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Alterations of Vascular Endothelial Growth Factor A Expression and Microvessel Density Associated With Polypropylene Vaginal Mesh

Kowalski, Joseph T., MD*; Goodheart, Michael J., MD; Genadry, Rene, MD*; Bhattarai, Ava, MD; Bradley, Catherine S., MD, MSCE*

Female Pelvic Medicine & Reconstructive Surgery: April 20, 2018 - Volume Publish Ahead of Print - Issue - p
doi: 10.1097/SPV.0000000000000593
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Objective Vaginal mesh exposure is the most common complication from mesh use in prolapse and incontinence surgery. Angiogenesis is an essential component of tissue healing, and defective angiogenesis plays a role in chronic wounds. We hypothesized that patients with exposures will have impaired angiogenesis as evidenced by altered tissue vascular endothelial growth factor A (VEGFA) expression and microvessel density. The study objective was to compare angiogenesis in women with vaginal mesh exposures, those with vaginal mesh without exposures, and in women who were mesh-naive.

Methods Patients undergoing polypropylene mesh removal and patients without mesh undergoing urinary incontinence or prolapse surgery were recruited. Full-thickness vaginal epithelial biopsies were obtained. The relative abundance of VEGFA RNA was measured with reverse transcription-polymerase chain reaction. The VEGFA and CD31 immunohistochemistry were also performed.

Results Ninety-two subjects were enrolled and biopsied. Mean age (SD) was 57.2 (12.8) years, 16 (17.4%) were smokers, and 68 (73.9%) were postmenopausal.

The VEGFA RNA expression did not differ between subjects with mesh exposure and with mesh but no exposure (P = 0.89). However, compared with subjects with no mesh, vaginal VEGFA expression was decreased in subjects with any implanted mesh (relative expression, 0.72; P = 0.02). Microvessel density was increased in subjects with mesh exposure compared with subjects with no mesh (P < 0.01). The VEGFA expression by immunohistochemistry was significantly lower in postmenopausal subjects without estrogen treatment compared with premenopausal and postmenopausal subjects being treated with estrogen (P = 0.02).

Conclusions The presence of polypropylene mesh and hormonal status are associated with evidence of altered angiogenesis.

From the *Division of Female Pelvic Medicine and Reconstructive Surgery, †Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, and ‡Department of Pathology, University of Iowa Hospitals and Clinics.

Correspondence: Joseph T. Kowalski, MD, Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology, University of Iowa Hospitals and Clinics, 200 Hawkins Dr, PFP OBGYN, Iowa City, IA 52245. E-mail: joseph-kowalski@uiowa.edu.

This study was supported by 2015 PFD Research Foundation Mesh/Graft Science in Pelvic Reconstructive Surgery grant. The authors have declared they have no conflicts of interest.

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