Transurethral and suprapubic mesh resection after Prolift® bladder perforation: a case report

Bladder perforation is a complication which can occur after a Prolift® procedure and may enhance vesicovaginal fistula formation. Different methods of management of bladder perforation caused by mesh procedures are described in the literature, and most authors advise complete excision of the mesh. In the case described in this article, we propose a combined transurethral and suprapubical approach as the optimal method for maximal tape removal, being both minimally invasive and less damaging to the vesical wall. A suprapubical catheter can be removed shortly after surgery to enable optimal tissue healing of the vesical mucosa.     

An algorithm for managing patients who have Composix® Kugel® ventral hernia mesh

Composix^® Kugel^® (CK) mesh is a prosthetic available since 2000 for ventral hernia repair. A recent voluntary, class I recall of CK has caused concern regarding implantable medical devices and has caused many patients to seek medical attention and advice related to their hernia repair. Surgeons are required to answer many patient inquiries and address their concerns. Although the Food and Drug Administration (FDA) warnings can help guide surgeons in dealing with events such as this recall, detailed information and algorithms are lacking. We present information regarding the composite mesh recall and propose an algorithm for the management of patients who have had this mesh implanted.     

Perioperative experience of pelvic organ prolapse repair with the Prolift® and Elevate® vaginal mesh procedures

Introduction and hypothesis

We compared the operative and immediate postoperative experience of the trocar-based Prolift® and non-trocar-based Elevate® techniques used to repair vaginal prolapse.

Methods

A retrospective review of Prolift and Elevate repairs was performed. Baseline characteristics and operative and postoperative variables evaluated included compartment(s) repaired, adjacent organ injury, operative time (OT), change in hemoglobin (ΔH), pain score, narcotic use, length of stay (LOS), and short-term complications. Categorical variables were assessed as counts and percent frequency. Data were compared using chi-squared analysis and paired t test.

Results

Prolift (n?=?143) and Elevate (n?=?77) patients were similar in age (p?=?0.19). Concurrent hysterectomy was done in 22 (15.4 %) and 24 (31.2 %), respectively, and concurrent midurethral sling placed in 100 (70 %) and 50 (65 %), respectively. LOS (median, 25th,75th) after anterior/apical compartment repairs was shorter with Elevate, whether with (1.0; 1.0,1.5 vs. 2.0 days;1.0, 2.0; p?=?0.003) or without (2.0; 1.0, 2.0 vs. 2.0 days; 2.0, 3.0; p?=?0.024) hysterectomy, but no differences in OT, ΔH, pain score, or narcotic use occurred. Posterior compartment mean pain scores were lower with Prolift (3.6 ± 2.2 vs. 1.7 ± 1.5, p?=?0.035), and three-compartment-repair pain scores were lower with Elevate (0.6 ± 1.3 vs 2.5 ± 1.9; p?=?0.013). Three bladder injuries occurred with Prolift but none with Elevate.

Conclusions

Operative and postoperative experiences were similar between groups; however, Elevate anterior/apical repairs had shorter LOS, which might reflect more aggressive discharge planning. There were no bowel or major vascular injuries, and the Prolift trocar bladder injuries did not alter the surgical procedure.     

TIGR® matrix surgical mesh – a two-year follow-up study and complication analysis in 65 immediate breast reconstructions

