Pelvic Floor Disorders: Surgical Approach

27. Synthetic and Biological Meshes for Pelvic Floor Disorders

Gabriele Böhm 


Department of General and Visceral Surgery, Katholische Stiftung Marienhospital, Teaching Hospital University RWTH Aachen, Aachen, Germany

Gabriele Böhm



New innovative surgical procedures will achieve general acceptance and change former standards if they have the capacity to improve clinical outcome.

27.1 Introduction

New innovative surgical procedures will achieve general acceptance and change former standards if they have the capacity to improve clinical outcome.

An improvement in the outcome in surgery for pelvic organ prolapse (POP) was sought, as re-operation rates after traditional POP and urinary incontinence surgery were high [1], with 60% of female patients undergoing re-intervention at the same anatomical site, and 32% of females developing a hidden support defect requiring additional intervention at a different pelvic site. The recurrence rate following pelvic surgery within the anterior compartment has been shown to be 40% [2]. These recurrence rates were observed with the traditional plication-type surgical techniques, particularly for the anterior compartment. As a result, in the hope of reducing such high recurrence rates, novel techniques for POP repair were described and disseminated within the surgical community.

The idea of adding graft augmentation to the traditional plication-type technique was in agreement with the aim of tissue reinforcement and the improvement of outcomes achieved by mesh augmentation for abdominal wall hernia repair [34]. Within the field of POP surgery, the use of graft reinforcement has gained wide acceptance and the burning question is now: which graft is best to use?

Biological meshes are currently very much in vogue within the surgical community. There is nothing new about ‘biologicals’: in the 1960s, fascia lata was used regularly as a material for hernia repair, for example to cover congenital diaphragmatic defects. It had a convincing haptic and was easy to insert. Why then, was there a powerful search for new synthetic materials?

The main advantage of biologic mesh is its supposedly superior role within contaminated areas and resistance to infection. But is this proclaimed advantage scientifically sufficiently supported?

What are the pros and cons of biologic and synthetic mesh? There is some good new research that may lead us in the right direction. And within the context of rather extreme warnings from the US Food and Drug Administration with regard to the use of synthetics in the urogynecological field, one should read the evidence rather carefully [56].

Warnings were issued about transperineal or transvaginal insertion of synthetic meshes with regard to reported rates of complications such as mesh extrusion or viscous erosion. Studies highlighted the fact that the type of surgical insertion technique (blind insertions via trocars) might have more effect on the outcome than the type of mesh used [7]. In other studies, the complication rates of extrusion or erosion were found to be similar or higher with biological mesh compared with synthetic mesh [6].

The decision for or against one particular mesh material becomes more and more difficult given the vast amount of different materials on the market. Factors influencing the decision are the biology of the patient, the anatomical location and its role for functional improvement, the anatomical insertion site, a contaminated or noncontaminated operative area, and financial considerations.

The requirements of any biomaterial for the use in humans are:

·               Elasticity according to its surrounding needs

·               Structural stability (e.g., form, surface, three-dimensional construction)

·               Resistance to degradation by host cells for at least 1 year or longer (depending on its supposed function: e.g., permanent support material or temporary scaffold for tissue regeneration in its place)

·               Biocompatibility

·               Nontoxic, nonteratogenic, noninfectious, hypoallergic

·               Integration within its new surrounding tissue

Additional future benefits are likely to include:

·               Stimulation of tissue regeneration in its place

·               Anti-adhesive toward cavities such as the abdominal or thoracic cavity

·               Surface modification according to needs, e.g., pharmaceuticals, active agents influencing the inflammatory reaction, and agents promoting tissue regeneration

·               Surface modification for the visualization of the inserted material

There is a plea for more preclinical research in the field of pelvic floor surgery before the launch of new mesh designs [89]. We fully support this plea and support the tendency towards more physiological, mechanical, and biomolecular research of the pelvic floor. The standardization of measuring parameters is a requirement that is long overdue.

