Objective Define the impact of prolapse mesh on the biomechanical properties of the vagina by comparing the prototype Gynemesh PS (Ethicon, Somerville, NJ) to 2 new generation lower stiffness meshes, SmartMesh (Coloplast, Minneapolis, MN) and UltraPro (Ethicon). Design A study employing a non-human primate model Setting University of Pittsburgh Population 45 parous rhesus macaques Methods Meshes were implanted via sacrocolpexy after hysterectomy and compared to Sham. Because its stiffness is highly directional UltraPro was implanted in two directions: UltraPro Perpendicular (less stiff) and UltraPro Parallel (more stiff), with the indicated direction referring to the blue orientation lines. The mesh-vaginal complex (MVC) was excised en toto after 3 months. Main Outcome Measures Active mechanical properties were quantified as contractile force generated in the presence of 120 mM KCl. Passive mechanical properties (a tissues ability to resist an applied force) were measured using a multi-axial protocol. Results Vaginal contractility decreased 80% following implantation with the Gynemesh PS (p=0.001), 48% after SmartMesh (p=0.001), 68% after UltraPro parallel (p=0.001) and was highly variable after UltraPro perpendicular (p =0.16). The tissue contribution to the passive mechanical behavior of the MVC was drastically reduced for Gynemesh PS (p=0.003) but not SmartMesh (p=0.9) or UltraPro independent of the direction of implantation (p=0.68 and p=0.66, respectively). Conclusions Deterioration of the mechanical properties of the vagina was highest following implantation with the stiffest mesh, Gynemesh PS. Such a decrease associated with implantation of a device of increased stiffness is consistent with findings from other systems employing prostheses for support.

Objective To compare the impact of the prototype prolapse mesh Gynemesh PS to that of two new generation lower stiffness meshes, UltraPro and SmartMesh, on vaginal morphology and structural composition. Design A mechanistic study employing a non-human primate (NHP) model. Setting Magee-Womens Research Institute at the University of Pittsburgh. Population Parous rhesus macaques, with similar age, weight, parity and POP-Q scores. Methods Following IACUC approval, 50 rhesus macaques were implanted with Gynemesh PS (n=12), UltraPro with its blue line perpendicular to the longitudinal axis of vagina (n=10), UltraPro with its blue line parallel to the longitudinal axis of vagina (n=8) and SmartMesh (n=8) via sacrocolpopexy following hysterectomy. Sham operated animals (n=12) served as controls. Main Outcome Measures The mesh-vagina complex (MVC) was removed after 12 weeks and analyzed for histomorphology, in situ cell apoptosis, total collagen, elastin, glycosaminoglycan content and total collagenase activity. Appropriate statistics and correlation analyses were performed accordingly. Results Relative to sham and the two lower stiffness meshes, Gynemesh PS had the greatest negative impact on vaginal histomorphology and composition. Compared to sham, implantation with Gynemesh PS caused substantial thinning of the smooth muscle layer (1557 ± 499μm vs 866 ± 210 μm, P=0.02), increased apoptosis particularly in the area of the mesh fibers (P=0.01), decreased collagen and elastin content (20% (P=0.03) and 43% (P=0.02), respectively) and increased total collagenase activity (135% (P=0.01)). GAG (glycosaminoglycan), a marker of tissue injury, was the highest with Gynemesh PS compared to sham and other meshes (P=0.01). Conclusion Mesh implantation with the stiffer mesh Gynemesh PS induced a maladaptive remodeling response consistent with vaginal degeneration.

