mickey karram md director of urogynecology the christ hospital clinical professor of ob/gyn &...
TRANSCRIPT
MICKEY KARRAM MD
DIRECTOR OF UROGYNECOLOGY
THE CHRIST HOSPITAL
CLINICAL PROFESSOR OF OB/GYN & UROLOGY
UNIVERSITY OF CINCINNATI
Vaginal Insertion of Mesh Vaginal Insertion of Mesh for Incontinence and for Incontinence and Prolapse; How will the Prolapse; How will the Recent FDA Warning Recent FDA Warning Impact our Clinical Impact our Clinical PracticePractice
1-Review current FDA requirements for approval of a drug or device
2-Discuss the history of industry driven mesh kits for incontinence and prolapse
3-Review prevelance of mesh complications after surgeries for SUI and Pelvic Organ Prolapse
4-Discuss impact of recent FDA warning
5-Future of pelvic floor surgery and medico-legal implications
OBJECTIVES
FDA Regulatory Process;A DOUBLE –EDGED SWORD
WHY IS THE PROCESS REQUIRED BY THE FDA SO DIFFERENT FOR A DRUG VS A DEVICE?
1. Budget differences between CDRH vs CDER
2. 1976 ruling on devices that occurred after Dalkon Shield problems
3. Differences between financial status of pharmaceuticals vs device companies
Regulatory Approval - DrugsFour phase process
I II III IV
TIME ( 7 -10 yrs)
Regulatory Approval - DrugsPhase I
Safety
Initial human exposure – healthy volunteers
CV, Metabolic, Bioavailability
Pharmacokinetics (half life etc)
Pharmacodynamics (unique issues with compound)
Regulatory Approval - DrugsPhase II
Class specific adverse eventsSafety monitoringDose rangingPharmacokinetics
Usually 20-80 patients2-3 year process
Regulatory Approval - DrugsPhase IIIBIG DECISION; REQUIRES HUNDREDS/THOUSANDS OF PATIENTS;
RCT – expanded exposureMay include active comparator (not
absolute)Efficacy / Tolerability / SafetySpecial patient populations
Several year process ;70-90% get approved
Recent Drugs that went through Phase III trials and got rejected by FDA
DULOXETINE (LILLY)
INTRINSA (P&G)
Regulatory Approval-Drugs
Phase IV
Postmarket studies to define additional information including risks benefits, and optimal use
FDA Regulations
Filing for a new device or material
510(K) Premarket Notification Process
PMA Premarket Approval Process
Classes of DevicesClass I-Low potential for harm (bandages, gloves etc)Class II-May be harmful, requires
special controls, labeling requirements, post market surveilence
(meshes, instruments etc)Class III-Should require PMA (heart valves,breast implants etc)
Examples of 510(k) products that were withdrawn from market
• TMJ implant
• Bladder slings
• Renu moisture/loc
• Heart valves
• Orthopedic prosthesis
1-In 1996 Boston Scientific obtained 510(k) approval for the PrtoGen Sling
2-In 1998 Ethicon/Gynecare obtained 510(k) approval for TVT
3-In 2002 Ethicon/Gynecare obtained 510(k) approval for Gynemesh for repair of prolapse
HISTORY OF INDUSTRY DRIVEN MESH KITS FOR INCONTINENCE AND PROLAPSE
510 (k) Clearance of Surgical Mesh (1992-2010)
510(k) Clearance of Surgical Mesh by Material Category
CURRENTLY AVAILABLE SYNTHETIC SLINGS• RETROPUBIC; below to above vs above
to below
• PREPUBIC
• TRANSOBTURATOR; outside in vs inside out
• MINI-SLING; urogenital diaphragm vs obturator internus
• GENERIC SYNTHETIC SLINGS
Abdominal Sacrocolpopexy
Mesh Overlay Techniques Mesh Overlay Techniques
MESH KITS – TROCAR BASED SYSTEMS
1- Prolift (Gynecare)
2- Apogee & Perigee (AMS)
3- Avaulta (Bard)
MESH KITS; DIRECT ACCESS SYSTEMS
1-ELEVATE (AMS)
2-UPHOLD & PINNACLE (BSC)
3-PROSIMA (GYNECARE)
Manufacturer and User DeviceExperience Database;•Requires mandatory reporting by manufacturer•Voluntary reporting by user; most users do not manage their own mesh complications
MAUDE DATABASE
1.Between Jan 1, 2008 & Dec 31, 2010; the FDA received 2874 reports of complications associated with surgical mesh used to repair SUI and POP; with 1503 associated with POP.
2.The most frequent complications reported were erosion through the vagina, pain, infection, bleeding, dyspareunia, organ perforation, and urinary problems.
3.There were also reports of recurrent prolapse, neuromusculsar problems, vaginal scarring or shrinkage, & emotional problems.
Recent warning from July 2011;What the FDA said
1-Obtain specialized training for each mesh placement technique
2-Be vigilant for potential adverse events especially erosion and infection
3-Watch for c/o associated with the tools; especially bowel, bladder and blood vessel perforation
4-Inform patients about the potential for serious complications; including pain and narrowing of the vagina
5-Provide patients with a copy of the patient labeling from the manufacturer if available
FDA Recommendations to Physicians
MESH COMPLICATIONS
• Vaginal Exposure
• Vaginal Pain & Dyspareunia
• Vaginal Scarring and Loss of Vaginal Tissue
• Visceral Injury
• Thigh Pain and Referred Pain
Extensive review of published data with conclusions that question efficacy of mesh for prolapse repair
FDA White Paper
Panel will be asked to discuss
1-Risks associated with vaginal mesh for POP repair
2-Based on available data is their adequate assurance of the effectiveness of vaginal mesh used for POP repair
3-Do risks of mesh repair outweigh potential benefits
4-Are more studies needed to document safety and efficacy; if so recommend study design outcome measures etc
5-Does the panel agree with the FDA regarding abdominal mesh repair has been proven to be safe and efficacious
6-SHOULD VAGINAL MESH KITS BE RECLASSIFIED AS CLASS III DEVICES
FDA Obstetrics & Gynecology Devices Advisory Committee Meeting; Sept 8 & 9; 2011
Mayo Data – Mesh ComplicationsComplications specific to synthetic material use continue to increase
Multiple surgeries to address complications may be necessary, and may incompletely resolve symptoms
Potential for underreporting – only 14% referred from original treating physician
Dyspareunia and recurrent prolapse are common reasons for referral
Blandon et al. Int Urogynecol J 2009 Feb10 (EPub)
Mesh Complications; How Common are They
The BIG QUESTION
Severe mesh complications are occurring; but are the majority of them TECHNICAL or WOULD THEY OCCUR IN THE BEST OF HANDS
What about Complications with Meshes?
Outcomes for Pelvic Organ Prolapse
• Vaginal anatomy; bulge, pressure, mass
• Visceral symptoms: Urinary and bowel symptoms
• Sexual activity and expectations
• Future surgical procedures or medicines to manage failures or complications
Who should ultimately be responsible for training surgeons to utilize new devices or materials?• The company that makes and sells the
device. • The hospital in which the surgeon performs
the surgery • The medical organization or society that
represents the surgeon. • A formal credentialling board made up of an
expert panel. • Certified, trained proctors that have
demonstrated competence in this area or device.
• Other
YES1-How we teach and train 2-How we consent3-Medico-legal implications4-Hospital credentialing 5-Reimbursement by third party payers
Will this warning have a long term impact on our clinical practice?