Tension-free vaginal mesh repair for recurrence of pelvic organ prolapse after vaginal mesh procedures: a case report

A 61-year-old woman presented with the chief complaint of a vaginal bulge for 2 years. She had undergone two operations for pelvic organ prolapse. The initial procedure was the Manchester procedure and posterior colporrhaphy, and the second was a vaginal repair with mesh for recurrent rectocele 3 years after the initial surgery. She noticed the vaginal bulge shortly after the second surgery. A gynecological examination revealed a stage III rectocele associated with a 2 cm, firm mass at the posterior vaginal wall. T2-weighted magnetic resonance imaging showed a 2 × 3 cm high-intensity mass located between the vaginal wall and rectum. The recurrent rectocele might have been caused by incomplete support from the mesh, which was not fixed in the vaginal wall, resulting in formation of a mass. The patient underwent complete mesh removal and tension-free vaginal mesh-posterior surgery for the rectocele. The excised mesh had shrunk from a 7 × 5 cm rectangle mesh preoperatively into a firm 2 × 2 × 3 cm mass. No recurrence has been seen for 18 months postoperatively.     

Obturator neuropathy: an adverse outcome of a trans-obturator vaginal mesh to repair pelvic organ prolapse

We report a case of obturator neuropathy induced by trans-obturator vaginal mesh surgery for symptomatic cystocele. Initial electromyography excluded genito-femoral and pudendal nerve deficiency. Typical clinical arguments for severe obturator neuropathy at physical examination led to vaginal revision surgery with hemi-resection of the mesh to the ischio-pubic branch. This fully relieved obturator-induced pain and reversed adductor muscle motor deficiency.     

Long-term outcome after transvaginal mesh repair of pelvic organ prolapse

Introduction and hypothesis

The aim of this study was to report long-term subjective and objective outcomes after the transvaginal mesh (TVM) procedure in long-term. Possible late-onset complications were of particular interest.

Methods

This was a retrospective analysis of TVM performed using Prolift? transvaginal mesh measuring subjective outcome using validated questionnaires. Objective outcome was assessed using the Pelvic Organ Prolapse Quantification (POP-Q) system using two definitions: POP-Q stage?≤?1, and vaginal wall prolapse at or above the hymen or vaginal apex not descending below the upper third of the vagina. Complications were reported with the Prosthesis/Graft Complication Classification Code designed by the International Continence Society/International Urogynecological Association (ICS/IUGA).

Results

Of 195 patients, 161 (82.6 %) participated this study after a median of 7 years. The scores in questionnaires evaluating urinary (UI) or anal incontinence and constipation or pelvic floor symptoms were low, indicating favorable surgical outcomes. Altogether, 80.1 % of patients were satisfied with the procedure. Anatomical cure was 56.4 % and 69.3 % depending on the definition used. Reoperation due to POP in any compartment was performed in 16.2 % of patients. Mesh exposure rate was 23 %, most of these being asymptomatic and of late onset.

Conclusions

Outcome of the TVM procedure was satisfactory. Anatomical cure was inferior to subjective cure. Mesh exposure rate was high; most exposures observed in the long-term were of late onset and were asymptomatic.

     

Short-term outcome after transvaginal mesh repair of pelvic organ prolapse

The objective of this study is to report on short-term outcomes after pelvic organ prolapse repair using Prolift® transvaginal mesh. A 3-year multicenter prospective cohort study was performed in 28 centers. Assessment preoperatively and at 2 months postoperatively included the condition-specific pelvic organ prolapse quantification system (POP-Q) and a macroscopic inflammatory scale. Subjective outcome was measured using the urogenital distress inventory (UDI) and the incontinence impact questionnaire (IIQ-7). Surgical characteristics and adverse events during follow-up were registered in a separate protocol. The evaluation is based on the interim safety analysis and includes 2-month evaluations of 123 cases. Pelvic organ perforation occurred in four cases (3.2%), three bladder injuries and one case of rectal perforation. At the 2-month follow-up, there were two cases of mesh exposure, an increase of mild–moderate granuloma formation in the operated areas (P?P?相似文献   

The effect of pelvic organ prolapse repair on vaginal sensation

Introduction and hypothesis

The objective was to evaluate vaginal and clitoral sensation before and after robotic sacrocolpopexy for the repair of pelvic organ prolapse.

