Anatomic relationships of the tension-free vaginal mesh trocars

Transvaginal treatment of anterior and apical genital prolapses using an Ultra lightweight mesh: Restorelle® Direct Fix™. A retrospective study on feasibility and morbidity

BACKGROUND

Vaginal mesh safety information is limited, especially concerning single incision techniques using ultra lightweight meshes for the treatment of anterior pelvic organ prolapse (POP).

OBJECTIVE

To determine the intraoperative and postoperative complication rates after anterior POP repair involving an ultralight mesh (19g/m²): Restorelle^® Direct Fix™.

METHODS

A case series of 218 consecutive patients, operated on between January 2013 and December 2016 in ten tertiary and secondary care centres, was retrospectively analyzed. Eligible patients had POP vaginal repair (recurrent or not) planned with anterior Restorelle^® Direct Fix™ mesh (with or without posterior mesh). Surgical complications were graded using the Clavien-Dindo classification.

RESULTS

Intraoperative complications were bladder wound (0.5%), rectal wound (0.5%), ureteral injuries (0.9%). 98.2% of the patient did not have per operative complications. We observed one fail of procedure. Early complications mainly included urinary retention (8.7%) urinary tract infections (5.5%) and haematoma (2.7%). One haematoma required surgical treatment and another, embolization. 80.7% of the patient did not have complications during hospitalization and 80.3% did not have complication at the follow up visit. None of the analyzed factors (age, body mass index, surgical history, grade of prolapse or concomitant procedure) was significantly associated with the risk of perioperative complications. A total of 2.8% patients had grade III complications according Clavien Dindo. None had grade IV or V.

CONCLUSIONS

This multicentre case-series on the early experience of the use of anterior Restorelle^® Direct Fix™ mesh showed a satisfactory technical feasibility and a low rate of grade III complications according Clavien Dindo. Long term studies are necessary to assess anterior Restorelle^® Direct Fix™ mesh performances and to appraise patient satisfaction feedback.

Determination of a Central Avascular Triangle within the Obturator Foramen: A Radioanatomic Study

PURPOSE

To map the vascular anatomy of the obturator foramen using fixed anatomic landmarks.

METHOD

Twenty obturator regions were dissected in 10 fresh female cadavers after vascular blue dye injection in five cadavers (50%). Furthermore, 104 obturator regions were reconstructed by angiotomodensitometry from 52 women under investigation for suspected arterial disease. The anatomy of the obturator region was mapped by measuring the distance of vascular structures from the middle of the two branches of the ischiopubic bone, which were used as fixed landmarks.

RESULTS

The bifurcation of the obturator artery was at a mean (SD) distance of 30.0 mm (4.5) from the middle of the ischiopubic branch (MISP). The anterior branch of the obturator vessels was 15.2 mm (10.1) from the MISP. The posterior branch of the obturator vessels was 5.5 mm (4.0) and 23.6 mm (8.7) from the middle of the outer edge of the obturator foramen (MOE) and the MISP, respectively. Using 5° and 95° percentiles of these measurements we defined a central avascular triangle.

CONCLUSIONS

Our data show that, beyond inter-individual variations, a central triangular avascular area can be identified in the obturator foramen between the posterior and anterior obturator artery using fixed landmarks.

How to manage peroperative haemorrhage when vaginally treating genital prolapse

Surgery of genital prolapse causes haemorrhagic complications in about 1% of cases. The pelvis is highly vascular and accessing the usual landmarks of vaginal surgery, in particular the sciatic spine, is delicate work. Meticulous dissection of closed spaces is often difficult, and exposure and haemostatic procedures will be challenging in the event of any bleeding complication. When fixing prosthesis to the sacrospinous ligament, the inferior gluteal artery and its coccygeal branch are at risk. Fixation to the sacrospinous ligament must be performed more than 25mm away from the sciatic spine and, if possible, must not transfixiate it. Safe insertion of prosthesis requires sufficient experience, and an adequate learning curve. Being aware of vascular anatomy allows one to understand and treat haemorrhagic incidents. Packing or selective embolization seem to be the two methods to adopt, depending on the severity of bleeding and the conditions of exposure on the one hand, and on the technical resources available for embolization, on the other. Hypogastric ligature appears to be ineffective in this context.

Anatomic study of prolapse surgery with nonanchored mesh and a vaginal support device

OBJECTIVE

The purpose of this study was to evaluate the anatomic position and relations to neighboring neurovascular structures of polypropylene implants after vaginal repair with nonanchored mesh and a vaginal support device in a cadaver model.

STUDY DESIGN

We undertook anatomic dissection of 6 cadavers, with and without prolapse after surgery.

