Differentiated polypropylene tension free sling (T-Sling) in noninvasive treatment of pubocervical fascia defects. 5-year follow up
Authors : Ceresoli A, Guarneri A, Colombo F, Seveso M, Grasso Macola G, Cazzaniga A, Romano’ Ai Ling
Institution: Cattedra di Urologia II di Milano – Ospedale Classificato “San Giuseppe”
INTRODUCTION AND AIM OF THE STUDY
Effectiveness and tolerance of a differentiated polypropylene (PP) partially absorbable tension-free sling deliverable by transobturator (TO) access in vaginal treatment of cystocele associated with type II stress urinary incontinence was assessed in a 5 – year retrospective study.
MATERIALS AND METHODS
The T-Sling is a mesh composed of 2 different materials.The 2 lateral aspects of the mesh are composed of a 2 cm-width monofilament nonabsorbable polypropylene mesh with a 1-cm center absorbable monofilament of polydioxanone (PDO).After anterior repair the T sling has been delivered by TO access and alligned under the proximal urethra and the bladder. All patients had a urinary questionaire, voiding diary,preoperative multichannel urodynamics studies and cystography. Cure was defined as subjective patient satisfaction with negative objective evaluation.Failure as subjective patient’s unsatisfaction and poor objective results.Improvement was defined as not having achieved the results of cure.48 patients with grade II and III anterior wall prolapse according to Baden Walker classification , had been treated by vaginal route with cystocele repair and interposition of the differentiated PP tension freee sling positioned underneath the proximal urethra and the bladder neck with TO approach.22(45,8%) had grade IIa and 16(33,3%) grade IIb anterior vaginal prolapse with stress urinary incontinence secondary to urethral hypermobility.10(20,8%) patients without preoperative stress urinary incontinence had grade III anterior vaginal prolapse symptomatic for low urinary tract syndrome
RESULTS
Cure was reached in 44 (91,6%) of the patients, improvement was found in 3 patients (6,2%). Early postoperative complications were 3 cases of urinary infection - treated successfully with wide spectrum antibiotics- and 1 local cutaneous hematoma reabsorbed in 15 days.There were observed 1 early urethral erosion, 2 early vaginal erosion and 3 late vaginal erosion. Excision of single side of the mesh was sufficient to cure patient preserving functional results. No incidence of de novo detrusor instability or cystocele recurrence has been showed in the long term follow up ranging from 6 to 65 months, mean 42,2 months . 3 (6,2%) patients complained partial urinary incontinence relapse within 4 months from operation
DISCUSSION
Polypropylene has long term follow up showing excellent results providing a durable framework for the in – growth of collagen with a high tolerance to infection and has been found to be safely used in the treatment of Stress Urinary Incontinence (SUI) .
Synthetic material should provide a nonantigenic framework that is gradually interlaced or replaced by host fibroplasia resulting in a strong stable aponeurotic structure.Within a twelve month interval synthetic flat meshes shrink up to 20-30% contribuiting to an increase in pressure on the urethra or contigous organs causing tardive retention and urethral erosion leading to a secondary surgical procedure. These harmful complications however may suggest not to place synthetic slings against visceral organs such as bladder and urethra, if possible. There is also an evidence indicating a relationship between post-operative complications and the mesh design with a correlation between voiding disorders after sling procedure and distance of the sling from the bladder neck. Incorporation of absorbable PDO material central into the design of the sling allows a surgical implantation of PP away from the urethra and the bladder neck in a tension free fashion preserving urethral vascular supply , mucosal seal and preventing from tardive outlet obstruction. When the PP material is placed into the body a fibroblastic reaction is produced that is immediate and allows it to remain in place. After hydrolysis dissolved the central portion, the 2 non absorbable portion are detached from themselves rendering a true “tension free sling” under the urinary tract and far away from direct contact of the urethra and bladder. .When placed from one arcus tendinous to the other the 2 ends of PP create a fibroblastic reaction rebuilding the primary anatomic preoperative defect of the pubocervical fascia by secondary intention.
CONCLUSION
In these series vaginal implantation of the new differentiated PP, partially absorbable T-Sling has been shown to be an effective procedure alternative to open surgery procedures in treatment of the cystocele associated with urethral hypermobility. Differentiated PP T-Sling procedure when delivered via TO approach showed no major perioperative complications , resulting in a efficient minimally invasive technique with a short hospital stay and low morbidity either at short term results and at medium follow up
REFERENCES
1) Kuo HC Anatomical and functional results of pubovaginal sling procedure using polypropylene mesh for the treatment of stress urinary incontinence, J.Urology. 2001;166:152-157
2) Delorme E,Droupy S,de Tayrac R,Delmas V Transobturator tape (Uratape):a new minimally-invasive procedure to treat female urnary incontinence. Eur.Urol. 2004 Feb;45(2):203-7
Authors : Ceresoli A, Guarneri A, Colombo F, Seveso M, Grasso Macola G, Cazzaniga A, Romano’ Ai Ling
Institution: Cattedra di Urologia II di Milano – Ospedale Classificato “San Giuseppe”
INTRODUCTION AND AIM OF THE STUDY
Effectiveness and tolerance of a differentiated polypropylene (PP) partially absorbable tension-free sling deliverable by transobturator (TO) access in vaginal treatment of cystocele associated with type II stress urinary incontinence was assessed in a 5 – year retrospective study.