Methods

Twenty-two women, mean age 63 years (range 41–77), were admitted for robotic sacrocolpopexy repair of pelvic organ prolapse; 4 were lost to follow-up. Quantitative sensory thresholds for warm, cold, and vibratory sensations were measured at the vagina (anterior and posterior areas) and clitoris 1 day before and a mean of 12?±?4 months following surgery. Student’s paired t test was used to compare sensory thresholds before and after surgery.

Results

For the 18 women who completed follow-up, sensitivity was significantly higher after surgery (sensory threshold decreased) at the clitoral and vaginal regions, to cold and warm stimuli. In contrast, the vaginal and clitoral vibratory sensory thresholds did not change significantly following surgery.

Conclusion

The repair of pelvic organ prolapse by robotic sacrocolpopexy could potentially play a role in restoring clitoral and vaginal wall sensation. The effects of these sensory changes on sexual function and the quality of sexual life need further investigation.

     

Complications of transvaginal monofilament polypropylene mesh in pelvic organ prolapse repair

Introduction and hypothesis  This study aimed to document intraoperative and postoperative complications associated with the use of transvaginal polypropylene mesh in the repair of pelvic organ prolapse (POP). Methods  This is a retrospective review of 127 cases of transvaginal repair of POP using synthetic mesh. Results  Mean postoperative value (±SD) for pelvic organ prolapse quantification (POPQ) measurements Aa, Ap, and C were: −2.4 ± 1.1 (cm), −2.4 ± 0.9 (cm), and −7.7 ± 1.2 (cm), respectively. The difference between preoperative and postoperative values of these points was significant (p < 0.0001). Mesh erosion rate was 13/127 (10.2%) with significant correlation between mesh erosion and concurrent vaginal hysterectomy (p = 0.008). Combined anterior and posterior vaginal mesh surgery increased the risk of intraoperative bleeding and blood transfusion (p < 0.05). Conclusions  Concurrent vaginal hysterectomy is associated with increased risk of vaginal mesh erosion. Combined anterior and posterior vaginal mesh repair is an increased risk factor for intraoperative bleeding and blood transfusion.     

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.     

Transvaginal mesh technique for pelvic organ prolapse repair: mesh exposure management and risk factors

Prosthetic reinforcement in the surgical repair of pelvic prolapse by the vaginal approach is not devoid of tolerability-related problems such as vaginal erosion. The purposes of our study are to define the risk factors for exposure of the mesh material, to describe advances and to recommend a therapeutic strategy. Two hundred and seventy-seven patients undergoing surgery due to pelvic prolapse with transvaginal mesh technique were included in a continuous, retrospective study between January 2002 and December 2003. Thirty-four cases of mesh exposure were observed within the 2 months following surgery, which represents an incidence of 12.27%. All the patients were medically treated, nine of whom were found to have completely healed during the check-up performed at 2 months. In contrast, 25 patients required partial mesh exeresis. Risk factors of erosion were concomitant hysterectomy [OR=5.17 (p=10⁻³)] and inverted T colpotomy [OR=6.06 (p=10⁻²)]. Two technical guidelines can be defined from this study as regards the surgical procedure required in order to limit mesh exposure via the vaginal route. The uterus must be preserved, and the number and extent of colpotomies needed to insert the mesh must be limited.     

Postoperative urinary retention following vaginal mesh procedures for the treatment of pelvic organ prolapse

Introduction and hypothesis  

The objective of the study was to assess vaginal mesh procedures and patient characteristics that are associated with postoperative urinary retention (PUR) following pelvic reconstructive surgery.     

