Anil Krishna Dass

Assessment of collagen-coated anterior mesh through morphology and clinical outcomes in pelvic reconstructive surgery for pelvic organ prolapse.

STUDY OBJECTIVE To assess the morphologic features of anterior armed transobturator collagen-coated polypropylene mesh and its clinical outcomes in pelvic reconstructive surgery to treat pelvic organ prolapse. DESIGN Evidence obtained from several timed series with intervention (Canadian Task Force classification II-3). SETTING Chang Gung Memorial Hospital, Taoyuan, Taiwan, China. PATIENTS Between April 2010 and October 2012, 70 patients underwent surgery to treat symptomatic pelvic organ prolapse, stage III/IV according to the POP-Q (Pelvic Organ Quantification System). INTERVENTION Anterior armed transobturator collagen-coated mesh. MEASUREMENT AND MAIN RESULTS Morphologic findings and clinical outcome were measured. Morphologic features were assessed via 2-dimensional introital ultrasonography and Doppler studies. Clinical outcome was measured via subjective and objective outcome. Objective outcome was assessed via the 9-point site-specific staging method of the International Continence Society Pelvic Organ Prolapse Quantification before the operation and at 1-year postoperative follow-up. Subjective outcome was based on 4 validated questionnaires: the 6-item UDI-6 (Urogenital Distress Inventory), the 7-item IIQ-7 (Incontinence Impact Questionnaire), the 6-item POPDI-6 (Pelvic Organ Prolapse Distress Inventory 6), and the 12-item PISQ-12 (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire), at baseline and at 12 months after the operation. Data were obtained for 65 patients who underwent the combined surgery and were able to comply with follow-up for >1 year. Ultrasound studies reveal that mesh length tends to shorten and decrease in thickness over the 1-year follow-up. Vagina thickness also was reduced. Neovascularization through the mesh was observed in <8.5% of patients in the first month and at 1 year, and was evident in approximately 83%. The mesh exposure rate was 6.4%. The recorded objective cure was 90.8% (59 of 65 patients), and subjective cure was 89.2% (58 of 65 patients) at mean (SD) follow-up of 19.40 (10.98) months. At 2 years, UDI-6, IIQ-7, and POPDI-6 scores were all significantly decreased (p < .001), whereas the PISQ-12 score was significantly increased (p = .01). CONCLUSIONS Ultrasound features suggest that the degeneration of collagen barrier may be longer than expected and that integration of collagen-coated mesh could occur up to 1 year. A substantially good clinical outcome was noted.

A delayed type of ureteric injury developed after transobturator mesh procedure for massive prolapse.

We report on a rare case of delayed presentation of ureteric injury with a transobturator mesh kit for anterior vaginal wall prolapse repair along with conventional vaginal pelvic reconstructive surgery: a case of a 56-year-old multiparous, postmenopausal woman with a body mass index of 22.1 kg/m, who had continuous leakage of urine per vagina 28 days after vaginal hysterectomy, mesh-augmented anterior repair with Avaulta Plus Anterior support system kit (CR Bard Inc, Covington, Ga), and sacrospinous ligament fixation for stage IV pelvic organ prolapse. Pelvic computed tomographic scan with contrast revealed an intact bladder, right hydroureteronephrosis, and right ureterovaginal fistula. Immediate laparotomy performed revealed that the right lower mesh arm was entangled with the distal end of the right ureter, 1.5 cm from the ureteric orifice. Category, time, site classification was 4CaT2S5. Right ureteric reimplantation was performed uneventfully. We herein emphasize that the development of a delayed type of ureteric injury is a possible associated complication of transobturator mesh surgery for the prolapse.

Lower urinary tract dysfunction resulting from a 10-year retained intravesical absorbable suture from a uterine myomectomy

Intravesical foreign bodies may be a result of migration from adjacent organs or penetrative injury, or they may be self-introduced or iatrogenic from medical or surgical procedures. Urinary tract infections, abnormal biochemistry, abnormal urinary tract anatomy, and the presence of foreign bodies within the urinary tract have been identified as risk factors for bladder stone formation [1]. There have been reports of bladder stones associated with a foreign body in patients who had a pelvic organ surgery previously [2] .T he foreign body acts as a site for encrustation and calculi formation [3]. Patients may be asymptomatic or may show some mild discomfort. Common symptoms are hematuria, dysuria, voiding difficulties, increased urinary frequency, and a weak urinary stream. A 50-year-old patient presented to our unit with complaints of intermittent lower abdominal pain. She complained of lower urinary tract symptoms, predominantly a weak urinary stream and voiding difficulties. Ten years earlier, she had a uterine myomectomy. However, postoperatively, she developed complications due to tuboovarian abscess that required a re-laparotomy. She also had a history of hypertension that was well controlled with medications. She had had three vaginal deliveries with no complications. Her body mass index was 38.2 kg/m 2 . Upon pelvic examination, no abnormal findings were noted. A urine culture did not show infection. An upright abdominal and pelvic X-ray revealed a radio-opaque density or calcification over the right ureteric orifice (Fig. 1). There was also mild scoliosis of the lumbar spine. We performed a scheduled cystoscopic examination. We removed a 1.5 cm 0.9 cm bladder stone and noted an abnormal foreign body at the bladder dome. The features of the foreign body were suggestive of a potential mesh material (Fig. 2). The patient’s symptoms improved after the cystoscopy, but prior to any further intervention, we performed further evaluation of the foreign body with a computed tomography scan of the pelvis. The results showed normal pelvic organs with no evidence of a foreign body. We counseled the patient, and she underwent another cystoscopic examination. Transurethral removal of the suture with endoscopic forceps was performed while the patient was under general anesthesia. No complications were encountered. The bladder mucosa was inspected (Fig. 3). The foreign body disintegrated upon examination. A histological analysis confirmed the foreign body as a suture material with granulomatous reaction and inflammatory granulation tissue. The patient had an indwelling bladder catheter for 1 day and had an excellent recovery. At the 2 months’ postprocedure follow-up, the patient was symptom free, and a repeat cystoscopic examination revealed normal findings. In animal and clinical studies, it has been reported that foreign bodies can act as a nidus for stone formation [4]. Bladder stone formation has been reported to occur on exposed nonabsorbable sutures and mesh [2,3,5]. There are very few reported cases of stone formation on absorbable sutures [1,6]. In our case, it may be possible that during surgery for the uterine myomectomy or during the second surgery, the suture was passed inadvertently into the bladder dome. The removed foreign body was confirmed to be a suture material. We believe that this foreign body is a remnant of the suture used in the patient’s surgical procedure 10 years ago. In this case, the suture may be a contributing factor to the development of bladder calculi and may be the cause of the