BACKGROUND Despite good anatomic and functional outcomes, urogynecologic polypropylene meshes that are used to treat pelvic organ prolapse and stress urinary incontinence are associated with significant complications, most commonly mesh exposure and pain. Few studies have been performed that specifically focus on the host response to urogynecologic meshes. The macrophage has long been known to be the key cell type that mediates the foreign body response. Conceptually, macrophages that respond to a foreign body can be dichotomized broadly into M1 proinflammatory and M2 proremodeling subtypes. A prolonged M1 response is thought to result in chronic inflammation and the formation of foreign body giant cells with potential for ongoing tissue damage and destruction. Although a limited M2 predominant response is favorable for tissue integration and ingrowth, excessive M2 activity can lead to accelerated fibrillar matrix deposition and result in fibrosis and encapsulation of the mesh. OBJECTIVE The purpose of this study was to define and compare the macrophage response in patients who undergo mesh excision surgery for the indication of pain vs a mesh exposure. STUDY DESIGN Patients who were scheduled to undergo a surgical excision of mesh for pain or exposure at Magee-Womens Hospital were offered enrollment. Twenty-seven mesh-vagina complexes that were removed for the primary complaint of a mesh exposure (n = 15) vs pain in the absence of an exposure (n = 12) were compared with 30 full-thickness vaginal biopsy specimens from women who underwent benign gynecologic surgery without mesh. Macrophage M1 proinflammatory vs M2 proremodeling phenotypes were examined via immunofluorescent labeling for cell surface markers CD86 (M1) vs CD206 (M2) and M1 vs M2 cytokines via enzyme-linked immunosorbent assay. The amount of matrix metalloproteinase-2 (MMP-2) and matrix metalloproteinase-9 (MMP-9) proteolytic enzymes were quantified by zymography and substrate degradation assays, as an indication of tissue matrix degradation. Statistics were performed with the use of 1-way analysis of variance with appropriate post hoc tests, t-tests, and Fisher’s Exact test. RESULTS Twenty-seven mesh-vaginal tissue complexes were excised from 27 different women with mesh complications: 15 incontinence mid urethral slings and 12 prolapse meshes. On histologic examination, macrophages surrounded each mesh fiber in both groups, with predominance of the M1 subtype. M1 and M2 cytokines/chemokines, MMP-9 (pro- and active), and MMP-2 (active) were increased significantly in mesh-vagina explants, as compared with vagina without mesh. Mesh explants that were removed for exposure had 88.4% higher pro-MMP-9 (P = .035) than those removed for pain. A positive correlation was observed between the profibrotic cytokine interleukin-10 and the percentage of M2 cells (r = 0.697; P = .037) in the pain group. CONCLUSION In women with complications, mesh induces a proinflammatory response that persists years after implantation. The increase in MMP-9 in mesh exp...

Objective To evaluate the impact of prolapse meshes on vaginal smooth muscle structure (VaSM) and function, and to evaluate these outcomes in the context of the mechanical and textile properties of the mesh. Design Three months following the implantation of three polypropylene prolapse meshes with distinct textile and mechanical properties, mesh tissue explants were evaluated for smooth muscle contraction, innervation, receptor function, and innervation density. Setting Magee-Womens Research Institute at the University of Pittsburgh. Population Thirty-four parous rhesus macaques of similar age, parity, and pelvic organ prolapse quantification (POP–Q) scores. Methods Macaques were implanted with mesh via sacrocolpopexy. The impact of Gynemesh™ PS (Ethicon; n = 7), Restorelle® (Coloplast; n = 7), UltraPro™ parallel and UltraPro™ perpendicular (Ethicon; n = 6 and 7, respectively) were compared with sham-operated controls (n = 7). Outcomes were analysed by Kruskal–Wallis ANOVA, Mann–Whitney U–tests and multiple regression analysis (P < 0.05). Mean outcome measures Vaginal tissue explants were evaluated for the maximum contractile force generated following muscle, nerve, and receptor stimulation, and for peripheral nerve density. Results Muscle myofibre, nerve, and receptor-mediated contractions were negatively affected by mesh only in the grafted region (P < 0.001, P = 0.002, and P = 0.008, respectively), whereas cholinergic and adrenergic nerve densities were affected in the grafted (P = 0.090 and P = 0.008, respectively) and non-grafted (P = 0.009 and P = 0.005, respectively) regions. The impact varied by mesh property, as mesh stiffness was a significant predictor of the negative affect on muscle function and nerve density (P < 0.001 and P = 0.013, respectively), whereas mesh and weight was a predictor of receptor function (P < 0.001). Conclusions Mesh has an overall negative impact on VaSM, and the effects are a function of mesh properties, most notably, mesh stiffness.

