**2.2.3 TVT versus TOT outcomes**

TVT and TOT since their introduction in the treatment of female SUI have gained a great popularity and wide spread use in a large number of studies. Both techniques showed nearly equal efficacy with more than 80% cure rate in the majority of studies as mentioned before (Table 2, table 3). Novara et al, in a large systematic review and meta-analysis showed that patients treated with TVT had slightly higher objective cure rates (OR: 0.8;CI: 0.65–0.99; p = 0.04) than those treated with TOT; however, subjective cure rates were similar in both technique **(Novara et al, 2010)**. In a long term follow-up after 5 years both TVT and TVT-O procedures were safe, with equivalent results (72.9% and 71% of patients objectively cured after TVT-O and TVT, respectively) **(Angioli et al, 2010)**.

#### **2.3 Material used for midurethral slings**

Over the past years there was a great evolution in the use of biological and synthetic materials in the treatment of different reconstructive pelvic surgery e.g. SUI and pelvic organ prolapse (POP) in an effort to improve surgical outcomes. However, the potential benefits of using grafts need to be carefully balanced against the risks of using foreign materials to the patient's body. Amid in 1997 published a classification for synthetic mesh used in abdominal hernia surgery based on the pore size (macroporous, microporous, submicro-porous) and fiber type (monofilaments or multifilament) of the synthetic mesh **(Amid, 1997)**. Synthetic grafts may be non-absorbable, absorbable, or a mixture of the two. The non-absorbable polypropylene mesh is the most common type used in reconstructive pelvic surgery. Synthetic tapes available in the market for urogynecological practice see (table 4).

Futuristic Concept in Management

with its use.

of Female SUI: Permanent Repair Without Permanent Material 297

bacterial colonisation within the interstices is impaired **(Winters et al, 2006)**. Monofilament mesh does not have small interstices and the risk of mesh infection and erosion is reduced

Fig. 3. Terminology used to classify synthetic implants. Magnified view of a part of a polypropylene tape as used for TVT procedure (Gynaecare, Johnson and Johnson) with

Biological implants have many sources; they may be an autologous graft (derived from the patient's own body tissue), allograft (derived from post-mortem tissue banks) or xenograft (derived from animals) **(Dwyer, 2006)**. Types of biologic implants available in the market

**Biological types Component Trade name** 

Fascia lata Vaginal mucosa

submucosal collagen Porcine non cross-linked dermal collagen Porcine dermal cross-linked collagen

Fetal bovine skin derived collagen scaffold

Bovine non-cross-linked pericardium

Table 5. Classification of biologic implant materials marketed for urogynecologic indications

Dura mater Lyodura

Surgisis (Cook)

InteXen (AMS) Pelvicol, Pelvisoft, Pelvilace (Bard) Xenform (Boston Scientific) Veritas (Synovis)

identification of filament type, interstitium, and pore size **(Deprest et al, 2006).** 

that can be used in urogynecology practice (table 5):

**Autologous grafts** Rectus fascia

**Allografts** Fascia lata

**(Deprest et al, 2006).** 

**Xenografts** Porcine non-cross-linked small intestine

The pore size and interstices distance between the fibers (figure 3) are important mesh characteristics that determine whether host inflammatory cell and fibroblasts can penetrate the mesh or not. The ideal synthetic tapes used for the treatment of SUI should have the following characters: made of polypropylene, low weight, macroporous, monofilament mesh, with an elasticity between 20 and 35%, as these tapes have a lower incidence of infection and tissue erosion **(Rosch et al, 2004; Deprest et al, 2006).**


**PTFE:** Polytetrafluoroethylene

**a** Collagen coated macroporous polypropylene materials.

**b** Several kinds of Surgipro (Tyco) materials are marketed under the same name and have different constructs.

Table 4. Classification and characteristics of synthetic implant materials marketed for urogynecologic indications **(Deprest et al, 2006).** 