In recent years, it has become increasingly popular to use matrices, such as acellular dermal matrices, in implant-based breast reconstruction. To lower the cost and to avoid implanting biological material, the use of synthetic meshes has been proposed. This is the first study examining TIGR^® Mesh in a larger series of immediate breast reconstruction. The aims of the study were to examine complications and predictors for complications. All consecutive patients operated on with breast reconstruction with TIGR^® Matrix Surgical Mesh and tissue expanders (TEs) or permanent implant between March 2015 and September 2016 in our department were prospectively included. Exclusion criteria were ongoing smoking, BMI (kg/m²)?>?30, planned postoperative radiation, and inability to leave informed consent. Fifteen breasts (23%) were affected by complications within 30 d: four (6.2%) major complications and eleven (17%) minor complications. The major complications included two implant losses and one pulmonary embolism (PE). Predictors for a complication were age over 51 years, BMI over 24.5?kg/m², large resection weight, and the need for a wise pattern excision of skin. Four minor surgical complications occurred after 30 d (minimum follow-up 17 months). There were no implant losses. In addition, minor aesthetic corrections, such as dog-ear resection, were performed in 10 breasts. In conclusion, breast reconstruction with a TE in combination with TIGR^® Matrix Surgical Mesh can be performed with a low complication rate.     

Self-fixating mesh for the Lichtenstein procedure—a prestudy

Introduction

Secure fixation of the mesh in groin hernia repair is essential to avoid mesh dislocation. The fixation, however, is also thought to be a source of chronic postoperative pain. We tested the new self-fixating mesh Parietene progrip^© vs. traditional suture fixating Lichtenstein repair in a double-blinded randomized study evaluating postoperative pain and the use of analgesics.

Methods

Fifty patients were randomized into two groups: Patients of group A (24 patients) were operated with the new self-fixating Parietene progrip^© mesh without fixation sutures and patients of group B (26 patients) were operated with the traditional Lichtenstein repair. Postoperative course including pain and the use of analgesics were monitored. Patients were reinvestigated after 6 months regarding pain score and the amount of analgesics used during this interval. Primary end point was pain on the first operative day.

Results

The visual analog scale pain score showed at the first postoperative day a significantly lower level in group A than in group B (mean 17.9 vs. 32.3 mm, p?=?0.03). Additionally, the cumulative dose of postoperatively required analgesics was lower in group A than in group B. The operative time in group A was significantly shorter than in group B. Six months after the operation, a trend toward a lower pain score was observed in group A, but this did not reach statistical significance.

Conclusions

This is the first randomized study to show a beneficial effect of the new self-fixating mesh on pain score. According to our investigations, operative time is reduced, which is a considerable fact with regard to economic aspects as well as the beneficial aspects for the patients. A study with a larger cohort of patients should be conducted to confirm the promising results of this exploratory study.     

Comparison of a single-use GlideScope® Cobalt videolaryngoscope with a conventional GlideScope® for orotracheal intubation

Background

This study was conceived to compare the single-use GlideScope^® Cobalt videolaryngoscope with the conventional GlideScope^® videolaryngoscope for orotracheal intubation, as judged by time to intubation (TTI) and ease of intubation.

Methods

One hundred patients with normal-appearing airways requiring orotracheal intubation for elective surgery were randomly allocated to have their tracheas intubated by a heterogeneous group of operators with the Cobalt GlideScope® or the conventional GlideScope^®. TTI was assessed by a blinded observer. Operators were blinded until the start of laryngoscopy. A visual analogue scale (VAS) assessed the ease of intubation. The number of intubation attempts, number of failures, glottic grades, and fogging of the video screen were recorded.

Results

There was no difference between the median TTI of the GlideScope^® Cobalt and the conventional GlideScope^® (40.1 sec, interquartile range [IQR] 34.1, 51.3 vs 39 sec, IQR 32.6, 48.1, respectively; P = 0.75). The ease of intubation was similar between the two devices (median Cobalt VAS: 16 mm, IQR 10.8, 27.3, vs median conventional VAS: 12.5 mm, IQR 10, 20.5, respectively; P = 0.12). There were no significant differences between the two devices with respect to glottic exposure, intubation attempts, failures, or video screen fogging.

Conclusions

The GlideScope^® Cobalt has similar performance characteristics compared with the conventional GlideScope^® videolaryngoscope when used for orotracheal intubation. The two devices can likely be used interchangeably. (ClinicalTrials.gov number, NCT00459797.)     

