Ali Azadi

To mesh or not to mesh with polypropylene: does carcinogenesis in animals matter?

Polypropylene in sheets has been been found to be carcinogenic in some laboratory animals. Although no human carcinogenicity has been reported, long-term follow-up in humans implanted with polypropylene mesh will be important.

Robotic Burch colposuspension: a surgical case and instructional video

Introduction and hypothesisThe Burch colposuspension is a well-studied and proven surgical treatment for stress urinary incontinence without intrinsic sphincter deficiency. The advent of the minimally invasive mid-urethral sling has given rise to diminished surgical experience in performing the Burch. Recent anti-mesh media and FDA notifications have caused patients to demand mesh-free surgery, resulting in an opportunity for the resurgence of the Burch procedure. The objective of this video is to demonstrate surgical technique and instruction for a robotic Burch colposuspension as well as recommendations for successful completion of the procedure. Additionally, the video reviews and illustrates pertinent surgical anatomy regardless of approach.MethodsThe patient is a 53-year-old woman who presented with symptoms of vaginal pressure, urinary incontinence, and constipation. She had symptoms and urodynamics consistent with mixed urinary incontinence without intrinsic sphincter deficiency and had been treated with antimuscarinics for overactive bladder. On examination she was found to have stage II prolapse. She desired surgical management of both her prolapse and stress incontinence.ConclusionRobotic Burch colposuspension can be completed in a safe and effective manner and should be considered as an option for patients in whom an anti-incontinence procedure is indicated and who are already undergoing robotic surgery.

Evaluation of surgical instrument handling on polypropylene mesh using scanning electron microscopy

Introduction and hypothesisTo evaluate the effect of surgical instruments handling on polypropylene mesh using scanning electron microscopy (SEM).MethodsWe applied different surgical instruments, including a few robotic ones, to pieces of polypropylene mesh. SEM was used to evaluate the morphological changes with this intervention.ResultsStraight hemostat, laparoscopic atraumatic grasper, laparoscopic needle driver, and robotic instruments (Bipolar forceps, Cadiere™ forceps, PK™ dissecting forceps and SutureCut™) were applied to the mesh. SEM images of tool-affected mesh regions in specimens handled by different instruments along with the images of intact mesh were obtained. Average mesh fiber diameters, as well as the average parameters characterizing instrument-affected regions, were measured. There was substantial widening of the fibers in specimens handled by hemostat or a needle holder. An elliptical but much longer and narrower tool marking with more surface roughness was observed in mesh handled by a grasper. A ∼25-μm-wide and ∼200-μm-long strap was split on one side from the core of the fiber caused by Cadiere™.ConclusionsThere are morphological changes to polypropylene mesh caused by instrument handling. These changes are different depending on the instrument used. These alterations vary from changes in the surface creating roughness of the fiber, compression of the mesh with narrowing of the fiber in at least one direction or actual splitting or pitting of the fiber. Since there are no data regarding the effect of these morphological changes to the ultimate functioning of the mesh, surgeons should minimize mesh handling by instruments.

Tumor-Like Reaction to Polypropylene Mesh from a Mid-Urethral Sling Material Resembling Giant Cell Tumor of Vagina

Background Polypropylene material is widely used in gynecological surgery. There are few reports regarding its carcinogenic potential. There is lack of evidence supporting tumor formation directly attributed to the use of polypropylene material. Case This patient is a 49-year-old woman with a history of stress urinary incontinence which required a MiniArc® Sling who presented with a hard, tender, immobile mass on the anterior vaginal wall. Pathological analysis of the mass revealed a tumor-like reaction to the polypropylene material that resembled a giant cell tumor of soft tissue. Conclusion The use of polypropylene in surgery is ubiquitous across disciplines; thus consideration for a tumor-like reaction to the material should exist for patients who present with a mass near the surgical site.