Anatomical Position of Four Different Transobturator Mesh Implants for Female Anterior Prolapse Repair

 

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Abstract

Purpose: Polypropylene mesh implants are frequently used for pelvic floor reconstruction in women. Yet they vary in size and fixation. The purpose of this study is to compare four mesh products with regard to their anatomical positioning and functionality within the pelvic floor, to determine whether each mesh fits equally well in a female cadaver. Methods: One female pelvis was dissected, opening the retropubic space exposing the endopelvic fascia and demonstrating the arcus tendineus fasciae pelvis (ATFP). Anatomical parameters were measured before and after implanting four meshes via the transobturator approach. Results: The anterior fixation of the ATFP was found to be 5 mm lateral to the symphysis in this cadaver. The endopelvic fascia covered 54.6 cm². The obturator nerve was located 35 mm from the white line. The distance of the proximal and lateral points of mesh fixation from the ischial spine or ATFP varied from 0 to 25 mm. The meshes varied in size and anatomical positioning. Conclusion: These observations demonstrate the necessity of developing optimally sized meshes and appropriate introducer techniques that can provide sufficient vaginal support. Surgeons, furthermore, need profound knowledge of anatomy, the patientʼs pelvic floor defect and the meshes available on the market.

Zusammenfassung

Vaginale Polypropylenimplantate werden zur Rekonstruktion des weiblichen Beckenbodens angewendet. Jedoch variieren die verschiedenen, auf dem Markt angebotenen Produkte in Form, Größe und Verankerungstechniken. Gegenstand dieser Studie ist es, 4 Produkte in eine weibliche Leiche zu implantieren, diese hinsichtlich der anatomischen Position und Funktionalität im Beckenboden zu untersuchen und festzustellen, ob die 4 Produkte in gleicher Weise in den Beckenboden dieser Leiche passen. Es wurde eine weibliche Frischleiche seziert. Die endopelvine Faszie wurde freigelegt und der Arcus tendineus fascia pelvis (ATFP) dargestellt. Vier auf dem Markt verfügbare transobturatorische Mesh-Implantate wurden nacheinander implantiert entsprechend der Herstellerangaben. Anatomische Parameter wurden vor und nach Mesh-Implantation festgehalten. Der anteriore Fixationspunkt des ATFP zeigte sich in dieser Leiche 5 mm lateral der Symphyse. Die endopelvine Faszie bedeckte einen Bereich von 54,6 cm². Der N. obturatorius wurde 35 mm entfernt vom ATFP dargestellt. Die Entfernung der proximalen und lateralen Fixationspunkte der Mesh-Implantate von der Spina ischiadica oder dem ATFP variierten von 0 bis 25 mm. Die Implantate unterscheiden sich in Größe und Lage zu anatomischen Strukturen. Zusammenfassend demonstrieren diese Ergebnisse die Notwendigkeit der Entwicklung von Implantaten optimaler Größe. Darüber hinaus benötigen die Anwender dieser Implantate detailliertes Wissen über die anatomischen Verhältnisse ihrer Patientin und auch der auf dem Markt erhältlichen Produkte, um ein zufriedenstellendes postoperatives Ergebnis zu ermöglichen.