Nasotracheal fibreoptic intubation: a randomised controlled trial comparing the GlideRite® (Parker-Flex® Tip) nasal tracheal tube with a standard pre-rotated nasal RAE™ tracheal tube

In a randomised controlled study, we compared the ease of railroading a GlideRite^® nasal tracheal tube over a fibrescope with that of a pre‐rotated RAE? nasal tracheal tube. We studied 110 anaesthetised patients with no known airway difficulties undergoing elective dental or maxillofacial surgery. Impingement was more common with the GlideRite tubes (11/55 (20%)) compared with the pre‐rotated RAE tubes (3/55 (5%); p = 0.02). The median (IQR [range]) time to intubation (GlideRite 7.6 (4.7–10.8 [3.0–46.2]) s; RAE 8.0 (6.2–10.7 [2.4–30.0]) s) and postoperative sore throat numerical ratings (GlideRite 2 (0–3 [0–10]); RAE 2 (0–5 [0–8])) were similar. A 90° anticlockwise pre‐rotation of a standard nasal RAE tube has a higher initial rate of successful railroading at first attempt and is therefore superior to a GlideRite nasotracheal tube during nasal fibreoptic intubation.     

“Sports” hernia: treatment with biologic mesh (Surgisis)

Background Groin pain in athletes is caused by a wide range of musculoskeletal disorders. Occasionally, a palpable bulge at the external ring or ultrasound may not demonstrate a hernia. When athletes do not respond to conservative treatment, a “sports” hernia should be considered. Methods A retrospective review of 750 laparoscopic preperitoneal hernias was performed. A sports hernia was defined as a tear in the transversalis fascia that was not evident by preoperative physical exam. A 7 × 10-cm biologic mesh, Surgisis, was placed, uncut, over the myopectinate orifice and fixed with five tacks or fibrin glue. Patients were followed up at 2 and 6 weeks, 6 months, and 1 year. Results Ten professional and amateur athletes were found to have sports hernias. Operative time averaged 32 min. There were no major complications. All athletes returned to full activities in 4 weeks. Only one patient did not show improvement in his symptoms. No patient developed a recurrent hernia. Conclusions Laparoscopic exploration should be considered in athletes with chronic groin pain that does not improve after conventional treatments have failed. Furthermore, biologic mesh (Surgisis) should be considered for the repair of inguinal sports hernias.     

TiLoop® Bra mesh used for immediate breast reconstruction: comparison of retropectoral and subcutaneous implant placement in a prospective single-institution series

Background

Immediate implant reconstruction after a conservative mastectomy is an attractive option made easier by prosthetic devices. Titanized polypropylene meshes are used as a hammock to cover the lower lateral implant pole. We conducted a prospective nonrandomized single-institution study of reconstructions using titanium-coated meshes either in a standard muscular mesh pocket or in a complete subcutaneous approach. The complete subcutaneous approach means to wrap an implant with titanized mesh in order to position the implant subcutaneously and spare muscles.

Methods

Between November 2011 and January 2014, we performed immediate implant breast reconstructions after conservative mastectomies using TiLoop® Bra, either with the standard retropectoral or with a prepectoral approach. Selection criteria included only women with normal Body Mass Index (BMI), no large and very ptotic breasts, no history of smoking, no diabetes, and no previous radiotherapy. We analyzed short-term outcomes of such procedures and compared the outcomes to evaluate implant losses and surgical complications.

Results

A total of 73 mastectomies were performed. Group 1 comprised 29 women, 5 bilateral procedures, 34 reconstructions, using the standard muscular mesh pocket. Group 2 comprised 34 women, 5 bilateral procedures, 39 reconstructions with the prepectoral subcutaneous technique. Baseline and oncologic characteristics were homogeneous between the two groups. After a median follow-up period of 13 and 12 months, respectively, no implant losses were recorded in group 1, and one implant loss was recorded in group 2. We registered three surgical complications in group 1 and two surgical complications in group 2.