Synthetic mesh in the surgical repair of pelvic organ prolapse: current status and future directions

In light of the recent Food and Drug Administration public health notification regarding complications associated with transvaginally placed mesh for pelvic organ prolapse (POP) repair, we review recent literature to evaluate current outcomes and complication data, analyze the clinical need for mesh on the basis of genetic and biochemical etiologies of POP, and investigate trends of mesh use via an American Urological Association member survey. Mesh-based techniques show better anatomic results than traditional repair of anterior POP, but subjective outcomes are equivalent. Further research and Level I evidence are required before mesh-based repair of POP can be standardized. Adequate surgical training and patient selection should decrease complication rates.     

Basic procedures in tension‐free vaginal mesh operation for pelvic organ prolapse

A variety of tension‐free vaginal mesh (TVM) systems are available for surgical treatment of pelvic organ prolapse (POP). These include Prolift, Apogee/Perigee and Avaulta, all of which vary in terms of mesh size, shape and surgical technique to such an extent that they cannot truly be considered the same operation for the purpose of evaluating results. I began carrying out self‐made mesh cut out from Gynemesh PS in 2005. This system has four main characteristics: (i) the mesh is intended as a replacement for defective visceral pelvic fascia; (ii) it bridges between the left and right arcus tendineus fascia pelvis (white line, or ATFP); (iii) large‐size mesh is held in place by passing cannulas through the obturator fascia (anterior wall) or the sacrospinous ligament (SSL) to attach the arms of the mesh graft; and (iv) the bladder neck is preserved. The mesh that I have used since then has been essentially similar to the Prolift System, developed by a French TVM group, in terms of size and shape of its central portion. Mesh grafts used for the anterior wall are quite large, so skillful execution will provide sufficient room between the left and right ATFP in almost all cases. This video discusses the fundamental techniques necessary for skillful execution of the tension‐free vaginal mesh (TVM) procedure using the Prolift System, focusing on the following points: (i) surgical separation of the correct layers of the vaginal wall, and the area separated, and effective hemostasis; (ii) precise puncture technique, especially the second puncture for the anterior TVM (TVM‐A) procedure and the sacrospinous ligament (SSL) puncture in the posterior TVM (TVM‐P) procedure; (iii) firmly securing the mesh to the vaginal wall or cervical canal; and (iv) careful mesh placement and formation of a bridge between the left and right arcus tendineus fascia pelvis (ATFP). Proper separation of the vaginal wall layers, in particular, is crucial for preventing unnecessary blood loss and mesh erosion. The second puncture in the TVM‐A is the most important of the puncture maneuvers for the procedure. Penetrating the tough tissue near the ischial spine represents a significant challenge, and the SSL penetration in the TVM‐P procedure is unexpectedly difficult for those without sufficient experience. In order to become proficient, the surgeon must have hands‐on experience under the supervision of experts. Finally, TVM is a relatively new procedure, so one must master the fundamentals before gaining true proficiency. The technique does not call for virtuosity on the part of the surgeon, but key points must be mastered to reduce the risk of complications and recurrences. With repeated hands‐on training, surgical skills will gradually improve to the requisite level. This is a translated section of a video article originally published in Japanese as a DVD in the Audio‐Visual Journal Vol.15 No.15. 2009 by The Japanese Urological Association.     

Postoperative voiding function in patients undergoing tension-free vaginal mesh procedure for pelvic organ prolapse

Introduction and hypothesis  

We compared pre- and postoperative voiding function in patients with POP and assessed the efficacy of urodynamic studies in these cases.     