For many years, synthetic as well as biological mesh materials were inserted and studied at different hernia locations, mostly the groin and abdominal wall. Knowledge from these locations can be partially used for other applications such as hiatus hernia, diaphragmatic hernia, urogenital prolapse and rectal prolapse, or pelvic diaphragmatic insufficiencies.

When choosing the right mesh, the surgeon has to consider the following:

·               Mesh material

·               Required durability of the material

·               Elasticity

·               Adjacent organ involvement

·               Movement rate and likelihood of side-effects due to friction

·               Pressure necrosis

·               Contact with the peritoneal cavity

·               Bacterial contamination

·               Surgical insertion site

Meshes can be of biological or synthetic material.

Biological mesh materials can be classified into three groups:

·               Autologous material

·               Allografts (human acellular cadaveric materials)

·               Xenografts (animal acellular cadaveric materials).

It is important that these materials are chemically processed in different ways. First, they have to be devitalized. This can be achieved in different ways. The chemicals used might have an effect on the functional quality of the product as well as on the host that will receive the implant. For further information we refer to chemical information sites. Box 27.1 gives some examples of biological materials.

Box 27.1

Examples of biological materials

Autologous grafts:

   Fascia lata

   Rectus fascia


   Human cadaveric dermis:

    AlloDerm (LifeCell Corporation, Branchburg, New Jersey, USA)

    FlexHD (Ethicon, Cornelia, Georgia, USA)

   Cadaveric fascia lata:

    Suspend Tutoplast (Mentor Corporation, Santa Barbara, California, USA)

    FasLata (CR Bard, Covington, Georgia, USA)


   Porcine dermis:


     Permacol (Covidien, Mansfield, Massachusetts, USA)

     Collamend (Davol, Warwick, Rhode Island, USA)

     Pelvicol Acellular Collagen Matrix (CR Bard)

     PelviSoft BioMesh (like the above, only with perforations)

     (CR Bard)


     Strattice (LiefeCell Corporation)

     XenMatrix (Davol)

   Porcine small intestinal submucosa:

    Surgisis (Cook Surgical, Bloomington, Indiana, USA)

   Bovine dermis:

    Xenform Soft-Tissue Repair Matrix (Boston Scientific, Natick, Massachusetts, USA)

    SurgiMend (TEI Biosciences, Boston, Massachusetts, USA)

   Bovine pericardium:

    Veritas (Synovis Surgical Innovation, St Paul, Minnesota, USA)

    Tutomesh (RTI Biologics, Alachua, Florida, USA)

Some biomaterials are cross-linked in order to render the biomaterial less vulnerable to rapid breakdown of collagens and proteins by collagenases and other proteinases. The amount of cross-linking defines the time required for degradation of these biomaterials. For example, 100% cross-linking may render the material impenetrable by host cells and therefore not degradable. The latter goes often hand in hand with encapsulation of the material and isolation from normal tissue turnover. This is not an ideal situation.

Synthetic materials can be classified into absorbable and nonabsorbable, monofilament and multifilament, knitted or woven, microporous and macroporous, and heavyweight and lightweight meshes. Box 27.2gives some examples of synthetic materials.

Box 27.2

Examples of synthetic meshes


   GORE®BIO-A® Tissue reinforcement (polyglycolic acid:trimethylene)

   carbonate (PGA:TMC) fibers (Gore & Associates, Inc., Newark, Delaware, USA)


   Gynemesh (polypropylene) (Ethicon, Norderstedt, Hamburg)

   Smart Mesh (polypropylene, light weight) (Coloplast, Orton, Peterborough, UK)

   ePTFE (polytetrafluorethylene) (Gore & Associates, Inc., Newark, Delaware, USA)

   PVDF (polyvinylidene difluoride) (Dahlhausen GmbH & FEG Textiltechnik Aachen, Germany)

   Parietex Prosup (polyester, large pore, heavyweight)(Tyco Healthcare, Gosport, Hampshire, UK)

Mixed, partially absorbable:

   Vypro® (polypropylene plus polyglactin) (Ethicon, Norderstedt, Hamburg)

   Ultrapro® (polypropylene plus polyglecaprone-25, large pore, lightweight) (Ethicon, Norderstedt, Hamburg)