Conclusions

Titanium-coated polypropylene meshes, as a tool for immediate definitive implant breast reconstruction, resulted as safe and effective in a short-term analysis, both for a retropectoral and a totally subcutaneous implant placement. Long-term results are forthcoming. A strict selection is mandatory to achieve optimal results. Level of Evidence: Level II, therapeutic study.     

Is there a place for a biological mesh in perineal hernia repair?

Purpose

This study aimed to determine the outcome of perineal hernia repair with a biological mesh after abdominoperineal resection (APR).

Method

All consecutive patients who underwent perineal hernia repair with a porcine acellular dermal mesh between 2010 and 2014 were included. Follow-up was performed by clinical examination and MRI.

Results

Fifteen patients underwent perineal hernia repair after a median of 25 months from APR. Four patients had a concomitant contaminated perineal defect, for which a gluteal fasciocutaneous flap was added in three patients. Wound infection occurred in three patients. After a median follow-up of 17 months (IQR 12–24), a clinically recurrent perineal hernia developed in 7 patients (47 %): 6 of 11 patients after a non-cross-linked mesh and 1 of 4 patients after a cross-linked mesh (p = 0.57). Routine MRI at a median of 17 months revealed a recurrent perineal hernia in 7 of 10 evaluable patients, with clinical confirmation of recurrence in 5 of these 7 patients. No recurrent hernia was observed in the three patients with combined flap reconstruction for contaminated perineal defects.

Conclusion

A high recurrence rate was observed after biological mesh repair of a perineal hernia following APR.

     

Decreased hernia recurrence using autologous platelet-rich plasma (PRP) with Strattice™ mesh in a rodent ventral hernia model

Background

Recurrence after ventral hernia repair (VHR) remains a multifactorial problem still plaguing surgeons today. Some of the many contributing factors include mechanical strain, poor tissue-mesh integration, and degradation of matrices. The high recurrence rate witnessed with the use of acellular dermal matrices (ADM) for definitive hernia repair has reduced their use largely to bridging repair and breast reconstruction. Modalities that improve classic cellular metrics of successful VHR could theoretically result in improved rates of hernia recurrence; autologous platelet-rich plasma (PRP) may represent one such tool, but has been underinvestigated for this purpose.

Methods

Lewis rats (32) had chronic ventral hernias created surgically and then repaired with Strattice? mesh alone (control) or mesh + autologous PRP. Samples were harvested at 3 and 6 months postoperatively and compared for gross, histologic, and molecular outcomes of: neovascularization, tissue incorporation, peritoneal adhesions, hernia recurrence, and residual mesh thickness.

Results

Compared to control at 3 months postoperatively, PRP-treated rats displayed significantly more neovascularization of implanted mesh and considerable upregulation of both angiogenic genes (vEGF 2.73-fold, vWF 2.21-fold) and myofibroblastic genes (αSMA 9.68-fold, FSP-1 3.61-fold, Col1a1 3.32-fold, Col31a1 3.29-fold). Histologically, they also showed enhanced tissue deposition/ingrowth and diminished chronic immune cell infiltration. Peritoneal adhesions were less severe at both 3 (1.88 vs. 2.94) and 6 months (1.63 vs. 2.75) by Modified Hopkins Adhesion Scoring. PRP-treated rats experienced decreased hernia recurrence at 6 months (0/10 vs. 7/10) and had significantly improved ADM preservation as evidenced by quantification of residual mesh thickness.

Conclusions

PRP is an autologous source of pro-regenerative growth factors and chemokines uniquely suited to soft tissue wound healing. When applied to a model of chronic VHR, it incites enhanced angiogenesis, myofibroblast recruitment and tissue ingrowth, ADM preservation, less severe peritoneal adhesions, and diminished hernia recurrence. We advocate further investigation regarding PRP augmentation of human VHR.

