Management of Erosion of Graft Materials in Pelvic Floor Reconstruction

We present an overview of the current literature and management techniques for vaginal extrusion or urinary tract erosion of graft materials used in pelvic floor reconstruction. A MEDLINE search was performed to identify literature pertaining to the incidence and management of vaginal or urinary tract exposure of graft materials commonly used in anti-incontinence and pelvic floor reconstructive procedures. Dependent on the type of mesh material used, a vaginal extrusion rate of up to 77% has been reported. The currently accepted, loosely woven, monofilament type I polypropylene meshes appear to have acceptable lower exposure rates in the range of 1–3% for slings, but with the larger area of mesh used in prolapse repairs, the rate increases to up to 10%. With the current widespread use of graft materials to reinforce pelvic floor reconstructive techniques, it is imperative for surgeons to be familiar with potential complications related to the materials and proper management of these complications. Although it is beginning to appear that the benefit of using some synthetic materials may outweigh the risks, proper management and understanding of the risks is important in order to counsel our patients appropriately and responsibly prior to their surgeries

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

Practice patterns in the diagnosis and treatment of fecal incontinence with sacral neuromodulation: Can urologists impact this gap in care?

ObjectiveThe prevalence of fecal incontinence (FI) is 8% in the United States. Many patients will not seek treatment and the condition is underdiagnosed. Sacral neuromodulation (SNM) is effective in treating FI, and so urologists can play a key role in its treatment. We examine the practice patterns and treatment of FI with SNM in our institution.Material and methodsThe electronic medical record was queried for the proportion of patients seen for FI in the institution, the urology department, and among the female pelvic medicine and reconstructive surgery (FPMRS) urologists. The patients who underwent SNM for FI were evaluated for progression to second stage procedure.ResultsThe proportion of patients seen for FI is 0.96% in the institution as a whole, 7.9% in the urology department, and 17.9% among FPMRS urologists. Fourteen patients underwent first stage SNM for FI or dual urinary/fecal incontinence, and they all progressed to a second stage procedure. Thirteen of these were performed by FPMRS urologists.ConclusionIn our institution, the proportion of patients seen for FI was lower than the prevalence of this condition. Because patients with urinary incontinence are more likely to have FI, urologists are in a unique position to identify these patients and offer treatment that can improve their quality of life. We acknowledge a gap in care of the patients with FI and an opportunity for urologists to help patients with this devastating yet treatable condition

Long-Term Follow-up of Polypropylene Bone Anchored Slings

Introduction The transvaginal bone anchored polypropylene sling (BAS) has proven to be a successful treatment for patients with SUI. However, there is limited data on long-term outcomes following BAS with polypropylene mesh. We report our series of patients who had at least 3 years of follow-up after placement of BAS. Materials and Methods A retrospective review of prospectively collected data of patients undergoing BAS for stress urinary incontinence (SUI) with minimum 3 year follow-up was performed. Outcomes and complications were determined from annual mailed post-operative questionnaires. Results 142 patients who had undergone BAS and had answered post-operative questionnaires at a minimum of 3 years were identified. Average follow-up was 58 months (range 36-97 months). The overall success rate was 71% with a dry rate of 27%. Complications occurred in 9% of patients, more commonly in patients without a history of anti-incontinence procedure. Conclusions Although less commonly used, BAS with polypropylene mesh is associated with an acceptable success rate at long term follow-up but a low completely dry rate

“Beyond the Bump” – Insight Into the Postpartum Women's Experience of Pelvic Organ Prolapse as Expressed on Reddit

To qualitatively analyze the biopsychological experiences of postpartum women regarding pelvic organ prolapse (POP) as expressed on Reddit, a widely used internet platform for anonymous discussion and information sharing. POP is a prevalent condition in postpartum women, yet personal experiences are often not discussed due to social stigma. “Beyondthebump,” a Subreddit forum for postpartum mothers with >57,000 subscribers, was queried for “prolapse” to collect postings on POP in August 2018. Posts were analyzed qualitatively by 2 independent researchers. The principles of grounded theory were applied and preliminary themes were generated. These themes were used to derive emergent concepts. We analyzed 28 unique posts with 390 responses from 2014 to 2018. Qualitative analysis yielded 3 preliminary themes. (1) Women were unaware POP could occur postpartum and frustrated by the lack of prenatal discussion. (2) Women expressed a need for supportive, comprehensive, and immediate care. (3) Attributed symptoms of POP included pain and discomfort, causing difficulty with daily life. Three emergent concepts were derived. (1) POP is a difficult, debilitating condition with mental and physical effects. (2) Women with POP were self-driven and actively sought help. (3) There was motivation to increase POP awareness. Postpartum women's perspectives on POP focused on the difficulty of continuing life routines, self-drive for improvement, and motivation to raise awareness for others. Through learning from women's self-reported experiences, physicians can better meet women's needs and improve care for POP

A Rapid Method to Preoperatively Assess Frailty for Older Patients with Pelvic Floor Conditions

Purpose: Assessment of frailty can help surgeons predict perioperative risk and guide preoperative counseling. However, current methods are often cumbersome in the clinical setting. We prospectively compared the effectiveness of a rapid picture based Clinical Frailty Scale (CFS-9) assessed by patient and surgeon against reference standard Fried Frailty Index in older patients with pelvic floor conditions. Materials and Methods: We enrolled 71 patients between March 2018 and June 2019. Frailty assessment using CFS-9 (scale ranging from very fit to terminally ill) was performed followed by the Fried Frailty Index, a validated tool of 5 measures (shrinking, physical energy, activity, grip strength, walking speed). Correlations and agreement between Fried Frailty Index and CFS-9 scores from the treating surgeon, a second surgeon (surgeon 2) and patient were analyzed using sensitivity, specificity, area under the curve and Cohen's Kappa. Results: The patient cohort was mostly female (97.2%), with a mean age (+/- SD) of 73.0 (+/- 5.9) years and 23.9% were frail using the Fried Frailty Index. Compared to the Fried Frailty Index, CFS-9 scores of the treating surgeon, surgeon 2 and patient had AUC values (95% CI) of 0.86 (0.77-0.86), 0.91 (0.84-0.91) and 0.88 (0.79-0.88), respectively. As assessed by Cohen's Kappa the CFS-9 scores all had substantial (surgeon 2, Kappa 0.66, 95% CI 0.46-0.85 or moderate (all other CFS9 measures, Kappa 0.44 to 0.58) agreement with the Fried Frailty Index scores. Conclusions: Rapid and effective validated tools to screen for frailty are needed in the clinical setting. CFS- 9 is an excellent predictor of frailty compared to the Fried Frailty Index for patients with pelvic floor conditions