Sedation and local anaesthesia for vaginal pelvic floor repair of genital prolapse using mesh

In this study of the surgical repair of pelvic organ prolapse (POP), the vaginal pelvic floor repair with mesh (PFR-Mesh) procedure was used. The procedure is originally named TVM. All 55 patients in the series were operated upon under sedation and local anaesthesia as pain relief. The objectives were twofold. Firstly, the objective was to evaluate peri-operative and immediate post-operative complications. Secondly, the objective was to evaluate the feasibility of performing these relatively complex procedures under sedation and local anaesthesia. The visual analogue scale (VAS) was used to record pain during and after the operations. At a follow-up visit 8–12 weeks post-operatively, a self-instructed questionnaire evaluating subjective opinions of the operation itself and the post-operative period was handed in. Of the 55 patients, anterior, posterior and total PFR-Mesh procedures were performed in 39 (71%), 12 (22%) and 4 (7%) patients, respectively. Mean age was 68 years (52–93). All patients could be operated as scheduled under sedation and local anaesthesia. Mean operative time was 38 min (26–70). Peri-operative complications consisted of two cases of bladder perforation with the superior needle in an anterior repair and vaginal perforation with the inferior needle also in an anterior repair. At the conclusion of the operation VAS was recorded to be 0–3 in 65% of the patients. There were no immediate post-operative complications. Out of 55 patients, 35 (64%) left the ward on the day of operation whilst the remaining 20 (36%) patients stayed for only one night. The safety of the PFR-Mesh procedure and the feasibility of performing these procedures under sedation and local anaesthesia were demonstrated. However, expertise in vaginal surgery is required.     

Single-incision mesh repair versus traditional native tissue repair for pelvic organ prolapse: results of a cohort study

Introduction and hypothesis

To compare the efficacy and safety of the Elevate? anterior and posterior prolapse repair system and traditional vaginal native tissue repair in the treatment of stage 2 or higher pelvic organ prolapse.

Methods

A cohort study was conducted between January 2010 and July 2012. Patients who underwent transvaginal pelvic reconstruction surgery for prolapse were recruited. The primary outcome was anatomical success 1 year after surgery. The secondary outcome included changes in the quality of life and surgical complications. Recurrence of prolapse was defined as stage 2 or higher prolapse based upon the pelvic organ prolapse qQuantification system.

Results

Two hundred and one patients (100 in the Elevate? repair group and 101 in the traditional repair group) were recruited and analyzed. The anatomical success rate of the anterior compartment was significantly higher in the Elevate? repair group than in the traditional repair group (98 % vs 87 %, p?=?0.006), but not for the apical (99 % vs. 6 %, p?=?0.317) or posterior (100 % vs 97 %, p?=?0.367) compartments after a median 12 months of follow-up. Both groups showed significant improvements in the quality of life after surgery with no statistical difference. Mesh-related complications included extrusion (3 %) and the need for revision of the vaginal wound (1 %). Those in the mesh repair group had a longer hospital stay (p?=?0.04), operative time (p?<?0.001), and greater estimated blood loss (p?=?0.05). Other complications were comparable with no statistical difference.

Conclusions

The Elevate? prolapse repair system had a better 1-year anatomical cure rate of the anterior compartment than traditional repair, with slightly increased morbidity.     

Vaginal placement of synthetic mesh for pelvic organ prolapse

Since 2004, use of synthetic mesh has increased in vaginal surgery for the treatment of pelvic organ prolapse. However, concerns exist about the safety and efficacy of transvaginally placed mesh. Based on the currently available limited data, although many patients undergoing mesh-augmented vaginal repairs heal well without problems, there seems to be a small but significant group of patients who experience permanent and life-altering sequelae, including pain and dyspareunia, from the use of vaginal mesh. The American College of Obstetricians and Gynecologists and the American Urogynecologic Society provide background information on the use of vaginally placed mesh for the treatment of pelvic organ prolapse and offer recommendations for practice.     

Medium-term clinical outcomes following surgical repair for vaginal prolapse with tension-free mesh and vaginal support device

Introduction and hypothesis  

This study was designed to evaluate clinical outcomes ≥2 years following surgery with polypropylene mesh and vaginal support device (VSD) in women with vaginal prolapse, in a prospective, multi-center setting.     