Mixed, nonabsorbable:

   Dynamesh IPOM (Polypropylene plus polyvinylidinchloride at abdominal side)

   (Dahlhausen GmbH & FEG Textiltechnik)

Additional surface modifications:

   Proceed® (Polypropylene plus polydioxanone and cellulose)(Ethicon, Norderstedt, Hamburg)

   Parietene composite: polypropylene plus collagen/polyethylenglycol/glycerol coating) (Covidien, Mansfield, Massachusetts, USA)

27.2 Biological Materials

Lyophilized bovine dura mater was used regularly for congenital diaphragmatic hernia repair. The surgical haptic was good, and the material was flexible enough to fit into a dome-shaped form. With the occurrence of BSE (bovine spongiform encephalopathy) and possible transmission of Creutzfeldt-Jakob disease, bovine neuron-related materials were withdrawn from the market after 1992. Despite new avitalization processes, a residual small risk of prion or viral transmission cannot be excluded. Examples of substitutes for neuron-based materials include bovine pericardium [10], porcine pericardium, bowel wall, or fascia; however, the available size of these materials is not always sufficient for repair of large hernias. Large surface area materials, such as dermal matrix or small bowel mucosa, chemically processed and reconstituted, are used for this purpose.

27.2.1 Acellular Biological Materials

Examples of two prototypes of acellular biological materials are discussed: Surgisis® and Permacol®.

Surgisis (Cook Surgical, Bloomington, Indiana, USA) was produced following studies by Hodde et al. [11] describing the development of an extracellular matrix (ECM) made from sterilized porcine small bowel mucosa with its ECM components. Related studies by Cook Surgical postulated complete new tissue regeneration, which was qualitatively similar to the surrounding tissue [12]. As yet, there have been no long-term randomized studies to prove its superior quality. Clinical results comparing Surgisis with other meshes for use in diaphragmatic hernia demonstrated a similarly high recurrence rate of 50% [13]. Our own animal studies demonstrated that 4 months after insertion Surgisis had disintegrated and had been substituted by lower-quality scar tissue, resulting in inferior mechanical quality compared with a polypropylene mesh [1417]. No improvement of tissue tensile strength was found when comparing animals implanted with Surgisis with control animals without mesh [18]. In a rat model, animals with Surgisis had a much lower tensile strength compared with polypropylene [19].

Surgisis did not show any convincing advantage compared with synthetic materials with respect to seroma formation, adhesions, tensile strength [20], shrinkage [21], and recurrence rates following hernia repair [22].

In summary, the insufficient mechanical strength of Surgisis renders it unsuitable for any application where mechanical support is essential [23], e.g., pelvic prolapse surgery.

Permacol (acellular cross-linked porcine dermal matrix) is another type of biomaterial that is regularly inserted in different hernia locations, including parastomal hernias, and plevic prolapse surgery [24]. Within this group of crosslinked meshes, collagen molecules are covalently bound to each other following chemical processing. This protects the material to a certain degree against degradation by host tissue collagenases. In a study, Permacol showed satisfactory tensile strength over 6 months and better mechanical properties compared with other cross-linked materials [20]. Another study demonstrated a lower hernia recurrence rate with Permacol compared with polytetrafluoroethylene (PTFE) [25]; however, the follow-up time was short and patient numbers were small. In prolapse surgery, clinical short-term results were shown to be promising [26].

However, several recent studies have revealed problems with the use of biological meshes. In a long-term follow-up study using different materials for abdominal incisional hernia repair, Permacol did not show an advantage compared with synthetic meshes [25]. In a clinical study, the recurrence rate of incisional hernia at 18 months using Permacol was 15%, with a complication rate of 35% (e.g., wound infection) [27]. This is no improvement on currently used synthetic meshes. The fistula rate following the use of Permacol intra-abdominally is low, but not unheard of; equally, bowel adhesions with the need for re-intervention have been described [6].

Additionally, Permacol has shown a marked inflammatory response in rats up to 40 days postimplantation, and no ingrowth of skeletal muscle cells [28].

