Are Two Meshes Better than One in Sacrocolpopexy for Pelvic Organ Prolapse? Comparison of Single Anterior versus Anterior and Posterior Vaginal Mesh Procedures

<b><i>Introduction:</i></b> Sacrocolpopexy (SC) is the main treatment option for the repair of anterior and apical pelvic organ prolapse (POP). Indications and technical aspects are not standardized, and the question remains whether it is necessary to place a mesh on both anterior and posterior vaginal walls, particularly in cases with only minor or no posterior compartment prolapse. The present study aimed to compare the anatomical and functional outcomes of single anterior mesh only versus anterior and posterior mesh procedures in SC. <b><i>Materials and Methods:</i></b> Our prospectively maintained database on POP was used to identify patients who had undergone either abdominal or mini-invasive SC from January 2006 to October 2019. Patients with symptomatic or unmasked stress urinary incontinence (SUI) were not included in the study and were treated using the pubo-vaginal cystocele sling procedure. Objective outcomes included clinical evaluation of pre-existing or de novo POP by the halfway system and POP-q classifications, as well as the development of de novo SUI. Subjective outcomes were assessed using the Pelvic Floor Impact Questionnaire (PFIQ-7) with questions on bladder, bowel, and vaginal functions. Persistent or de novo constipation and overactive bladder were defined as bowel symptoms and urinary urgency/frequency/urinary incontinence after surgery. <b><i>Results:</i></b> Ninety-five women with symptomatic anterior and apical POP underwent SC. Forty-one patients were treated with only anterior vaginal mesh (group A), and 54 with anterior and posterior mesh (group B). There were no differences between the pre- and post-operative characteristics of the 2 groups. In group B, there were 2 blood transfusions, 1 wound dehiscence, and 3 mesh erosions/extrusion after abdominal SC (Clavien-Dindo II), and in group A, there was 1 ileal lesion after laparoscopic SC (Clavien-Dindo III). There were no differences between the 2 groups in either anatomical or functional outcomes during 3 years of follow-up. <b><i>Conclusions:</i></b> SC with single anterior vaginal mesh has similar results to SC with combined anterior/posterior mesh, regardless of the surgical approach. The single anterior mesh may reduce the risk of complications (mesh erosion/extrusion), and offers better subjective outcomes with improved quality of life. Anterior/posterior mesh may be justified in the presence of clinically significant posterior POP.

Two-year outcomes of surgeon-tailored trans obturator tape for female stress urinary incontinence: a randomized, comparative, trial with traditional trans obturator tape

Background Previously, we presented the short-term outcomes of surgeon-tailored mesh in patients with SUI undergoing TOT. In this report, we aim to highlight the two-year outcomes of surgeon tailored mesh in terms of subjective and objective cure rates, as well as late complications. Methods We performed a randomized, open-label comparative trial that recruited women with SUI who were scheduled to undergo TOT. Eligible patients were randomly allocated in a 1:1 ratio to receive traditional TOT mesh or surgeon-tailored polyethylene mesh. All patients were followed up for two years. Results At the end of the follow-up, there were 13 women in the traditional TOT mesh group and 14 patients in the surgeon-tailored polyethylene mesh group. Concerning the primary outcome of the present study, the cure rate was 100% in the surgeon-tailored polyethylene mesh (n = 14) and 92.9% in the traditional TOT mesh group (p = 0.39). One woman reported improved symptoms in the traditional TOT mesh group. There were no reported failures in both groups. Concerning safety, the incidence of de novo urgency was 0% in the surgeon-tailored polyethylene mesh group, compared to 7.1% in the traditional TOT mesh group (p = 0.34). None of the women in both groups reported mesh erosions, dyspareunia, or need for reoperation. Conclusion Surgeon-tailored mesh for patients undergoing TOT is a cost-effective technique, which has comparable long-term outcomes, in terms of cure rate and complications, to the traditional costly meshes. Larger multicentre studies should confirm our results.

