Surgical treatment of vaginal vault prolapse using different prosthetic mesh implants: a finite element analysis

Aroj Bhattarai; Medisa Jabbari; Ralf Anding; Manfred Staat

doi:10.1515/teme-2017-0115

Article

Surgical treatment of vaginal vault prolapse using different prosthetic mesh implants: a finite element analysis

Aroj Bhattarai
Aroj Bhattarai is a scientific employee and a PhD student at FH Aachen University of Applied Sciences. He studied Bachelor of Science in Civil Engineering (2004–2009) at Western Region Campus, Tribhuvan University in his home country, Nepal, the land of nature. He received his M.Sc. in computational engineering from the Technical University of Dresden, Germany (2010–2012). In 2013 he joined the Biomechanics laboratory at FH Aachen University of Applied Sciences as a PhD candidate. He has 9 publications. His research mainly focuses on the finite element method to optimize the surgical repairs of the female pelvic floor dysfunctions using prosthetic mesh implants.
, Medisa Jabbari
Medisa Jabbari is a master student of biomedical engineering at FH Aachen University of Applied Sciences, Germany. She studied Bachelor of Engineering in “Biomedizinische Technik” (2011–2014) at the same university. She finished her bachelor thesis at Forschungszentrum Jülich in the bioelectric field which led to some publications. She started her master of biomedical engineering at the same university in 2014. In 2015 she joined the Biomechanics laboratory and started her first project which was focused on the simulation of prosthetic mesh implants for incontinence problems. Her master thesis is about finite element simulation of different types of prosthetic mesh implants used in sacrocolpopexy technique for treatment of apical-vaginal cuff prolapse. Her work in this period has also resulted so far in a poster award at the Biomedica 2016, Aachen.
, Ralf Anding
Ralf Anding is vice-chairman of the Neurourology section at the University Hospital Bonn. He finished medical school at the Ruhr-University Bochum in 1992 and received his doctor’s degree in 1993. He is a board certified Urologist since 1998 and received certifications for specialized Urology Surgery and Urology Oncology in 2004 and 2011, respectively. The focus of his work is functional Urology and pelvic floor disorders, he established centers of excellence for incontinence surgery and pelvic floor disorders in three hospitals since 2000. He co-authored over 50 publications and book chapters.
and Manfred Staat
Manfred Staat is director of the Institute of Bioengineering and a full professor at the FH Aachen University of Applied Sciences, Germany. He received his PhD in mechanics from RWTH Aachen University in 1988. From 1988 to 1997 he worked at the Forschungszentrum Jülich in the Institute of Reactor Safety and Reactor Technology on probabilistic fracture mechanics and plasticity. He has co-authored more than 160 publications. His current research interests include limit and shakedown analysis, stochastic optimization, biomechanical modelling and numerical simulation of cells, tissues and organs, mechanical testing and modelling of soft materials including tissues and implants.

Published/Copyright: February 8, 2018

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From the journal tm - Technisches Messen Volume 85 Issue 5

Abstract

Particularly multiparous elderly women may suffer from vaginal vault prolapse after hysterectomy due to weak support from lax apical ligaments. A decreased amount of estrogen and progesterone in older age is assumed to remodel the collagen thereby reducing tissue stiffness. Sacrocolpopexy is either performed as open or laparoscopic surgery using prosthetic mesh implants to substitute lax ligaments. Y-shaped mesh models (DynaMesh, Gynemesh, and Ultrapro) are implanted in a 3D female pelvic floor finite element model in the extraperitoneal space from the vaginal cuff to the first sacral (S1) bone below promontory. Numerical simulations are conducted during Valsalva maneuver with weakened tissues modeled by reduced tissue stiffness. Tissues are modeled as incompressible, isotropic hyperelastic materials whereas the meshes are modeled either as orthotropic linear elastic or as isotropic hyperlastic materials. The positions of the vaginal cuff and the bladder base are calculated from the pubococcygeal line for female pelvic floor at rest, for prolapse and after repair using the three meshes. Due to mesh mechanics and mesh pore deformation along the loaded direction, the DynaMesh with regular rectangular mesh pores is found to provide better mechanical support to the organs than the Gynemesh and the Ultrapro with irregular hexagonal mesh pores.