The cross-linked Permacol has demonstrated better mechanical qualities compared with non-cross-linked materials [20], but inferior qualities compared with synthetic meshes. Similar findings were shown in an animal study comparing Pelvicol® with Pelvisoft®, Gynemesh®, and Surgisis. The polypropylene-based Gynemesh showed the highest tensile strength and least stiffness compared with the cross-linked Pelvicol. In addition, Pelvicol showed encapsulation after 3 months insertion time, whereas Gynemesh was found to be incorporated [29]. A clinical study using Surgisis or Pelvicol for sacrocolpopexy at 2 years follow-up found the anatomical recurrence rate to be very high (70%), with a functional recurrence rate of 40% [30].

These results compare very badly with studies on prolapse surgery using synthetic meshes. On the other hand, long-term clinical follow-up results on the use of synthetic mesh for laparoscopic anterior rectopexy for rectal prolapse describe very low recurrence rates of no more than 5% [3132].

Additionally, the hope for superior behavior of biological materials within a contaminated area is contradicted by multiple studies. Following inoculation of meshes with bacteria, findings have indicated a possible higher tendency of infection when using biological materials [33]. Additionally, inoculation seems to weaken the tensile strength of the biological mesh [34].

In summary, biological materials have not shown convincing superiority compared with synthetic nonabsorbable meshes in hernia repair [3536], or in prolapse/pelvic floor surgery [3739]. Another disadvantage with biomaterials is their inconsistent ECM composition (e.g., type and amount of collagen). Therefore, their functional outcome is not predictable, plus, this inconsistency renders them unsuitable for surface modulation.

27.3 Synthetic Meshes

Synthetic meshes are frequently used in hernia surgery, in the knowledge that they produce good long-term results. Typical qualities include good biocompatibility, reproducibility, and consistency. The concept of lightweight and heavyweight meshes is well established [40]. The basis for this concept was the finding that the host inflammatory response depends on the material density and pore size of the mesh construct. A lightweight and large-pore-size mesh is more suitable than a heavyweight and small-pore-size mesh.

However, a limited inflammatory reaction is tolerated and is required for tissue remodeling and adequate scar formation [41]. Therefore the density of the material was reduced and the pore size was enlarged, which led to optimal tissue incorporation of the mesh and avoidance of biofilm production [4245], with no impact on the good mechanical qualities of the material [4649].

Mesh shrinkage of synthetic meshes is in the range of 3–30%, depending on their location, textile structure, and weight [50]. In hernia surgery, this is compensated by mesh overlap.

For the intra-abdominal application of meshes, anti-adhesive materials are added to the mesh. For example, Proceed® has a cellulose cover on its abdominal side [5152]. Studies comparing polypropylene meshes with different covers suggest that there is room for further improvement [5253].

Ultrapro® (polypropylene plus polyglecaprone-25) has demonstrated superior biocompatibility in animal studies in comparison with other synthetic materials [54], and is one of the most frequently used materials in hernia surgery [55].

PTFE was known for its lack of elasticity and tendency toward encapsulation and failed tissue integration [21]. It was hoped that there would be an improvement in these properties in the expanded version of PTFE: ePTFE. In one study, it showed fewer adhesions compared with polypropylene in the intra-abdominal position, but it also showed a shrinkage rate of 30% [51].

Another advantage of synthetic meshes, is the possibility of surface modulation [5657].

27.3.1 Surface-modulated Meshes

The search for the ideal mesh is ongoing. The advantage of synthetic meshes is the possibility of modifying the surface of currently available commercial meshes (Fig. 27.1) [5659]. It is possible to add active agents such as antibiotics, protein- repellent substances, and inflammatory response proteins. Also, one can configure a three-dimensional scaffold that allows cell inoculation according to the required needs. Ongoing in vitro research is attempting to establish a system in order to test cell interaction with different biomaterials [6064]. Controlled release of active substances (e.g., antibiotics, cytokines, growth hormones) bound to the mesh is also easily achieved [65].


