Tanya M. Nazemi

Complications of grafts used in female pelvic floor reconstruction: Mesh erosion and extrusion

Introduction: Various grafts have been used in the treatment of urinary incontinence and pelvic prolapse. Autologous materials such as muscle and fascia were first utilized to provide additional anatomic support to the periurethral and pelvic tissues; however, attempts to minimize the invasiveness of the procedures have led to the use of synthetic materials. Complications such as infection and erosion or extrusion associated with these materials may be troublesome to manage. We review the literature and describe a brief overview of grafts used in pelvic floor reconstruction and focus on the management complications specifically related to synthetic materials. Materials and Methods: We performed a comprehensive review of the literature on grafts used in pelvic floor surgery using MEDLINE and resources cited in those peer-reviewed manuscripts. The results are presented. Results: Biologic materials provide adequate cure rates but have associated downfalls including potential complications from harvesting, variable tissue quality and cost. The use of synthetic materials as an alternative graft in pelvic floor repairs has become a popular option. Of all synthetic materials, the type I macroporous polypropylene meshes have demonstrated superiority in terms of efficacy and fewer complication rates due to their structure and composition. Erosion and extrusion of mesh are common and troublesome complications that may be managed conservatively with observation with or without local hormone therapy, with transvaginal debridement or with surgical exploration and total mesh excision, dependent upon the location of the mesh and the mesh type utilized. Conclusions: The ideal graft would provide structural integrity and durability with minimal adverse reaction by the host tissue. Biologic materials in general tend to have fewer associated complications, however, the risks of harvesting, variable integrity of allografts, availability and high cost has led to the development and use of synthetic grafts. Synthetic grafts have a tendency to cause higher rates of erosion and extrusion; however, these complications can be managed successfully.

Transvaginal bone-anchored sling for the treatment of female stress urinary incontinence: effect of Valsalva leak point pressure and prior pelvic surgery on outcomes

The effect of lower Valsalva leak point pressure (VLPP) and previous pelvic surgery on outcomes following sling surgery is controversial. We assessed outcomes following bone-anchored sling (BAS) placement in patients with intrinsic sphincteric deficiency (ISD) and previous pelvic surgery. A retrospective review of 149 patients undergoing BAS placement was performed. Patients were stratified by VLPP (≥60, <60, and <30) and by history of previous anti-incontinence/pelvic floor surgery. Outcomes were assessed using a questionnaire comprising validated urogenital distress inventory (UDI)-6, incontinence impact questionnaire (IIQ)-7 questionnaires and additional items addressing satisfaction. In comparing the three VLPP cohorts, the percentage of patients reporting incontinence episodes of <1/week (64%, 68%, and 63%, respectively) and postoperative UDI/IIQ questionnaire scores were similar (p > 0.2, all comparisons). Lower rates of patients achieving <1 episode of incontinence per week (50%; p = 0.07) and worse UDI/IIQ scores (p = 0.02) were associated with patients with ≥2 prior surgeries. Whereas results are similar following BAS in patients with or without varying degrees of ISD, worse outcomes are associated with prior surgery.

Cadaveric Fascial Sling with Bone Anchors: Minimum of 24 Months of Follow-up

OBJECTIVES Available published studies to define outcomes using cadaveric fascia for transvaginal urethral sling placement have revealed, in general, disappointing outcomes. However, limited data exist detailing long-term outcomes using this sling type and, more specifically, fascial grafts prepared using solvent-dehydrated techniques. We present our long-term outcomes using non-frozen solvent-dehydrated cadaveric fascia lata for transvaginal urethral sling placement with bone anchors. METHODS A retrospective review was performed of 354 patients who had undergone non-frozen solvent-dehydrated cadaveric fascia lata for transvaginal urethral sling placement with bone anchors with a minimal follow-up of 24 months. A subjective assessment was performed using validated incontinence and quality-of-life questionnaires performed at 6 and 12 months and annually thereafter. RESULTS A total of 238 patients (67%) completed follow-up questionnaires with a minimum of 24 months of follow-up. Of the 238 respondents, 71%, 67%, and 65% reported fewer than one episode of stress urinary incontinence per week, and 63%, 58%, and 59% of respondents reported minimal clinical improvement of 70% at a minimal follow-up of 24, 48, and 60 months, respectively. The corresponding rates of dryness were 34%, 27%, and 22% for the same follow-up periods. The Urogenital Distress Inventory, 6-item, and Incontinence Impact Questionnaire, 7-item, scores were not significantly different statistically when compared at each assessed follow-up point. CONCLUSIONS Our data suggest that non-frozen solvent-dehydrated cadaveric fascia lata for transvaginal urethral sling placement with bone anchors is a safe and efficacious procedure for the treatment of stress urinary incontinence. Mild decreases in subjective satisfaction and improvement were seen during an extended follow-up period, although the validated questionnaire scores remained stable throughout the same period. However, a significant reduction in the dry rate was also observed during extended follow-up.