/vaginal hematoma (OR 0.32, 95% CI 0.16-0.63), and long-term voiding dysfunction (OR 0.32, 95% CI 0.17-0.61). However, the risk of thigh/groin pain seemed higher in the transobturator group (OR 2.53, 95% CI 1.72-3.72). We found no statistically significant differences in the risks of other complications between the two approaches.

Conclusions

This meta-analysis shows analogical objective and subjective cure rates between the retropubic and transobturator approaches to midurethral sling placement. The transobturator approach was associated with lower risks of several complications. However, good-quality studies with long-term follow-ups are warranted for further research.