Fig. 27.1

Electronmicroscopy of a surface-modified mesh: electrospun absorbable nanoweb on Ultrapro® mesh. PLGA (polylactide glycolic acid) with NCO-sP(EO-stat-PO) as a possible carrier for active substances

27.4 Summary

In summary, the individual needs of the patient, the target location and its required function, and the insertion route [66] plus its surrounding communicating tissue [67] will decide whether a biological or synthetic, absorbable or nonabsorbable material, is most suitable.

The main advantage of synthetic material is its precise reproducibility, absent infectious risk, and possibility for surface modification, and addition of active agents such as inflammatory modulators or stem cell inoculation. Mechanical qualities of different synthetic meshes have been studied and the surgeon has to decide whether a stiffer or more elastic material is needed. For prolapse surgery, a more elastic mesh such as Ultrapro or smart mesh seems advisable, considering the proximity to the rather vulnerable vaginal tissue [67]. In order to avoid mesh erosion into or constriction of viscous organs (rare, but devastating for the patient when it happens) we would recommend use of as little implant material as possible, never surrounding an organ completely, and covering the material with a good amount of the patients’ own tissue as a barrier. These recommendations are fulfilled, for example, in the anterior rectocolposuspension technique described by D’Hoore and Penninckx [68], using a small strip of mesh and covering it completely with peritoneum and fat.



Olsen AL, Smith VJ, Bergstrom JO et al (1997) Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Obstet Gynecol 89:501–506PubMedCrossRef


Paraiso MF, Ballard LA, Walters MD (1996) Pelvic support defects and visceral and sexual function in women treated with sacrospinous ligament suspension and pelvic reconstruction. Am J Obstet Gynecol 175:1423–1431PubMedCrossRef


Scott NW, McCormack K, Graham P et al (2002) Open mesh versus non-mesh for repair of femoral and inguinal hernia. Cochrane Database Syst Rev 4:CD002197PubMed


A Gomelsky, DF Penson, Dmochowski RR (2010) Pelvic organ prolapse (POP) surgery: the evidence for the repairs. BJU 107:1704–1719


Morgan DM (2012) Discussion: the use of biological materials in urogynecologic reconstruction: a systematic review. Plast Reconstr Surg 130:254S–255SPubMedCrossRef


Yurteri-Kaplan LA, Gutman RE (2012) The use of biological materials in urogynecologic reconstruction: a systematic review. Plast Reconstr Surg 130:242S–253SPubMedCrossRef


Brubaker L, Norton PA, Albo ME et al (2011) Adverse events over two years after retropubic or transobturator midurethral sling surgery: findings from the trial of midurethral sling (TOMUS) study. Am J Obstet Gynecol 205:498.e1–e6CrossRef


Deprest J, Feola A (2013) The need for preclinical research on pelvic floor reconstruction. BJOG 120:141–143PubMedCrossRef


Slack M, Ostergard D, Cervigni M, Deprest J (2012) A standardized description of graft-containing meshes and recommended steps before the introduction of medical devices for prolapse surgery. Int Urogynecol J 23:15–26CrossRef


van Tuil C, Saxena AK, Willital GH (2006) Experience with management of anterior abdominal wall defects using bovine pericard. Hernia 10:41–47PubMedCrossRef


Hodde JP, Johnson CE (2007) Extracellular matrix as a strategy for treating chronic wounds. Am J Clin Dermatol 8:61–66PubMedCrossRef


Hodde J (2006) Extracellular matrix as a bioactive material for soft tissue reconstruction. ANZ J Surg 76:1096–1100PubMedCrossRef


Grethel EJ, Cortes RA, Wagner AJ et al (2006) Prosthetic patches for congenital diaphragmatic hernia repair: Surgisis® vs Gore-Tex. J Pediatr Surg 41:29–33PubMedCrossRef


Böhm G, Binnebosel M, Krähling E et al (2011) Influence of the elasticity module of synthetic and natural polymeric tissue substitutes on the mobility of the diaphragm and healing process in a rabbit model. J Biomater Appl 25:771–793PubMedCrossRef


