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Section 8. Medical science
However, accumulation of VPA in carriers of CYP2C9*3 poly- carriers of polymorphic allelic variants CYP2C9*3 compared
morphism can be traced not all authors [12]. On the other with carriers of “wild” polymorphic allelic variant is shown in a
hand, a higher concentration of VPA in the blood is shown in study conducted in Japan [9].
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Dovlatov Zyaka Asaf ogly, City Clinical Botkin Hospital, Moscow, Russia, urologist, E-mail: dovlatov.zyaka@mail.ru Seregin Alexander Vasilyevich, chief of Urology Department E-mail: 41urology@41urology.ru Loran Oleg Borisovich,
Russian Medical Academy of Postgraduate Education, Moscow, Russia, chief of Urology and Chirurgical Andrology Department E-mail: oleg_loran@gmail.com
Late complications and quality of life of women after using mesh implants for the pelvic organ prolapsed
Abstract: Great experience clinical use mesh implants for pelvic organ prolapse treatment was the basis for achieving a low incidence of postoperative complications and high quality of life after surgery.
Keywords: pelvic organ prolapse, complications, quality of life.
Introduction 3 % and 94 %, depending on the approaches to the for-
The frequency of pelvic organ prolapse (POP) in the mation of a population sample and diagnosis of the dis-
female population according to various sources is between ease [1, 15-107]. Currently, synthetic mesh implants occupy
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Late complications and quality of life of women after using mesh implants for the pelvic organ prolapsed
a leading position in the treatment of POP, which became possible due to their properties such as strength and durability, pathogenesis based concept of establishment, minimal invasiveness and morbidity [2, 168-174]. However, most studies aimed at evaluating the results of the use of mesh implants for the treatment of POP have a short period of follow-up (12 months) [3, 22-30; 4, 117-126]. This fact determines the relevance of research on the long-term results of the use of synthetic materials for the treatment of POP in women.
Materials and methods
Surgical treatment using mesh implants performed in 376 women aged 43-76 years (median — 64 years) with the POP stage II-IV according to the classification POP-Q in the City Clinical Botkin Hospital (Moscow) in the period from 2004 to 2014. System Prolift™ (Gynecare, USA) was used in 286 (76.1 %) women, the system Prolift+M™ (Gynecare, USA) — 90 (23.9 %). Total reconstruction of the pelvic floor was performed in 220 (58.5 %) patients (Prolift™ and Prolift+MTM — in 167 and 53 patients, respectively), the reconstruction of the anterior region of the pelvic floor — in 69 (18.4 %) patients (Prolift™ and Prolift+MTM — in 51 and 18 patients, respectively), the reconstruction of the posterior region of the pelvic floor — in 87 (23.1 %) patients (Prolift™ and Prolift+MTM — in 68 and 19 patients, respectively). The following surgical procedures are performed because of concomitant diseases: vaginal hysterectomy for benign diseases of the uterus (uterine fibroids, adenomyosis, endometrial hyperplasia) — in 64 (17.0 %) patients; abdominal hysterectomy — in 4 (1.1 %) patients; hysterotrachelectomy because its elongation — 24 (6.4 %) patients; kolpoperineol-evatoroplastiku — 32 (8.5 %) patients; front colporrhaphy — in 2 (0.5 %) patients; setting synthetic suburethral tape (TVT or TVT-O) for incontinence — in 149 (39.6 %) patients.
We use two specific questionnaires to assess quality of life of patients: Pelvic Floor Distress Inventory-20 (PFDI-20) and Pelvic Floor Impact Questionnaire-7 (PFIQ-7). Quality of life was assessed before surgery and at 1, 6, 12 months after surgery, and in the future — 1 once a year. Terms of follow-up of patients ranged from 6 to 110 months (median — 52 months).
Statistical analysis performed using the program Statis-tica v. 17.0 (StatSoft, USA). Comparing groups of patients on various parameters are made using the criterion x2, the dynamics of quality of life was assessed using the Wilcoxon method. The difference between the compared parameters were considered significant at the level of statistical significance (P < 0.05).
Results and discussion
During this period of follow-up recurrence of prolapse was observed in 14 (3.7 %) patients, out ofwhich 12 patients re-set mesh prosthesis and two patients with POP stage II with minimal clinical signs of disease conducted conservative treatment. After re-establishment of the implant in any case there was no recurrence. This result of POP treatment can be considered relatively good. For example, according
to a systematic review B. Feiner et al. [5, 15-24], based on the analysis of treatment outcomes in 2653 women in 30 different studies, the objective success of the treatment of POP using mesh implants range from 87 % to 95 %.