Sexual function in women before and after transvaginal mesh repair for pelvic organ prolapse

The aim of the study was to assess sexual function in women before and after surgery with transvaginal mesh for pelvic organ prolapse. Women were invited to complete a sexual function questionnaire including the Lemack and the Pelvic Organ Prolapse Urinary Incontinence Sexual Questionnaires (PISQ-12) before undergoing surgery and 1 year after surgery. Eighty-three complete pre and postoperative questionnaires were analyzed. Mean age was 65.1 years. Forty-six were sexually inactive and 37 were sexually active women. Two sexually active women completed the preoperative PISQ-12 questionnaire retrospectively after surgery. There were no significant differences after surgery in the answers to the Lemack questionnaire and PISQ-12 scores. These results suggest that nonabsorbable transvaginal mesh repair of genital prolapse does not impair sexual function 1 year after surgery. Nevertheless, patients should not necessarily expect a significant improvement in sexual function outcome following transvaginal mesh repair for genital prolapse.     

Clinical pathway for tension-free vaginal mesh procedure: Evaluation in 300 patients with pelvic organ prolapse

Objectives:   To evaluate a clinical pathway of discharge on postoperative day 3 for the tension-free vaginal mesh (TVM) procedure in patients with pelvic organ prolapse (POP).
Methods:   Between May 2006 and December 2007, 305 consecutive women with POP quantification stage 3 or 4 were planned to undergo the TVM procedure in a single general hospital. Excluding five patients with concomitant hysterectomy, a pathway (removal of the indwelling urethral catheter on the next morning, discharge on postoperative day 3) was applied to the remaining 300 patients. The perioperative complications and postoperative hospitalization were prospectively evaluated in this case series.
Results:   Perioperative complications were: bladder injury (11 cases, 3.7%), vaginal wall hematoma (two cases, 0.7%), rectal injury (one case, 0.3%) and temporary hydronephrosis (one case, 0.3%). None needed blood transfusion. The indwelling urethral catheters were removed on the next morning as in the pathway in 287 cases (95.6%), and none required clean intermittent catheterization at home. Postoperative hospitalization was within 3 days in 280 cases (93.3%). The six cases (2.0%) with longer hospitalization were due to complications (two cases of bladder injury, one of rectal injury, one of blood loss over 200 mL, one of temporary urinary retention, and one of hydronephrosis). Two patients were re-hospitalized within one month due to vaginal bleeding or gluteal pain.
Conclusions:   Patients generally accepted the pathway of discharge on postoperative day 3 in spite of the Japanese culture preferring a longer hospital stay.     

Risk factors in the failure of surgical repair of pelvic organ prolapse

IntroductionPelvic organ prolapse (POP) surgery has variable results of recurrence and complications. We have aimed to analyze our outcomes in order to know the factors associated with anatomical and functional failure in POP surgery.Material and methodsA retrospective study of 69 patients who underwent POP surgery at our hospital was performed. Registered variables were: Age, BMI, number of deliveries, previous pelvic surgery, menopause, quality of life, urinary incontinence, associated frequency-urgency symptoms, high POP stage, vaginal compartments repaired, type of mesh, urethro-suspension and vaginal hysterectomy during POP surgery and its complications. Patients were evaluated at 1, 6 and 12 months post-surgery. The technique was considered as failed when relapse or mesh erosion occurred and when the patient is not satisfied or there was relapse. The sample is described, analyzing the relationship of the variables studied by univariate analysis (Chi square and Mann-Whitney U test) and a study was made of which variables may have predictive value in the failure of the repair (multiple logistic regression).ResultsSurgery failed in 17 patients during the follow-up at one year. BMI (29.6 ± 2.03 vs 27.1 ± 3.32), delivery number (3.4 ± 0.71 vs. 2.8 ± 1.88), menopause, frequency- urgency symptoms and number of vaginal compartments repaired were associated with treatment failure although only BMI, delivery number and frequency-urgency symptoms were defined as independent predictive variables when the logistic regression was carried out.ConclusionsOverweightness-obesity, previous delivery number and frequency-urgency symptoms before surgery are factors associated to anatomical and functional failure after POP repair.