MATERIALS AND METHODS
The T-Sling is a mesh composed of 2 different materials.The 2 lateral aspects of the mesh are composed of a 2 cm-width monofilament nonabsorbable polypropylene mesh with a 1-cm center absorbable monofilament of polydioxanone (PDO).After anterior repair the T sling has been delivered by TO access and alligned under the proximal urethra and the bladder. All patients had a urinary questionaire, voiding diary,preoperative multichannel urodynamics studies and cystography. Cure was defined as subjective patient satisfaction with negative objective evaluation.Failure as subjective patient’s unsatisfaction and poor objective results.Improvement was defined as not having achieved the results of cure.48 patients with grade II and III anterior wall prolapse according to Baden Walker classification , had been treated by vaginal route with cystocele repair and interposition of the differentiated PP tension freee sling positioned underneath the proximal urethra and the bladder neck with TO approach.22(45,8%) had grade IIa and 16(33,3%) grade IIb anterior vaginal prolapse with stress urinary incontinence secondary to urethral hypermobility.10(20,8%) patients without preoperative stress urinary incontinence had grade III anterior vaginal prolapse symptomatic for low urinary tract syndrome
RESULTS
Cure was reached in 44 (91,6%) of the patients, improvement was found in 3 patients (6,2%). Early postoperative complications were 3 cases of urinary infection - treated successfully with wide spectrum antibiotics- and 1 local cutaneous hematoma reabsorbed in 15 days.There were observed 1 early urethral erosion, 2 early vaginal erosion and 3 late vaginal erosion. Excision of single side of the mesh was sufficient to cure patient preserving functional results. No incidence of de novo detrusor instability or cystocele recurrence has been showed in the long term follow up ranging from 6 to 65 months, mean 42,2 months . 3 (6,2%) patients complained partial urinary incontinence relapse within 4 months from operation
DISCUSSION
Polypropylene has long term follow up showing excellent results providing a durable framework for the in – growth of collagen with a high tolerance to infection and has been found to be safely used in the treatment of Stress Urinary Incontinence (SUI) .
Synthetic material should provide a nonantigenic framework that is gradually interlaced or replaced by host fibroplasia resulting in a strong stable aponeurotic structure.Within a twelve month interval synthetic flat meshes shrink up to 20-30% contribuiting to an increase in pressure on the urethra or contigous organs causing tardive retention and urethral erosion leading to a secondary surgical procedure. These harmful complications however may suggest not to place synthetic slings against visceral organs such as bladder and urethra, if possible. There is also an evidence indicating a relationship between post-operative complications and the mesh design with a correlation between voiding disorders after sling procedure and distance of the sling from the bladder neck. Incorporation of absorbable PDO material central into the design of the sling allows a surgical implantation of PP away from the urethra and the bladder neck in a tension free fashion preserving urethral vascular supply , mucosal seal and preventing from tardive outlet obstruction. When the PP material is placed into the body a fibroblastic reaction is produced that is immediate and allows it to remain in place. After hydrolysis dissolved the central portion, the 2 non absorbable portion are detached from themselves rendering a true “tension free sling” under the urinary tract and far away from direct contact of the urethra and bladder. .When placed from one arcus tendinous to the other the 2 ends of PP create a fibroblastic reaction rebuilding the primary anatomic preoperative defect of the pubocervical fascia by secondary intention.
CONCLUSION
In these series vaginal implantation of the new differentiated PP, partially absorbable T-Sling has been shown to be an effective procedure alternative to open surgery procedures in treatment of the cystocele associated with urethral hypermobility. Differentiated PP T-Sling procedure when delivered via TO approach showed no major perioperative complications , resulting in a efficient minimally invasive technique with a short hospital stay and low morbidity either at short term results and at medium follow up
REFERENCES
1) Kuo HC Anatomical and functional results of pubovaginal sling procedure using polypropylene mesh for the treatment of stress urinary incontinence, J.Urology. 2001;166:152-157
2) Delorme E,Droupy S,de Tayrac R,Delmas V Transobturator tape (Uratape):a new minimally-invasive procedure to treat female urnary incontinence. Eur.Urol. 2004 Feb;45(2):203-7
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