Objective The impact of polypropylene mesh implantation on vaginal collagen and elastin metabolism was analyzed using a nonhuman primate model to further delineate the mechanism of mesh induced complications. Methods 49 middle aged parous rhesus macaques underwent surgical implantation of 3 synthetic meshes via sacrocolpopexy. Gynemesh PS (n=12) and two lower weight, higher porosity, lower stiffness meshes - UltraPro (n = 19) and Restorelle (n=8) were implanted, in which UltraPro was implanted with its blue orientation lines perpendicular (low stiffness direction, n=11) and parallel (high stiffness direction, n=8) to the longitudinal axis of vagina. Sham operated animals were used as controls (n=10). Twelve weeks after surgery, the meshtissue complex was excised and analyzed. Results Relative to Sham, Gynemesh PS had a negative impact on the metabolism of both collagen and elastin favoring catabolic reactions while UltraPro only induced an increase in elastin degradation. Restorelle had the least impact. As compared to Sham, the degradation of collagen and elastin in the vagina implanted with Gynemesh PS was increased with a simultaneous increase in active MMP-1, -8, -13 and total MMP-2, -9 (all P<0.05). The degradation of elastin (tropoelastin and mature elastin) was increased in the UltraPro implanted vagina with a concomitant increase of MMP-2, and -9 (all P<0.05). Collagen subtype ratio III/I was increased in both Gynemesh PS and UltraPro perpendicular groups (P<0.05). Conclusion Following implantation with the heavier, less porous and stiffer mesh, Gynemesh PS, the degradation of vaginal collagen and elastin exceeded synthesis, most likely as a result of increased activity of MMPs, resulting in a structurally compromised tissue.

Introduction and hypothesis Parity is the leading risk factor for the development of pelvic organ prolapse. To assess the impact of pregnancy and delivery on vaginal tissue, researchers commonly use nonhuman primate (NHP) and rodent models. The purpose of this study was to evaluate the ewe as an alternative model by investigating the impact of parity on the ewe vaginal mechanical properties and collagen structure. Methods Mechanical properties of 15 nulliparous and parous ewe vaginas were determined via uniaxial tensile tests. Collagen content was determined by hydroxyproline assay and collagen fiber thickness was analyzed using picrosirius red staining. Outcome measures were compared using Independent samples t or Mann–Whitney U tests. ANOVA (Gabriel’s pairwise post-hoc test) or the Welch Alternative for the F-ratio (Games Howell post-hoc test) was used to compare data with previously published NHP and rodent data. Results Vaginal tissue from the nulliparous ewe had a higher tangent modulus and tensile strength compared with the parous ewe (p < 0.025). The parous ewe vagina elongated 42 % more than the nulliparous ewe vagina (p = 0.015). No significant differences were observed in collagen structure among ewe vaginas. The tangent modulus of the nulliparous ewe vagina was not different from that of the NHP or rodent (p = 0.290). Additionally, the tangent moduli of the parous ewe and NHP vaginas did not differ (p = 0.773). Conclusions Parity has a negative impact on the mechanical properties of the ewe vagina, as also observed in the NHP. The ewe may serve as an alternative model for studying parity and ultimately prolapse development.