     

Brennnesseltrockenextrakt (Bazoton®-uno) in der Langzeittherapie des benignen Prostatasyndroms (BPS)

Zusammenfassung Die Phytotherapie des BPS hat in Deutschland eine lange Tradition. Insgesamt sind die zu den einzelnen Präparaten erhobenen Daten spärlich, wenn überhaupt vorhanden. Daher wurde eine randomisierte, doppelblinde, placebokontrollierte Multicenterstudie über 1 Jahr mit Bazoton^® uno (459 mg Brennnesselwurzeltrockenextrakt) an 246 Patienten durchgeführt. Die Hauptzielvariable IPSS verbesserte sich im Mittel (Daten normal verteilt) von 18,7±0,3 auf 13,0±0,5 und zeigte damit eine statistisch signifikante Überlegenheit im Vergleich zu Placebo (18,5±0,3 auf 13,8±0,5, p=0,0233). Der Lebensqualitätsindex zeigte am Ende der Therapie mit 65% verbesserten Patienten unter Bazoton^® uno im Vergleich zu 62% unter Placebo ebenfalls eine positive Tendenz, diese war aber nicht statistisch signifikant (p=0,69).Der maximale Harnfluss stieg im Median (Daten nicht normal verteilt) um 3,0±0,4 ml/s, unter Placebogabe um 2,9±0,4 ml/s und unterschied sich damit nicht statistisch signifikant (p=0,49), wie auch die Restharnmenge, die sich unter Bazoton^® uno im Median um 5,0±2,1 ml, unter Placebogabe um 4,0±1,6 ml reduzierte (p=0,67). Die Zahl der unerwünschten Ereignisse (29/38) als auch Infektionen der Harnwege etc. (3/10 Ereignisse) waren unter Bazoton^®-uno-Gabe deutlich seltener. Die Behandlung mit Bazoton^®-uno ist damit eine nebenwirkungsarme Therapieform des BPS mit Schwerpunkt in der Verbesserung irritativer Symptome und möglicher Senkung BPS-assoziierter Komplikationen durch die postulierte antiphlogistische und antiproliferative Wirkung des Brennnesselextrakts. Ausgeprägte Veränderungen des Harnstrahls und der Restharnmenge sind nicht zu erwarten.     

CaReS® (MACT) versus microfracture in treating symptomatic patellofemoral cartilage defects: a retrospective matched-pair analysis

Background

Treating patellofemoral articular cartilage lesions remains a challenging task in orthopedic surgery. Whereas microfracture and autologous chondrocyte implantation yield good results on femoral condyles, the therapeutic state of the art for treating patellofemoral lesions is yet to be determined. In this study, we compared the CaReS^® technique, which is a matrix-associated autologous chondrocyte implantation technique, to microfracture for treating patellofemoral articular cartilage lesions.

Methods

Between May 2003 and December 2005, 17 patients with an isolated patellofemoral cartilage defect (International Cartilage Repair Society III/IV) were treated with the CaReS^® technique at our department. After adjusting for inclusion and exclusion criteria, ten of these patients could be included in this study; ten patients treated with microfracture were chosen as a matched-pair group. Clinical outcome was evaluated 3 years after surgery by the 36-item Short Form Health Survey Questionnaire (SF-36), International Knee Documentation Committee (IKDC) subjective evaluation of the knee, Lysholm Score, and Cincinnati Modified Rating Scale scores.

Results

Patients treated with CaReS^® had statistically significantly improved IKDC, Lysholm, and Cincinnati scores 36 months after surgery compared with preoperatively. When comparing outcome between groups 36 months after surgery, there was no statistically difference in IKDC, Lysholm, and Cincinnati scores.

Conclusions

This is the first trial comparing the CaReS^® technique and microfracture for treating patellofemoral articular cartilage lesions, and results show that CaReS^® yields comparable results to microfracture. The small number of patients is a limiting factor of the study, leading to results without statistical significance. A multicentric prospective randomized study comparing the two procedures is desirable.