Allison E. Howard

The Mersilene mesh suburethral sling: A clinical and urodynamic evaluation☆

Abstract OBJECTIVES: Our purpose was to determine the efficacy and safety of the Mersilene (Ethicon, Inc., Somerville, N.J.) mesh sling. STUDY DESIGN: A total of 110 women diagnosed at the University of Massachusetts Medical Center with recurrent genuine stress incontinence, low-pressure urethra, or chronically increased intraabdominal pressure underwent a Mersilene mesh sling procedure. The women were followed up with yearly clinical and 1-year urodynamic evaluations. Sixty-seven patients had both preoperative and postoperative complete urodynamic evaluations. Paired t test was used except where stated. RESULTS: Seventy-nine of 83 patients (95%) who were examined at a mean of 15 months reported complete stress continence. Objective cure rate ( n = 72) by 1-year postoperative stress test was 93%. The pressure transmission ratio increased from 75% to 112% ( p CONCLUSIONS: The suburethral sling with Mersilene mesh is a safe, effective treatment for specific types of genuine stress incontinence on the basis of yearly clinical and 1-year urodynamic follow-up, and it demonstrates a low rejection rate.

Prepregnancy Weight, Gestational Weight Gain, and Risk of Growth Affected Neonates

BACKGROUND In 2009, the Institute of Medicine published revised gestational weight gain (GWG) guidelines with changes notable for altered body mass index (BMI) categorization as per World Health Organization criteria and a stated range of recommended gain (11-20 pounds) for obese women. The goal of this study was to evaluate associations between maternal BMI-specific GWG adherence in the context of these new guidelines and risk of small for gestational age (SGA) and large for gestational age (LGA) neonates. METHODS Subjects were a retrospective cohort of 11,203 live birth singletons delivered at 22-44 weeks at a Massachusetts tertiary care center between April 2006 and March 2010. Primary exposure was GWG adherence (inadequate, appropriate, or excessive) based on BMI-specific recommendations. SGA and LGA were defined as <10th and ≥90th percentiles of U.S. population growth curves, respectively. The association between GWG adherence and SGA and LGA was examined in polytomous logistic regression models that estimated adjusted odds ratios (AOR) stratified by prepregnancy weight status, controlling for potential confounders. RESULTS Before pregnancy, 3.8% of women were underweight, 50.9% were normal weight, 24.6% were overweight, and 20.6% were obese. Seventeen percent had inadequate GWG, and 57.2% had excessive GWG. Neonates were 9.6% SGA and 8.7% LGA. Inadequate GWG was associated with increased odds of SGA (AOR 2.51, 95% confidence interval [CI] 1.31-4.78 for underweight and AOR 1.78, 95% CI 1.42-2.24 for normal weight women) and decreased odds of LGA (AOR 0.5, 95% CI 0.47-0.73 for normal weight and AOR 0.56, 95% CI 0.34-0.90 for obese women). Excessive GWG was associated with decreased odds of SGA (AOR 0.59, 95% CI 0.47-0.73 for normal weight and AOR 0.64, 95% CI 0.47-0.89 for overweight women) and increased odds of LGA (AOR 1.76, 95% CI 1.38-2.24 for normal weight, AOR 2.99, 95% CI 1.92-4.65 for overweight, and AOR 1.55, 95% CI 1.10-2.19 for obese women). CONCLUSIONS Efforts to optimize GWG are essential to reducing the proportion of SGA and LGA neonates, regardless of prepregnancy BMI.

Society of gynecologic surgeons' survey: mesh use in vaginal prolapse surgery.

Objective: To evaluate the practice patterns of the Society of Gynecologic Surgeons (SGS) members and guests regarding the use of synthetic mesh in vaginal prolapse repair. Methods: A 26-item questionnaire regarding synthetic mesh use in vaginal prolapse repair was placed on the desks of those SGS attendees present at the fourth scientific session of the 2008 annual scientific meeting. Voluntary participation was requested and the survey questionnaires were retrieved at the sessions conclusion. Descriptive statistics and cross-tabulation using &khgr;2 tests were performed with SPSS. Results: One hundred twenty-eight of the 180 scientific session attendees completed the surveys. Sixty-nine percent (88/128) of the respondents identified themselves as urogynecologists and 45% (83/128) were male. Forty-five percent (58/128) were SGS members. Sixty-six percent (84/128) described their practice setting as academic, 28% (36/128) as community-based, and 6% (8/128) as other. The majority of the urogynecologists, 65% (64/88), used mesh at the time of survey completion versus 40% (8/18) of the obstetrician/gynecologists (P < 0.001). Fifty-nine percent (74/125) respondents were currently using mesh and 11% (14/125) reported using mesh at one time. Fifty-six percent (48/86) used mesh in both primary and recurrent repairs. For anterior repair, 97% (82/86) used mesh; of these, 31% (26/86) used only mesh kits, 33% (28/86) used only free mesh and 33% (28/86) reported using both. For posterior repair, 70% (62/88) used mesh; of these 18% (16/88) used only mesh kits, 26% (23/88) used only free mesh and 26% (23/88) used both. For anterior repair, 84% (71/85) dissected full-thickness and 43% (35/85) plicated connective tissue prior to inserting the mesh. The respondents had excised mesh for indications including: persistent drainage (59%), persistent pain (21%), hispareunia (21%), dyspareunia (16%), and asymptomatic exposure (11%). Fifty percent (44/88) initially managed mesh erosion with estrogen cream whereas 29% (26/88) started with mesh excision. Conclusions: This survey suggests that the majority of urogynecologists attending the 34th SGS annual scientific meeting have used vaginal mesh for prolapse repair, and they more commonly used it in the anterior as compared to the posterior compartment. This has occurred in the absence of prospective, controlled, high-quality studies supporting its efficacy and safety. Research is clearly needed in this area.

Long-term efficacy of the pubovaginal Mersilene mesh sling

OBJECTIVE The objective of the study was to determine the efficacy of the pubovaginal Mersilene mesh sling (PVMMS) for complicated urodynamic stress incontinence (USI). STUDY DESIGN Between 1990 and 2008, patients with USI plus an at-risk diagnosis underwent a PVMMS by a single surgeon. They were followed up with urodynamics (UDE) and Pelvic Floor Distress Inventory-short form 20 (PFDI-20). Stratification was in an at-risk hierarchy: intrinsic sphincter deficiency (ISD) greater than recurrent USI (RUSI) greater than USI with chronically increased intraabdominal pressure (CI-IAP). A cough stress test determined objective cure. PFDI question 17 assessed subjective cure. RESULTS Three hundred six patients with ISD (43.5%), RUSI (26.8%), and CI-IAP (29.7%) had objective cure rates of 89.2% in the short term, 86.7% in the intermediate term, and 91.2% in the long term. A group of 48 patients with both short- and long-term UDEs showed cures of 100% and 91.7%. Long-term objective cure rates were: ISD, 90.5% (n = 21); RUSI, 84.2%, (n = 19); CI-IAP, 100% (n = 17). The mean score of postoperative PFDI question 17 was 0.57 (n = 119). Mean symptom improvement was -2.98 (n = 52; P < .0001). CONCLUSION We demonstrated PVMMS to be subjectively and objectively effective in long-term treatment of complicated forms of USI.