Late complications after surgery occurred in 32 (8.5 %) patients. When using Prolift™ rate of complications was 8.7 % (25/286), Prolift+MTM — 7.8 % (7/90). These types of mesh prosthesis did not differ significantly in frequency of late complications (P = 0.071). The following types of late postoperative complications occurred among all patients: vaginal erosion — in 9 (2.4 %) patients, dyspareunia — in 8 (2.1 %), overactive bladder de novo — in 5 (1.3 %), prosthesis displacement t — in 4 (1.1 %), urge urinary incontinence de novo — in 3 (0.8 %), stress urinary incontinence de novo — in 2 (0.5 %), recurrent stress urinary incontinence — in 1 (0.3 %).
Vaginal erosion is one of the most frequent specific complications associated with prosthetic mesh. Six of the nine patients erosion occurred on the front wall of the vagina, four — on the back. The implant is removed only in one patient when vaginal erosion combined with the displacement of the implant. Our results can be considered good enough, since the frequency of vaginal erosion of more than 5 % in most studies in recent years [6, 293-303; 7, 511-517]. The low incidence of vaginal erosion achieved due to the fact that we have eliminated the major risk factors of erosion: a T-shaped incision of the vagina, excessive excision vaginal tissue, lack screened vaginal tissue, the location of the prosthesis on vesico-vaginal and recto-vaginal fascia, the use of coalescent [8, 315-320].
Dyspareunia occurs on average 14 % according to a systematic review [9, 170-180]. The relatively low percentage of complications in our study was the result of perfect precision surgical technique and adequate postoperative rehabilitation of patients.
The displacement of the prosthesis occurs up to 35 % of cases reported in the literature [6, 293-303; 10, 242-250; 11, 529-534]. Low frequency of the prosthesis displacement we have achieved by providing a weak lateral tension when installing the implant, early treatment of the prosthesis erosions, and adequate action to reduce the risk of infection of the prosthesis (strict aseptic conditions, preoperative antibiotic and antibacterial treatment of complications). All four cases of prosthesis displacement occurred when the total reconstruction of the pelvic floor: two cases of complications occurred during the first month after treatment, the two — six months. It should be added that all patients in whom there was a displacement of the prosthesis does not comply with the recommendation to limit physical activity. The prosthesis is removed in only one case, when the displacement of the prosthesis combined with vaginal erosion (this case is described above), laparoscopic sacro-vaginal fixation of the prosthesis in combination with subtotal hysterectomy is performed in the other three cases.
The following treatment was performed for other complications. Sling surgery (TVT-O) was performed in 1 patient
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with recurrent stress urinary incontinence and 2 patients with stress urinary incontinence de novo, 3-month treatment with M-anticholinergics performed in all patients with urge urinary incontinence de novo and overactive bladder de novo.
The following features are found in the evaluation of the quality of life of patients using questionnaires PFDI-20 after surgery. The median quality of life decreased from preoperative 210 points to 124 points in 1 month after surgery (P = 0.001). This parameter has decreased significantly from 124 to 76 points 6 months after surgery (P = 0.002). The median quality of life was 72 points within 12 months after surgery, and this value is not different from the previous value (P = 0.592). The median quality of life later than 12 months after surgery was 75 points, and this value is not significantly different from the values achieved at 12 months (P = 0.614).
Similar trends in the quality of life and established by using a questionnaire PFIQ-7. The median quality of life before
surgery was 257 points, 1 month after surgery — 96 points (P < 0.001), at 6 months after surgery — 58 points (P = 0.002), 12 months after surgery — 55 points (P = 0.585), and in terms of more than 12 months after surgery — 60 points (P = 0.549).
Thus, the quality of life of patients significantly improved after use of mesh prosthesis for the treatment of POP during the first 6 months after surgery, in the future, it remains stable at the level reached in 6 months.
Conclusion
Great experience of use of the mesh prosthesis for the treatment of women POP enhance the effectiveness of the correction of this disease and reduce the incidence of postoperative complications. These results led naturally to improve the quality of life of patients after surgery compared to its preoperative condition.
Conflict of interest
The authors have no conflicts of interest.
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