Böhm G, Steinau G, Krähling E et al (2011) Is biocompatibility affected by constant shear stress?-Comparison of three commercially available meshes in a rabbit model. J Biomater Appl 25:721–741PubMedCrossRef


Lantis JC 2nd, Gallivan EK, Hekier R et al (2000) A comparison of collagen and PTFE patch repair in a rabbit model of congenital diaphragmatic hernia. J Invest Surg 13:319–325PubMedCrossRef


Sandoval JA, Lou D, Engum SA et al (2006) The whole truth: comparative analysis of diaphragmatic hernia repair using 4-ply vs. 8-ply small intestinal submucosa in a growing animal model. J Pediatr Surg 41: 518–523PubMedCrossRef


Trabuco EC, Zobitz ME, Klingele CJ, Gebhart JB (2007) Effect of host response (incorporation, encapsulation, mixed incorporation and encapsulation, or resorption) on the tensile strength of graft-reinforced repair in the rat ventral hernia model. Am J Obstet Gynecol 197:638.e1–6CrossRef


Konstantinovic ML, Lagae P, Zheng F et al (2005) Comparison of host response to polypropylene and non-cross-linked porcine small intestine serosal-derived collagen implants in a rat model. BJOG 112:1554–1560PubMedCrossRef


Gaertner WB, Bonsack ME, Delaney JP (2007) Experimental evaluation of four biologic prostheses for ventral hernia repair. J Gastrointest Surg 11:1275–1285PubMedCrossRef


Rauth TP, Poulose BK, Nanney LB, Holzman MD (2007) A comparative analysis of expanded polytetrafluoroethylene and small intestinal submucosa — implications for patch repair in ventral herniorrhaphy. J Surg Res 143:43–49PubMedCrossRef


Gupta A, Zahriya K, Mullens PL et al (2006) Ventral herniorrhaphy: experience with two different biosynthetic mesh materials, Surgisis® and Alloderm. Hernia 10:419–425PubMedCrossRef


Ozog Y, Konstantinovic ML, Verschueren S et al (2009) Experimental comparison for abdominal wall repair using different methods of enhancement by small intestinal submucosa graft. Int Urogynecol J 20:435–441CrossRef


Ahmad M, Sileri P, Franceschilli L, Mercer-Jones M (2012) The role of biologics in pelvic floor surgery. Colorectal Dis 14:19–23PubMedCrossRef


Mitchell IA, Garcia NM, Barber R et al (2008) Permacol: a potential biologic patch alternative in congenital diaphragmatic hernia repair. J Pediatr Surg 43:2161–2164PubMedCrossRef


Sileri P, Franceschilli L, De Luca E et al (2012) Laparoscopic ventral rectopexy for internal rectal prolapse using biological mesh: postoperative and short-term functional results. J Gastrointest Surg 16:622–628PubMedCrossRef


Shaikh FM, Giri SK, Durrani S et al (2007) Experience with porcine acellular dermal collagen implant in one-stage tension-free reconstruction of acute and chronic abdominal wall defects. World J Surg 31:1966–1972PubMedCrossRef


Kaya M, Baba F, Bolukbas F et al (2006) Use of homlogous acellular dermal matrix for abdominal wall reconstruction in rats. J Invest Surg 19:11–17PubMedCrossRef


Trabuco EC, Zobitz ME, Klingele CJ, Gebhart JB (2007) Effect of host response (incorporation, encapsulation, mixed incorporation and encapsulation, or resorption) on the tensile strength of graft-reinforced repair in the rat ventral hernia model. Am J Obstet Gynecol 197:638.e1–e6CrossRef


Clearhout F, De Ridder D, Van Beckevoort D et al (2010) Sacrocolpopexy using xenogenic acellular collagen in patients at increased risk for graft-related complications. Neurourol Urodynam 29:563–567


D’Hoore A, Cadoni R, Penninckx F (2004) Long-term outcome of laparoscopic ventral rectopexy for total rectal prolapse. Brit J Surg 91:1500–1505PubMedCrossRef