Zusammenfassung

Insbesondere ältere, mehrgebährende Frauen leiden häufiger an einem Scheidenvorfall nach einer Hysterektomie aufgrund der schwachen Unterstützung durch laxe apikale Bänder. Es wird angenommen, dass eine verringerte Menge an Östrogen und Progesteron im höheren Alter das Kollagen umformt, wodurch die Gewebesteifigkeit reduziert wird. Die Sakrokolpopexie ist eine offene oder laparoskopische Operation, die mit prothetischen Netzimplantaten durchgeführt wird, um laxe Bänder zu ersetzen. Y-förmige Netzmodelle (DynaMesh, Gynemesh und Ultrapro) werden in einem 3D-Modell des weiblichen Beckenbodens im extraperitonealen Raum vom Vaginalstumpf bis zum Promontorium implantiert. Numerische Simulationen werden während des Valsalva-Manövers mit geschwächtem Gewebe durchgeführt, das durch eine reduzierte Gewebesteifigkeit modelliert wird. Die Gewebe werden als inkompressible, isotrop hyperelastische Materialien modelliert, während die Netze entweder als orthotrope linear elastische oder als isotrope hyperlastische Materialien modelliert werden. Die Positionen des Vaginalstumpfs, der Blase und der Harnröhrenachse werden anhand der Pubococcygeallinie aus der Ruhelage, für den Prolaps und nach der Reparatur unter Verwendung der drei Netze berechnet. Aufgrund der Netzmechanik und der Netzporenverformung bietet das DynaMesh mit regelmäßigen rechteckigen Netzporen eine bessere mechanische Unterstützung und eine Neupositionierung des Scheidengewölbes, der Blase und der Urethraachse als Gynemesh und Ultrapro mit unregelmäßigen hexagonalen Netzporen.

Keywords: Apical prolapse; vaginal cuff; prosthetic mesh implants; sacrocolpopexy; finite element simulation; biomechanical modeling

Schlagwörter: Apikaler Prolaps; Vaginalstumpf; prothetische Netzimplantate; Sakrokolpopexie; Finite-Elemente-Simulation; biomechanische Modellierung

Funding statement: The first author has been partially funded by the German Federal Ministry of Education and Research through the FHprofUnt project “BINGO”, grant number 03FH073PX2.

About the authors

Aroj Bhattarai

Aroj Bhattarai is a scientific employee and a PhD student at FH Aachen University of Applied Sciences. He studied Bachelor of Science in Civil Engineering (2004–2009) at Western Region Campus, Tribhuvan University in his home country, Nepal, the land of nature. He received his M.Sc. in computational engineering from the Technical University of Dresden, Germany (2010–2012). In 2013 he joined the Biomechanics laboratory at FH Aachen University of Applied Sciences as a PhD candidate. He has 9 publications. His research mainly focuses on the finite element method to optimize the surgical repairs of the female pelvic floor dysfunctions using prosthetic mesh implants.

Medisa Jabbari

Medisa Jabbari is a master student of biomedical engineering at FH Aachen University of Applied Sciences, Germany. She studied Bachelor of Engineering in “Biomedizinische Technik” (2011–2014) at the same university. She finished her bachelor thesis at Forschungszentrum Jülich in the bioelectric field which led to some publications. She started her master of biomedical engineering at the same university in 2014. In 2015 she joined the Biomechanics laboratory and started her first project which was focused on the simulation of prosthetic mesh implants for incontinence problems. Her master thesis is about finite element simulation of different types of prosthetic mesh implants used in sacrocolpopexy technique for treatment of apical-vaginal cuff prolapse. Her work in this period has also resulted so far in a poster award at the Biomedica 2016, Aachen.

Ralf Anding

Ralf Anding is vice-chairman of the Neurourology section at the University Hospital Bonn. He finished medical school at the Ruhr-University Bochum in 1992 and received his doctor’s degree in 1993. He is a board certified Urologist since 1998 and received certifications for specialized Urology Surgery and Urology Oncology in 2004 and 2011, respectively. The focus of his work is functional Urology and pelvic floor disorders, he established centers of excellence for incontinence surgery and pelvic floor disorders in three hospitals since 2000. He co-authored over 50 publications and book chapters.

Manfred Staat

Manfred Staat is director of the Institute of Bioengineering and a full professor at the FH Aachen University of Applied Sciences, Germany. He received his PhD in mechanics from RWTH Aachen University in 1988. From 1988 to 1997 he worked at the Forschungszentrum Jülich in the Institute of Reactor Safety and Reactor Technology on probabilistic fracture mechanics and plasticity. He has co-authored more than 160 publications. His current research interests include limit and shakedown analysis, stochastic optimization, biomechanical modelling and numerical simulation of cells, tissues and organs, mechanical testing and modelling of soft materials including tissues and implants.

Acknowledgment

We thank Prof. M. C. Sora for the CAD model of the plastinated cross sections.

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Received: 2017-9-15

Revised: 2018-1-17

Accepted: 2018-1-19

Published Online: 2018-2-8

Published in Print: 2018-5-25

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Articles in the same Issue

https://doi.org/10.1515/teme-2017-0115

Keywords for this article

Apical prolapse; vaginal cuff; prosthetic mesh implants; sacrocolpopexy; finite element simulation; biomechanical modeling