• References

• 1 Debodinance P, Berrocal J, Clave H et al. [Changing attitudes on the surgical treatment of urogenital prolapse: birth of the tension-free vaginal mesh]. J Gynecol Obstet Biol Reprod 2004; 33: 577-588
  CrossrefPubMedGoogle Scholar
• 2 Nguyen JN, Burchette RJ. Outcome after anterior vaginal prolapse repair: a randomized controlled trial. Obstet Gynecol 2008; 111: 891-898
  CrossrefPubMedGoogle Scholar
• 3 Graefe F, Beilecke K, Tunn R. Vaginal vault prolapse following cystectomy: transvaginal reconstruction by mesh interposition. Int Urogynecol J 2012; Sep 7 [Epub ahead of print]
  PubMedGoogle Scholar
• 4 Graefe F, Marschke J, Dimpfl T et al. Vaginal vault suspension at hysterectomy for prolapse – myths and facts, anatomical requirements, fixation techniques, documentation and cost accounting. Geburtsh Frauenheilk 2012; 72: 1099-1106
  Article in Thieme ConnectPubMedGoogle Scholar
• 5 Naumann G, Kölbl H. Current developments and perspectives on the diagnosis and treatment of urinary incontinence and genital prolapse in women. Geburtsh Frauenheilk 2012; 72: 202-210
  Article in Thieme ConnectPubMedGoogle Scholar
• 6 Chen L, Ashton-Miller JA, Hsu Y et al. Interaction among apical support, levator ani impairment, and anterior vaginal wall prolapse. Obstet Gynecol 2006; 108: 324-332
  CrossrefPubMedGoogle Scholar
• 7 de Tayrac R, Devoldere G, Renaudie J et al. Prolapse repair by vaginal route using a new protected low-weight polypropylene mesh: 1-year functional and anatomical outcome in a prospective multicentre study. Int Urogynecol J Pelvic Floor Dysfunct 2007; 18: 251-256
  CrossrefPubMedGoogle Scholar
• 8 Diwadkar GB, Barber MD, Feiner B et al. Complication and reoperation rates after apical vaginal prolapse surgical repair: a systematic review. Obstet Gynecol 2009; 113 (2 Pt 1) 367-373
  CrossrefPubMedGoogle Scholar
• 9 de Tayrac RGA, Chauveaud A, Fernandez H. Tension-free polypropylene mesh for vaginal repair of anterior vaginal wall prolapse. J Reprod Med 2005; 50: 75-80
  PubMedGoogle Scholar
• 10 DeLancey J. Structural anatomy of the posterior pelvic compartment as it relates to rectocele. Am J Obstet Gynecol 1999; 180: 815-823
  CrossrefPubMedGoogle Scholar
• 11 DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol 1992; 166 (6 Pt 1) 1717-1724 discussion 1724–1728
  CrossrefPubMedGoogle Scholar
• 12 Larson KA, Luo J, Yousuf A et al. Measurement of the 3D geometry of the fascial arches in women with a unilateral levator defect and “architectural distortion”. Int Urogynecol J 2011; 23: 57-63
  PubMedGoogle Scholar
• 13 Chen L, Ashton-Miller JA, DeLancey JO. A 3D finite element model of anterior vaginal wall support to evaluate mechanisms underlying cystocele formation. J Biomech 2009; 42: 1371-1377
  CrossrefPubMedGoogle Scholar
• 14 Larson KA, Luo J, Guire KE et al. 3D analysis of cystoceles using magnetic resonance imaging assessing midline, paravaginal, and apical defects. Int Urogynecol J 2011; 23: 285-293
  PubMedGoogle Scholar
• 15 Farthmann J, Watermann D, Niesel A et al. Lower exposure rates of partially absorbable mesh compared to nonabsorbable mesh for cystocele treatment: 3-year follow-up of a prospective randomized trial. Int Urogynecol J 2013; 24: 749-758
  CrossrefPubMedGoogle Scholar
• 16 Moreno Sierra J, Prieto Nogal SB, Galante Romo MI et al. [New technique for the repair of anterior pelvic floor compartment defects using a synthetic implant with biological coverage: approach, fixation and transobturator anchoring]. Arch Esp Urol 2007; 60: 45-50
  PubMedGoogle Scholar
• 17 Sagsoz N, Ersoy M, Kamaci M et al. Anatomical landmarks regarding sacrospinous colpopexy operations performed for vaginal vault prolapse. Eur J Obstet Gynecol Reprod Biol 2002; 101: 74-78
  CrossrefPubMedGoogle Scholar
• 18 Sand PK, Koduri S, Lobel RW et al. Prospective randomized trial of polyglactin 910 mesh to prevent recurrence of cystoceles and rectoceles. Am J Obstet Gynecol 2001; 184: 1357-1362 discussion 1362–1364
  CrossrefPubMedGoogle Scholar
• 19 Mostwin JL. Current concepts of female pelvic anatomy and physiology. Urol Clin North Am 1991; 18: 175-195
  PubMedGoogle Scholar
• 20 Pit MJ, De Ruiter MC, Lycklama A Nijeholt AA et al. Anatomy of the arcus tendineus fasciae pelvis in females. Clin Anat 2003; 16: 131-137
  CrossrefPubMedGoogle Scholar
• 21 Reisenauer C, Kirschniak A, Drews U et al. Anatomical conditions for pelvic floor reconstruction with polypropylene implant and its application for the treatment of vaginal prolapse. Eur J Obstet Gynecol Reprod Biol 2007; 131: 214-225
  CrossrefPubMedGoogle Scholar
• 22 Deffieux X, de Tayrac R, Huel C et al. Vaginal mesh erosion after transvaginal repair of cystocele using Gynemesh or Gynemesh-Soft in 138 women: a comparative study. Int Urogynecol J Pelvic Floor Dysfunct 2007; 18: 73-79
  CrossrefPubMedGoogle Scholar
• 23 Jacquetin B, Cosson M. Complications of vaginal mesh: our experience. Int Urogynecol J Pelvic Floor Dysfunct 2009; 20: 893-896
  PubMedGoogle Scholar
• 24 Davila GWBM, Biller DH, Walters MD. Current concepts in pelvic anatomy and reconstructive surgery. Clev Clin J Med 2005; 72: 20-27
  CrossrefPubMedGoogle Scholar
• 25 Albright TS, Gehrich AP, Davis GD et al. Arcus tendineus fascia pelvis: a further understanding. Am J Obstet Gynecol 2005; 193 (3 Pt 1) 677-681
  CrossrefPubMedGoogle Scholar
• 26 FitzGerald MP, Mollenhauer J, Bitterman P et al. Functional failure of fascia lata allografts. Am J Obstet Gynecol 1999; 181: 1339-1344 discussion 1344–1346
  CrossrefPubMedGoogle Scholar
• 27 Gandi SGR, Kwon C, Sand PK. A prospective randomized trial using solvent dehydrated fascia lata for the prevention of recurrent anterior vaginal wall prolapse. Am J Obstet Gynecol 2005; 192: 1649-1654
  CrossrefPubMedGoogle Scholar
• 28 Dietz HP. The role of two- and three-dimensional dynamic ultrasonography in pelvic organ prolapse. J Minim Invasive Gynecol 2010; 17: 282-294
  CrossrefPubMedGoogle Scholar