Type I macroporous mesh with (pore size >75 μm) allowing easier penetration of inflammatory cells such as leukocytes (9–15 μm), macrophages (16–20 μm), fibroblast and blood vessels into the graft to phagocytose bacteria (<1 μm) lowering the risk of infection, in addition host tissue in growth and incorporation is promoted resulting in good support. On the other hand, multifilament meshes have interstices that are <10 μm and bacteria (<1 μm) can replicate within these interstices. However, access to macrophages and ability to fight

The pore size and interstices distance between the fibers (figure 3) are important mesh characteristics that determine whether host inflammatory cell and fibroblasts can penetrate the mesh or not. The ideal synthetic tapes used for the treatment of SUI should have the following characters: made of polypropylene, low weight, macroporous, monofilament mesh, with an elasticity between 20 and 35%, as these tapes have a lower incidence of

**Pore size classification Component Trade name Fibre type** 

Prolene, Gynemesh, Gynemesh PS (Ethicon) Marlex, Pelvitex a (Bard) Surgipro b SPMM (Tyco) Vypro (Ethicon)

Monofilament

Monofilament Monofilament Monomultifilament

multifilament

multifilament multifilament multifilament multifilament

multifilament

Cellgard Monofilament

Vicryl (Ethicon)

Expanded PTFE Gore-Tex (Gore) multifilament

Mersilene (Ethicon) Teflon (Gore) Surgipro b SPM (Tyco) Surgipro b SPMW (Tyco)

Mycro-mesh (Gore)

infection and tissue erosion **(Rosch et al, 2004; Deprest et al, 2006).**

Polypropylene

Polypropylene/ Polyglactin 910 Polyglactin 910

Polyethylene PTFE Braided polypropylene Braided polypropylene– open weave Perforated Expanded PTFE

Polypropylene sheet

**b** Several kinds of Surgipro (Tyco) materials are marketed under the same name and have different

Type I macroporous mesh with (pore size >75 μm) allowing easier penetration of inflammatory cells such as leukocytes (9–15 μm), macrophages (16–20 μm), fibroblast and blood vessels into the graft to phagocytose bacteria (<1 μm) lowering the risk of infection, in addition host tissue in growth and incorporation is promoted resulting in good support. On the other hand, multifilament meshes have interstices that are <10 μm and bacteria (<1 μm) can replicate within these interstices. However, access to macrophages and ability to fight

Table 4. Classification and characteristics of synthetic implant materials marketed for

**Type I: Totally macroporous (pore size of >75 μm)** 

**Type II: Totally microporous (pore size of <10 μm)** 

**Type III: Micro or macro-micro** 

**Type IV: Submicronic pore size (pore size of <1 μm)** 

**PTFE:** Polytetrafluoroethylene

constructs.

**a** Collagen coated macroporous polypropylene materials.

urogynecologic indications **(Deprest et al, 2006).** 

bacterial colonisation within the interstices is impaired **(Winters et al, 2006)**. Monofilament mesh does not have small interstices and the risk of mesh infection and erosion is reduced with its use.

Fig. 3. Terminology used to classify synthetic implants. Magnified view of a part of a polypropylene tape as used for TVT procedure (Gynaecare, Johnson and Johnson) with identification of filament type, interstitium, and pore size **(Deprest et al, 2006).** 

Biological implants have many sources; they may be an autologous graft (derived from the patient's own body tissue), allograft (derived from post-mortem tissue banks) or xenograft (derived from animals) **(Dwyer, 2006)**. Types of biologic implants available in the market that can be used in urogynecology practice (table 5):


Table 5. Classification of biologic implant materials marketed for urogynecologic indications **(Deprest et al, 2006).** 

Futuristic Concept in Management

surgery **(Haylen et al, 2011).** 

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Fig. 4. A classification by category (C), time (T), and site (S) of complications directly related to the insertion of prostheses (meshes, implants, tapes) or grafts in female pelvic floor