RESULTS

All polypropylene implants were positioned in accordance with the prescribed surgical technique. This surgery reconstructed the entire anterior and posterior pelvic floor compartments without extension beyond the pelvic cavity. A safe distance between the implants and their neighboring neurovascular structures (obturator nerve and vessels, 2.8-3.3 cm; pudendal nerve and internal pudendal vessels, 1.8-2.2 cm; sacral plexus, 2-2.2 cm) was observed.

CONCLUSION

Anatomic cadaver dissection confirmed the accurate and safe placement of the polypropylene implants with the use of the prescribed surgical technique.

Variability of the retropubic space anatomy in female cadavers

OBJECTIVE

To characterize the anatomic relationships of clinically relevant structures in the retropubic space.

STUDY DESIGN

Detailed dissections were performed in 15 female cadavers.

RESULTS

The obturator vein was the closest of the obturator neurovascular structures to the ischial spine, median distance 3.4 cm (range, 1.8-4.8 cm). The vesical venous plexus included 2-5 rows of veins that coursed within the paravaginal tissue parallel to the bladder and drained into the internal iliac veins. The internal iliac vein was formed cephalad to the level of the ischial spine; the closest distance between these structures was 3.8 cm (1.6-6.2 cm).

CONCLUSION

The complexity and proximity of the large internal iliac venous system to the bony landmarks used for passage of trocars is described in this study. A thorough understanding of the vascular anatomy in this space should help avoid serious operative complications.

The relationship between superior attachment points for anterior wall mesh operations and the upper vagina using a 3-dimensional magnetic resonance model in women with normal support

OBJECTIVE

We examined structural relationships between anterior mesh kit suspension points and the upper vagina in women with normal support.

STUDY DESIGN

Eleven women with normal support underwent supine, multiplanar magnetic resonance pelvic imaging at rest and maximal Valsalva. Using 3-dimensional models generated from these images, anterior wall mesh kit anchoring points were identified along the arcus tendineus fascia pelvis. We then measured the percentage of anterior vagina above and posterior to superior suspension points.

RESULTS

The anterior vagina extended above superior attachment points in 100% of women at rest and in 73% during Valsalva. It extended posterior to them in 82% and 100% (rest and Valsalva, respectively). The mean percentage of anterior vaginal length above superior anchoring sites was 40 +/- 14% at rest and 29 +/- 12% during Valsalva.

CONCLUSION

The upper vagina lies above and posterior to superior suspension points in the majority of women with normal support.

Perineal approach to vascular anatomy during transobturator cystocele repair

OBJECTIVE

To evaluate the risk of vascular injury during transobturator approach of cystocele repair.

DESIGN

Dissection of the obturator area by perineal approach was performed after placement of mesh needles used for cystocele mesh repair.

SETTING

Surgery school of Paris.

POPULATION OR SAMPLE

Twenty obturator regions in ten fresh female cadavers.

METHODS

Transperineal dissection of the obturator area was conducted in ten fresh female anatomic subjects after inserting anterior Prolift needles.

MAIN OUTCOME MEASURES

The vascular anatomy of the obturator region was mapped. Distances between needles and vascular structures of the obturator area were measured three times and averaged for each side.

RESULTS

The anterior cannula-equipped needle perforated the gracilis and the adductor brevis muscles. The mean (SD) distance to the anterior obturator vessels was 21.2 (1.6) mm on the right side and 20.4 (1.5) mm on the left. The posterior needle perforated the adductor magnus. Its distance to the posterior division of the obturator vessels was 1.8 (1.0) mm on the right side and 1.1 (0.9) mm on the left.

CONCLUSIONS

During mesh cystocele repair by transobturator approach, the posterior obturator vessels division seems at risk of injury during the posterior needle insertion.

[What about transvaginal mesh repair of pelvic organ prolapse? Review of the literature since the HAS (French Health Authorities) report]

The French Health Authorities' (HAS) report of November 2006 concluded that the use of mesh at the time of transvaginal repair of pelvic organ prolapse (POP) should be limited to clinical research. This review intends to analyse and comment the recent data on this topic. A review on PubMed, on a personal database and actualisation until May 2008 has been performed choosing French or English language series concerning prolapse surgery with mesh disposed by the vaginal route. It includes six randomised controlled trials comparing transvaginal repair of POP with or without mesh: four about cystocele, one about rectocele and one about apical prolapse. Both surgical techniques and recurrence criteria are poorly standardised. The four randomised trials focusing on cystocele repair support the anatomical superiority of techniques using mesh, with similar functional results with or without mesh reinforcement. In the other indications, the results remain unclear or controversial. According to the randomised trials, the complications rate, except mesh exposure, is similar with and without mesh. However there are some specific complications when using mesh, such as mesh infection, mesh exposure or shrinkage and visceral extrusion. We recommend using vaginal reinforcement mesh with specific care in selected patients and we suggest some guidelines to be proposed for consensus at concerned French scientific societies.