Prevention of Incisional Hernia in Ovarian Cancer Patients Undergoing Midline Laparotomy

BACKGROUND: Incisional hernias (IH) are a frequent complication of midline laparotomies in abdominal surgery. This study was conducted in order to determine the efficacy of mesh placement and assess the optimal fascia closure technique to reduce the IH rate in patients surgically treated after being diagnosed with malignant or borderline ovarian tumors.METHODS: Retrospective data from patients undergoing midline laparotomy for borderline or ovarian cancer in Hospital del Mar, Barcelona, from January 2008 to December 2019 were collected. Patient demographic, preoperative and intraoperative characteristics and risk factors for hernia were reported. The incidence of IH between groups (mesh and non-mesh) and the technique used in fascial closure for each patient (small bites technique vs large tissue bites) was reported. RESULTS: In total, 133 patients with available data for follow-up were included. After clinical and radiological examination, 25 (18.79%) of them showed IH. 18 of 61(29.5%) patients in non-mesh group developed IH, compared with 7 of 72 (9.7%) in mesh group (OR 0.25, 95% CI 0.09-0.66, p<0.005). Patients of large tissue bites group showed higher prevalence of IH compared with small bites technique group without statistical significance (OR 0.46, 95% CI 0.17-1.24, p=0.119). The combination of mesh reinforcement and small bites technique for fascial closure significantly reduce IH risk (p=0.021). CONCLUSION: Incidence of IH is high in patients undergoing midline laparotomy for ovarian cancer or borderline ovarian tumor. The addition of a prophylactic mesh and use of small bites technique may reduce the incidence of IH and potentially minimize the social impact and costs of this complication.

O26 INFECTIOUS COMPLICATION IN RELATION TO THE PROPHYLACTIC MESH POSITION: THE PRIMA TRIAL REVISITED

Aim Prophylactic mesh reinforcement has proven to reduce the incidence of incisional hernia (IH). Fear of infectious complications may withhold the widespread implementation of prophylactic mesh reinforcement, particularly in the onlay position. Material and Methods Patients scheduled for elective midline surgery were randomly assigned to a suture closure group, onlay mesh group, or sublay mesh group. The incidence, treatment, and outcomes of patients with infectious complications were assessed through examining the adverse event forms. Data were collected prospectively for 2 years after the index procedure. Results Overall, infectious complications occurred in 14/107 (13.3%) patients in the suture group and in 52/373 (13.9%) patients with prophylactic mesh reinforcement (p = 0.821). Infectious complications occurred in 17.6% of the onlay group and 10.3% of the sublay group (p = 0.042). Excluding anastomotic leakage as a cause, these incidences were 16% (onlay) and 9.7% (sublay), p = 0.073. The mesh could remain in-situ in 40/52 (77%) patients with an infectious complication. The 2-year IH incidence after onlay mesh reinforcement was 10 in 33 (30.3%) with infectious complications and 15 in 140 (9.7%) without infectious complications (p = 0.003). This difference was not statistically significant for the sublay group. Conclusions Prophylactic mesh placement was not associated with increased incidence, severity, or need for invasive treatment of infectious complications compared with suture closure. Patients with onlay mesh reinforcement and an infectious complication had a significantly higher risk of developing an incisional hernia, compared with those in the sublay group.