Faucheron J-L, Voirin D, Riboud R et al (2012) Laparoscopic anterior rectopexy to the promontory for full-thickness rectal prolapse in 175 consecutive patients: short-and long-term follow-up. Dis Colon Rectum 55:660–665PubMedCrossRef


Barbolt TA (2006) Biology of polypropylene/polyglactin 910 grafts. Int Urogynecol J 17:S26–S30CrossRef


Bellows CF, Wheatley BM, Moroz K et al (2011) The effect of bacterial infection on the biomechanical properties of biological mesh in a rat model. PLoSOne 6:e21228CrossRef


Bellows CF, Smith A, Malsbury J, Helton WS (2013) Repair of incisional hernias with biological prosthesis: a systematic review of current evidence. Am J Surg 205:85–101PubMedCrossRef


Deerenberg EB, Mulder IM, Grotenhuis N et al (2012) Experimental study on synthetic and biological mesh implantation in a contaminated environment. Br J Surg 99:1734–1741PubMedCrossRef


Quiroz LH, Gutman RE, Shippey S et al (2008) Abdominal sacrocolpopexy: anatomic outcomes and complications with Pelvicol, autologous and synthetic graft materials. Am J Obstet Gynecol 198:557.e1–e5CrossRef


Blatnik J, Jin J, Rosen M (2008) Abdominal hernia repair with bridging acellular dermal matrix— an expensive hernia sac. Am J Surg 196:47–50PubMedCrossRef


Deprest J, De Ridder D, Roovers JP et al (2009) Medium term outcome of laparoscopic sacrocolpopexy with xenografts Compared to synthetic grafts. J Urol 182:2362–2368PubMedCrossRef


Klosterhalfen B, Junge K, Klinge U (2005) The lightweight and large porous mesh concept for hernia repair. Expert Rev Med Devices 2:103–117PubMedCrossRef


Rosch R, Junge K, Schachtrupp A et al (2003) Mesh implants in hernia repair. Inflammatory cell response in a rat model. Eur Surg Res 35:161–166PubMedCrossRef


Vaudaux P, Pittet D, Haeberli A et al (1989) Host factors selectively increase staphylococcal adherence on inserted catheters: a role for fibronectin and fibrinogen or fibrin. J Infect Dis 160:865–875PubMedCrossRef


Cheung AL, Fischetti VA (1990) The role of fibrinogen in staphylococcal adherence to catheters in vitro. J Infect Dis 161:1177–1186PubMedCrossRef


McDevitt D, Francois P, Vaudaux P, Foster TJ (1994) Molecular characterization of the clumping factor (fibrinogen receptor) of Staphylococcus aureus. Mol Microbiol 11:237–248PubMedCrossRef


Ni Eidhin D, Perkins S, Francois P (1998) Clumping factor B (ClfB), a new surface-located fibrinogen-binding adhesin of Staphylococcus aureus. Mol Microbiol 30:245–257CrossRef


Novitsky YW, Cristiano JA, Harrell AG et al (2008) Immunohistochemical analysis of host reaction to heavyweight-, reduced-weight-, and expanded polytetrafluoroethylene (ePTFE)-based meshes after short-and long-term intraabdominal implantations. Surg Endosc 22:1070–1076PubMedCrossRef


Harrell AG, Novitsky YW, Cristiano JA et al (2007) Prospective histologic evaluation of intra-abdominal prosthetics four months after implantation in a rabbit model. Surg Endosc 21:1170–1174PubMedCrossRef


Koninger J, Redecke J, Butters M (2004) Chronic pain after hernia repair: a randomized trial comparing Shouldice, Lichtenstein and TAPP. Langenbecks Arch Surg 389:361–365PubMedCrossRef


Bellon JM, Rodriguez M, Garcia-Honduvilla N et al (2009) Comparing the behavior of different polypropylene meshes (heavy and lightweight) in an experimental model of ventral hernia repair. J Biomed Mater Res B Appl Biomater 89B:448–455CrossRef


García-Ureña MA, Ruiz VV, Godoy AD et al (2007) Differences in polypropylene shrinkage depending on mesh position in an experimental study. Am J Surg 193:538–542PubMedCrossRef


