Yiap Loong Tan

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.

Anterior-Apical Single-Incision Mesh Surgery (SIMS): Surgical and Functional Outcomes at 1 Year

STUDY OBJECTIVES To study the surgical and functional outcomes of single-incision mesh surgery for treatment of advanced pelvic organ prolapse (POP). DESIGN Case series (Canadian Task Force classification II-3). SETTING University hospital. PATIENTS Sixty-five patients who underwent surgery to treat symptomatic POP greater than stage II according to the Pelvic Organ Prolapse Quantification System (POP-Q). INTERVENTION All patients underwent anterior-apical single-incision mesh surgery using the Elevate Anterior and Apical Prolapse Repair System. MEASUREMENTS AND MAIN RESULTS The primary objectives were anatomical correction of anterior and apical prolapse of POP stage I or greater and absence of voiding dysfunction reported via multi-channel urodynamic study at 6 months after surgery. Subjective outcome was measured via patient feedback using questions 2 and 3 of the Pelvic Organ Prolapse Distress Inventory 6 (POPDI-6). The secondary outcome was quality of life using the following: Urogenital Distress Inventory 6 (UDI-6), Incontinence Impact Questionnaire 7 (IIQ-7), POPDI-6, and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). Two-dimensional introital ultrasonography was performed in the first and third months after surgery and at 1-year follow-up. Descriptive statistics were used for demographic and perioperative data. The paired-samples t test was used for comparison of preoperative and postoperative continuous data. For all comparisons, a value of p < .05 was considered statistically significant. All statistical methods were performed using commercially available software (SPSS version 17). Postoperative data were available for 64 patients. The objective outcome was 96.9%, and the subjective outcome was 93.8%. All patients demonstrated significant improvement in anatomical outcomes after prolapse surgery (p < .05), and none experienced recurrence requiring further surgery. There was concomitant significant improvement in POPDI-6, UDI-6, IIQ-7, and PISQ-12 scores after surgery. A subanalysis of POP quantification measurements immediately after surgery and at 1-year postoperative follow-up demonstrated deepening of the C point and total vaginal length. Ultrasound evaluation demonstrated a significant increase in the length and thickness of mesh at 1-year follow-up. There has been no documented mesh extrusion to date. However, the number of patients with stress urinary incontinence has increased. Four patients received treatment, whereas in the remaining patients the condition was not severe enough to require surgical intervention. CONCLUSIONS Single-incision mesh surgery for treatment of advanced POP results in improvement in anatomical and quality-of-life outcomes. No mesh exposure was recorded in the first year after surgery; however, new onset of stress urinary incontinence may occur. Ultrasound evaluation demonstrated an increase in mesh length and thickness over time, with concurrent calculated lengthening of the C point and total vaginal length.

Ultrasonography and clinical outcomes following surgical anti-incontinence procedures (Monarc vs Miniarc)

OBJECTIVE To evaluate the ultrasound morphology and its clinical outcome among women who had undergone Miniarc™ vs Monarc™ in the treatment of stress urinary incontinence (SUI). STUDY DESIGN This was a prospective study on 140 patients with USI and undergone either Miniarc or Monarc surgery. From March 2010 to December 2011, patients with clinically SUI and urodynamic stress incontinence (USI) were included in the study. Objective cure of SUI was defined as no urinary leakage on provocative filling cystometry and 1-h pad test of <2 g. Subjective cure of SUI was the negative response to UDI-6. Introital ultrasound at one-year explored the sling and bladder necks position, mobility, sling tension, percentile of urethra where the sling was located and urethral kinking. RESULTS Postoperative data was available from 130 women. The ultrasound objective data for successful treatment post-operative follow-up was available from 119 women (46 Monarc, 73 Miniarc), the rest failed to follow-up. A bladder perforation was diagnosed in the Monarc group and 15 cases (7.1% of Monarc and 16.3% of Miniarc, p=0.082) of urinary retention was reported due to over-tensioning of the sling, majority of cases came from the Miniarc group. At rest and during Valsalva, analogous distances of the bladder neck and sling as well as the center of the urethral core were similar for both procedures. In both groups, shortest (Us) and longest diameters (Ul) of the urethral core were comparable at Valsalva which was significantly shorter and longer, respectively, compared to the values at rest. Sling position and percentage of urethral kinking were similar. Statistical analysis failed to detect any significant difference between the two groups with regards to the objective and subjective cure (p>0.05). CONCLUSIONS In conclusion, a Miniarc and Monarc exhibit similar mechanism of action with comparable subjective and objective clinical outcomes. Majority of urethral impingement was noted in the Miniarc group. A higher maximum urethral closure pressure (MUCP), longer resting Ul, and shorter resting Us suggested these observations. Postoperative ultrasonographic evaluation may give a promising future perspective for the evaluation of sling tension.

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.

Influence of anterior vaginal mesh with concomitant mid‐urethral sling surgery on stress urinary incontinence: clinical and sonographic outcome

To clinically and sonographically evaluate the influence of anterior vaginal mesh (AVM) surgery with concomitant mid‐urethral sling surgery (MUS) for stress urinary incontinence (SUI).

Clinical outcomes of mesh exposure/extrusion: presentation, timing and management

The Food and Drug Administration has recently highlighted an increase in reported complications associated with the use of transvaginal mesh.

Five-Year Outcome of MiniArc Single-Incision Sling Used in the Treatment of Primary Urodynamic Stress Incontinence

STUDY OBJECTIVE To evaluate the effectiveness and safety of the MiniArc single-incision sling in the treatment of urodynamic stress incontinence (USI) through 5 years. DESIGN Retrospective observational study (Canadian Task Force classification II-2). SETTING Tertiary referral center. PATIENTS Eighty-five patients with USI without needing concurrent procedures who underwent anti-incontinence surgery using the MiniArc SIMS from February 2010 to December 2011. INTERVENTIONS Anti-incontinence surgery. MEASUREMENTS AND MAIN RESULTS Objective cure was defined as no demonstrable leakage of urine on the cough stress test and 1-hour pad test weight <2 g. Subjective cure was based on negative response to Urinary Distress Inventory question 3, no leakage on coughing, sneezing, or laughing. Most patients were postmenopausal, overweight, and multiparous. Postoperative USI significantly improved (p < .001) through 3 years, and the 1-hour pad test showed significant improvement through 5 years (p < .001). Although 13 patients had recurrence of USI, no repeat surgery was done. The cumulative cure rates may show a declining trend of cure, yet subjective cure was 80.0% and objective cure 84.7%, with age as a significant risk factor for sling failure. CONCLUSION MiniArc maintains its effectiveness and safety in treatment of USI through 5 years with high objective and subjective cure rates and low incidence of complications.

Association of urodynamics and lower urogenital tract nerve growth factor after synthetic vaginal mesh implantation on a rat model

By investigating the association of urodynamics and urogenital nerve growth factor (NGF) levels in vaginal mesh surgery, we may be able to associate the likelihood of postoperative lower urinary tract symptoms developing as a result of synthetic mesh implanted for pelvic floor reconstructive surgery.

The transobturator outside in suburethral sling insertion procedure

This video describes the transobturator outside in suburethral sling surgical procedure for the indication of urodynamic stress urinary incontinence. A total of 170 cases were performed from January 2007 till December 2013. The average follow up was from 6 months till 7 years. The cure rate was 90%. There were no recurrences in our series. There was one patient with tape exposure after 3 years which required excision.

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