Mihaela Boț

Suture Materials and Technics, Possible Cause for C-Section Scar Defect

With the increasing number of births by Caesarean section a new pathology has made its presence felt, linked to the scarring of the low uterine transverse incision. It was found that after the birth by caesarean section some patients presented postmenstrual prolonged bleeding, spotting, pelvic pain and infertility. First described in 1995, the isthmocele is a healing defect in the anterior wall of the lower uterine segment at the caesarean hysterotomy site. This faulty scarring could be attributed to physiological peculiarities of the patient, to the suturing technique or ascribed to tissue reaction specifically to the type of suture material used. We found that it may be a correlation between the suture materials used and the appearance of the isthmocele. There are no large studies that asses the long-term outcome of C-section scar on prolonged menstrual bleeding, spotting and infertility and no comparison on the rate of appearance of this pathology by account of the suture material.

Painful Complications after Pelvic Floor Reconstructive Surgery in Transobturator Suburethral Vaginal Slings

Stress incontinence is a major social and health problem for middle-aged and elderly women, with an increasing prevalence as life expectancy increases. Reconstructive surgery techniques using vaginal mesh slings of polypropylene (synthetic grafts) have diversified in recent years, but at the same time various postoperative complications have been reported, among the frequent ones being pelvic pain, thigh pain and dyspareunia. The pain mechanism is not fully understood, but pathophysiological theories describe the pain as closely related to the structure, density, size and elasticity of the vaginal mesh, and the inflammatory response of the host.

Properties Analysis of Biological Grafts Used in Pelvic Surgery

Pelvic surgery addresses congenital malformations like Mullerian anomalies, pelvic organ prolapse or after radical intervention, while constructive surgery involves treatment of congenital/iatrogenic absence of organs: uterus or vagina. Intuitively, inert and nondegradable biomaterials appear ideal for this purpose, but surgical reality is that the persistence of a permanent foreign body in the wound has a lot of clinical postoperative disadvantages. This paper aims to discuss the properties of the biologic grafts, detailing the structure of biologic extracellular matrix, the biomechanical properties of biological grafts and the use of extracellular matrix in reconstructive pelvic surgery. A biologic graft used in pelvic surgery is a tridimensional extracellular matrix, acellular and of animal origin. It has as a low risk of transmission of viral and prionic infections and determines reduced inflammatory reaction and a low risk of rejection. The absence of crosslinking facilitates the colonization of the mesh by the host´s cells, thus avoids the foreign body reaction represented by the encapsulation of the mesh by the host. Our experience with clinical use of biological acellular grafts in reconstructive pelvic surgery includes oncoplastic surgery like in cases of vulvar cancer or neovagina reconstruction for Rokintansky syndrome, complications after prolapse surgery treated with polypropylene meshes or relapsing recto-vaginal fistulas. The biomechanical properties evaluated by tensile stress and elastic modulus revealed that biologic grafts with moderate collagen infiltration are the strongest. The degree of cross-linkage influences the rate of degradation and the degree of the inflammatory response triggered by the host organ. Cross-linked collagenous matrices induce little cell infiltration hence there is limited collagen remodeling and graft degradation. On the other hand, in non-cross- linked xenografts cell infiltration is greater with faster degradation rate and collagen production. The decrease in the mechanical strength of the graft materials is related to the lack of collagen infiltration into the material. In conclusion, taking into account the biomechanical properties of biologic grafts, these may be used in reconstructive pelvic surgery and oncoplastic surgery with little complications and good clinical results. They can be attached to large mucosal defects and on potentially septic tissue, they are mechanically resistant and they can be sutured on surrounding healthy tissue.

Synthetic Mesh Used in Gynecologic Reconstructive Surgery for Pelvic Floor Disorders

Pelvic floor disorders including stress urinary incontinence and pelvic organ prolapse represent a challenge for gynecologist or urogynecologist even nowadays. Conservative treatment for these conditions proves its effectiveness only in few cases selected from early forms of incontinence or prolapse the most cases being solved surgically. The introduction of the procedure imagined by Petros and Ulmsten, known as TVT (Trans Vaginal Tape) in which the medium urethra is supported by a synthetic tape produced in 1996 a revolution in the surgical treatment of stress urinary incontinence. Radical changes also appeared in pelvic organ prolapse surgery extrapolating the hernia repair procedure by using synthetic mesh. After nearly 20 years of experience the mesh surgery is today a common practice in urogynecology. Between 2011 and 2015 we operated in private practice a total number of 297 cases of which 187 cases of stress urinary incontinence and 110 cases of pelvic organ prolapse. From these 86 (78,1%) cases were represented by cystoceles, associated with early apical prolapse or rectoceles, 18 (16,3%) cases by apical prolapse (grade III-IV) and 6 (5,4%) cases by posterior compartment prolapse alone. We performed mesh surgery in 32 (29%) cases represented mainly by anterior compartment prolapse. In 6 (18,7%) cases we founded mesh extrusion which required partially resection. In two cases we performed large resection of anterior vaginal wall required grafting with acellular second generation graft. In all cases with mesh extrusion the biomechanical analysis revealed significant decrease in effective porosity of the mesh due to excessive tensioning or folding of the mesh. The use of mesh in stress urinary incontinence and pelvic organ prolapse represent a justified alternative in selected cases. The specific complications due to meshes are more frequent in prolapse surgery compared to stress urinary incontinence. In all cases altered effective porosity due to technical defects in surgery represents the leading cause.