Objective-The impact of polypropylene mesh implantation on vaginal collagen and elastin metabolism was analyzed using a nonhuman primate model to further delineate the mechanism of mesh induced complications.Methods-49 middle aged parous rhesus macaques underwent surgical implantation of 3 synthetic meshes via sacrocolpopexy. Gynemesh PS (n=12) and two lower weight, higher porosity, lower stiffness meshes -UltraPro (n = 19) and Restorelle (n=8) were implanted, in which UltraPro was implanted with its blue orientation lines perpendicular (low stiffness direction, n=11) and parallel (high stiffness direction, n=8) to the longitudinal axis of vagina. Sham operated animals were used as controls (n=10). Twelve weeks after surgery, the meshtissue complex was excised and analyzed.Results-Relative to Sham, Gynemesh PS had a negative impact on the metabolism of both collagen and elastin favoring catabolic reactions while UltraPro only induced an increase in elastin degradation. Restorelle had the least impact. As compared to Sham, the degradation of collagen and elastin in the vagina implanted with Gynemesh PS was increased with a simultaneous increase in active MMP-1, -8, -13 and total MMP-2, -9 (all P<0.05). The degradation of elastin (tropoelastin and mature elastin) was increased in the UltraPro implanted vagina with a concomitant increase of MMP-2, and -9 (all P<0.05). Collagen subtype ratio III/I was increased in both Gynemesh PS and UltraPro perpendicular groups (P<0.05). Condensation:The heavier, less porous and stiffer mesh Gynemesh PS increased the catabolism of collagen and elastin in the vagina, characterized by increased matrix degradation and MMPs.Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Conclusion-Following implantation with the heavier, less porous and stiffer mesh, Gynemesh PS, the degradation of vaginal collagen and elastin exceeded synthesis, most likely as a result of increased activity of MMPs, resulting in a structurally compromised tissue. NIH Public Access

Background: Polypropylene mesh is widely used for surgical treatment of pelvic organ prolapse and stress urinary incontinence. While these surgeries demonstrate favorable functional and anatomical outcomes, their use has been limited by complications, the two most common being exposure and pain. Growing evidence suggests T lymphocytes play a critical role in regulating the host response to biomaterials. Objectives: To define and characterize the T cell response and correlate the response to collagen deposition in fibrotic capsules in mesh tissue complexes removed for the complications of pain versus exposure. Study Design: Patients who were scheduled to undergo a surgical excision of mesh for pain or exposure at Magee-Women’s Hospital were offered enrollment. Forty- two mesh-vagina tissue complexes were removed for the primary complaint of exposure (n=24) versus pain (n=18). Twenty-one patients agreed to have an additional vaginal biopsy away from the site of mesh and served as control tissue. T cells were examined via immunofluorescent labeling for cell surface markers CD4+ (T helper), CD8+ (cytotoxic) and foxp3 (T regulatory cell). Frozen sections were stained with H&E for gross morphology and picrosirius red for collagen fiber analysis. Interrupted sodium-dodecyl sulfate gel electrophoresis was used to quantify the content of collagens type I and III, and the collagen III/I ratio. Growth factors TGF-β and CTGF implicated in the development of fibrosis were measured via enzyme-linked immunosorbent assays. Data were analyzed using Student’s t-tests, mixed effects linear regression, and Spearman’s correlation coefficients. Results: Demographic data were not different between groups except for BMI, which was 31.7 for the exposure group and 28.2 for pain (P=0.04). Tissue complexes demonstrated a marked, but highly localized foreign body response. We consistently observed a teardrop shaped fibroma encapsulating mesh fibers in both pain and exposure groups, with the T cells localized within the tip of this configuration away from the mesh-tissue interface. All three T cell populations were significantly increased relative to control - CD4+ Thelper (P<0.001), foxp3+ Treg (P<0.001) and CD8+ cytotoxic T cell (P=0.034) in the exposure group. In the pain group, only Thelper (P<0.001) and Treg cells (P<0.001) were increased, with cytotoxic T cells (P=0.520) not different from control. Picrosirius red staining showed a greater area of green (thin) fibers in the exposure group (P=0.025) and red (thick) fibers in the pain group (P<0.001). The ratio of area green/(yellow + orange + red) representing thin vs. thick fibers was significantly greater in the exposure group (P=0.005). Analysis of collagen showed that collagen type I was increased by 35% in samples with mesh complications (exposure and pain) when compared to controls (P=0.043). Strong correlations between the pro-fibrosis cytokine TGF-β and collagen type I and III were found in patients with pain (r≥0.833; P=0.01) but not exposure (P>0.7). Conclusion: T cell...