O01 PROPHYLACTIC MESH PLACEMENT DURING FORMATION OF AN END-COLOSTOMY LONG TERM RCT ON EFFECTIVENESS AND SAFETY

Aim To determine if prophylactic mesh placement is an effective, safe, and cost-effective procedure to prevent parastomal hernia (PSH) formation in the long term. Material and Methods In this multicenter superiority trial patients undergoing formation of a permanent colostomy were randomly assigned to either retromuscular mesh reinforcement or conventional colostomy formation. The primary endpoint was the incidence of a PSH after 5 years. Secondary endpoints were morbidity, mortality, quality of life and cost-effectiveness. Results A total of 150 patients were randomly assigned to the mesh group (n = 72) or non-mesh group (n = 78). For the long term follow up, we could analyse 113 patients since 37 patients were lost to follow-up. After a median follow-up of 60 months (IQR 48.6 – 64.4), 49 patients developed a PSH, 20 (27.8%) in the mesh group and 29 (37.2%) in the non-mesh group (p = 0.22; 95% CI -24 – 5.5). A total of 25 patients developed an incisional hernia, seven in the mesh group (10.4%) versus 18 in the non-mesh group (27.2%) (p = 0.013, 95% CI 3.5 – 30.0). No relevant differences were found in quality of life or cost-effectiveness between both study group. Conclusions Use of a prophylactic retromuscular mesh at the ostomy site delays but not reduces the incidence of PSH after 5 years of follow-up. It leads to less severe PSH according to the EHS and MM classification with fewer repairs needed. Furthermore it causes patients to have fewer stoma related complications necessitating change of appliances and it is safe without any adverse events or increase in morbidity.

Reconstructing Nanohydroxyapatite Prosthesis Based on CT-Scanning Data and Its Application in Spinal Injury

This study investigated the nanohydroxyapatite (nHA) prosthesis application effect based on CT-scanning data in spinal injury. This study chose 26 spinal injury patients treated in our hospital from September 2017 to September 2018, who were randomly divided into two groups. nHA prosthesis based on CT-scanning data was implanted in the nHA group, whereas titanium mesh was implanted in the titanium mesh group. Consequently, osteoblasts were cultured to test the biological activity of nHA and titanium alloy. In cell tests, we found osteoblasts could better adhere to nHA, and proliferation and activity were higher when planted on nHA material. After surgical treatment, all patients’ spinal symptoms (VAS score, JOA score, and Cobb angle) had improved and did not cause obvious inflammatory foreign body reactions. During a two-year follow-up, the fusion time and support settlement in the nHA group was lower, and the vertebral fusion rate and ASIA score were higher than those in the titanium mesh group. Thus, CT-scanning data could further improve the vertebral fusion rate in the nHA group. Consequentially, nHA prosthesis based on CT-scanning data is a better choice for spinal injury therapy.

In Vivo Evaluation of a Pectin-Honey Hydrogel Coating on Polypropylene Mesh in a Rat Model of Acute Hernia

Investigations about ventral hernia repair are focused on improving the quality, resistance, and biocompatibility of mesh. This study compared plain polypropylene mesh with a pectin-honey hydrogel-coated polypropylene mesh in an acute hernia model in rats. Forty Wistar rats, randomly assigned to two groups, were submitted to laparotomy, and a 1 cm × 2 cm fascial defect was created, centered on the midline. Uncoated (group C) or coated mesh (group T) was inserted in an inlay fashion to repair the defect. After 30 days, the rats were euthanized, and the presence of adhesions to the mesh was macroscopically evaluated. Histology and measurement of COX-2 as tissue inflammation markers were used to assess fascia tissue healing. Grades of adhesion were not different between groups. Histological score and COX-2 expression were not significantly different between groups, except for the higher inflammatory response demonstrated in group T. The pectin-hydrogel coated mesh could not reduce adhesion formation compared to uncoated polypropylene mesh but improved peritoneal regeneration and tissue healing.

Prevention of incisional hernia at the site of stoma closure with different reinforcing mesh types: a systematic review and meta-analysis