Novitsky YW, Harrell AG, Cristiano JA et al (2007) Comparative evaluation of adhesion formation, strength of ingrowth, and textile properties of prosthetic meshes after long-term intra-abdominal implantation in a rabbit. J Surg Res 140:6–11PubMedCrossRef


Emans PJ, Schreinemacher MHF, Gijbels MJJ et al (2009) Polypropylene meshes to prevent abdominal herniation. Can stable coatings prevent adhesions in the long term? Ann Biomed Eng 37:410–418PubMedCrossRef


Schreinemacher MH, Emans PJ, Gijbels MJ et al (2009) Degradation of mesh coatings and intraperitoneal adhesion formation in an experimental model. Br J Surg 96:305–313PubMedCrossRef


Junge K, Rosch R, Krones CJ et al (2005) Influence of polyglecaprone 25 (Monocryl) supplementation on the biocompatibility of a polypropylene mesh for hernia repair. Hernia 9:212–217PubMedCrossRef


Conze J, Kingsnorth AN, Flament JB et al (2005) Randomized clinical trial comparing lightweight composite mesh with polyester or polypropylene mesh for incisional hernia repair. Br J Surg 92:1488–1493PubMedCrossRef


Böhm G, Ushakova Y, Alizai HP et al (2011) Biocompatibility of PLGA/sP(EO-stat-PO)-coated mesh surfaces under constant shearing stress. Eur Surg Res 47:118–129PubMedCrossRef


Grafahrend D, Heffels KH, Beer MV et al (2011) Degradable polyester scaffolds with controlled surface chemistry combining minimal protein adsorption with specific bioactivation. Nat Mater 10:67–73PubMedCrossRef


Groll J, Fiedler J, Engelhard E et al (2005) A novel star PEG-derived surface coating for specific cell adhesion. J Biomed Mater Res A 74:607–617PubMed


Gasteier P, Reska A, Schulte P et al (2007) Surface grafting of PEO-based star shaped mole-cules for bioanalytical and biomedical applications. Macromol Biosci 7:1010–1023PubMedCrossRef


Neuss S, Apel C, Buttler P et al (2008) Assessment of stem cell/biomaterial combinations for stem cell-based tissue engineering. Biomaterials 29:302–313PubMedCrossRef


Weyhe D, Hoffmann P, Belyaev O et al (2007) The role of TGF-beta1 as a determinant of foreign body reaction to alloplastic materials in rat fibroblast cultures: comparison of different commercially available polypropylene meshes for hernia repair. Regul Pept 138:10–14PubMedCrossRef


van Wachem PB, Brouwer LA, van Luyn MJ (1999) Absence of muscle regeneration after implantation of a collagen matrix seeded with myoblasts. Biomaterials 20:419–426PubMedCrossRef


Kunisaki SM, Fuchs JR, Kaviani A et al (2006) Diaphragmatic repair through fetal tissue engineering: a comparison between mesenchymal amniocyte-and myoblast-based constructs. J Pediatr Surg 41:34–39PubMedCrossRef


Fuchs JR, Kaviani A, Oh JT et al (2004) Diaphragmatic reconstruction with autologous tendon engineered from mesenchymal amniocytes. J Pediatr Surg 39: 834–838PubMedCrossRef


Yao C, Prével P, Koch S (2004) Modification of collagen matrices for enhancing angiogenesis. Cells Tissues Organs 178:189–196PubMedCrossRef


Manodoro S, Endo M, Uvin P et al (2013) Graft-related complications and biaxial tensiometry following experimental vaginal implantation of flat mesh of variable dimensions. BJOG 120:244–250PubMedCrossRef


Liang R, Abramowitch S, Knight K (2012) Vaginal degeneration following implantation of synthetic mesh with increased stiffness. BJOG 120:233–243CrossRef


D’Hoore A, Penninckx F (2006) Laparoscopic ventral recto(colpo)pexy for rectal prolapse: surgical technique and outcome for 109 patients. Surg Endosc 20:1919–1923PubMedCrossRef