Purpose To evaluate safety and efficacy of a mesh reinforcement following stoma reversal to prevent stoma site incisional hernia (SSIH) and differences across the prostheses used. Methods A systematic search of PubMed/MEDLINE, EMBASE, SCOPUS and Cochrane databases was conducted to identify comparative studies until September 2020. A meta-analysis of postoperative outcomes and a network meta-analysis for a multiple comparison of the prostheses with each other were performed. Results Seven studies were included in the analysis (78.4% ileostomy and 21.6% colostomy) with a total of 1716 patients with (n = 684) or without (n = 1032) mesh. Mesh placement was associated with lower risk of SSIH (7.8%vs18.1%, OR0.266,95% CI 0.123–0.577, p < 0.001) than no mesh procedures but also with a longer operative time (SMD 0.941, 95% CI 0.462–1.421, p < 0.001). There was no statistically significant difference in terms of Surgical Site infection (11.5% vs 11.1%, OR 1.074, 95% CI 0.78–1.48, p = 0.66), seroma formation (4.4% vs 7.1%, OR 1.052, 95% CI 0.64–1.73, p = 0.84), anastomotic leakage (3.7% vs 2.7%, OR 1.598, 95% CI 0.846–3.019, p = 0.149) and length of stay (SMD − 0.579,95% CI − 1.261 to 0.102, p = 0.096) between mesh and no mesh groups. Use of prosthesis was associated with a significant lower need for a reoperation than no mesh group (8.1% vs 12.1%, OR 0.332, 95% CI 0.119–0.930, p = 0.036). Incidence of seroma is lower with biologic than polypropylene meshes but they showed a trend towards poor results compared with polypropylene or biosynthetic meshes. Conclusion Despite longer operative time, mesh prophylactic reinforcement at the site of stoma seems a safe and effective procedure with lower incidence of SSIH, need for reoperation and comparable short-term outcomes than standard closure technique. A significant superiority of a specific mesh type was not identified.

Outcomes following abdominoperineal resection 6 years retrospective study at a rural district general hospital

Background: A range of surgical techniques are used for perineal wound closure following Abdominoperineal Excision of the Rectum (APER). The aim of this study was to assess the safety and effectiveness of using a biological mesh for perineal wound closure and to compare the outcomes following conventional suture and mesh closure of the perineal wound.Methods: A single-centre retrospective study of a cohort of patients undergoing surgery for low rectal cancer between January 2013 and December 2018. Patient records were analysed for outcomes including perineal complication rates, length of hospital stay and impact of patient factors on complication rates in mesh vs no mesh group.Results: Of the total 43 patients included in the study, 13 (30%) had a conventional perineal closure whereas 30 patients (70%) had a biological mesh reconstruction. Early perineal wound complications were seen in 21/43 (49%) patients. Of those, 6 (29%) patients were in the no mesh group compared to 15 (71%) patients in the mesh group (p = 0.81). 84% of the patients who received neo adjuvant radiotherapy (NART) developed perineal wound infection. There was no statistically significant difference in the mesh and no mesh groups. None of the patient factors, other than preoperative anaemia, had a statistically significant association with the rate of complications in either of the groups.Conclusions: There was no statistically significant difference in the complication rate between primary and biological mesh closure. Biological mesh is safe for perineal reconstruction following APER.

Long-Term Dynamic Changes in Cosmetic Outcomes and Patient Satisfaction after Implant-Based Postmastectomy Breast Reconstruction and Contralateral Mastopexy with or without an Ultrapro Mesh Sling Used for the Inner Bra Technique. A Retrospective Correlational Study

Immediate implant-based postmastectomy breast reconstruction (IPMBR) with contralateral symmetrization has mostly short-term limited evidence of cosmetic outcomes. Because 84% of early-stage breast cancer patients have overall survival of more than 10 years, reconstructed breast symmetry should provide long-lasting results and acceptable patient satisfaction. Ageing, changes in body weight, and biomechanical changes after IPMBR and symmetrization may contribute to symmetry worsening. This non-interventional single-centre retrospective correlational study presents the clinical and aesthetic results of synthetic ULTRAPRO® mesh inner bra sling symmetrization mastopexy with standard mastopexies. According to the results, a total of 59 patients were enrolled in the mesh group (MG), and 58 patients were enrolled in the non-mesh group (NMG). There were no significant differences in surgical complications (p = 0.521; chi-square). The median sternal notch-to-nipple distance difference was 1 cm in the MG and 3.5 cm in the NMG from the last follow-up, and the median nipple-to-inferior mammary fold distance differences were 0.5 cm and 0.75 cm. The mesh did not hinder the follow-up investigation. In conclusion, ULTRAPRO® mesh sling symmetrization can be successfully used to decrease pseudoptosis and nipple down-migration, offering a safe alternative for long-lasting symmetry and high patient satisfaction.