Again, anatomical landmarks provide significant guidance. As I push the cannula-equipped guide through the ischioanal fossa with one hand, my nondominant finger is on the ischial spine waiting to feel the tip. (If the tip cannot be felt, you can stop and drop the handle of the guide, which will bring the tip up to where it can be felt through the levator ani muscle.)
The goal is to bring the tip of the guide up through the sacrospinous ligament into the dissected rectovaginal space. We want to be sure the tip is at least 2 cm medial to the ischial spine and 1 cm above the lower edge of the sacrospinous ligament. This keeps us far enough away from the pudendal nerve and the internal pudendal artery and vein that travel right underneath the ischial spine along the side wall of the pelvis, and away from the interior gluteal artery nerve and vein that travel near the upper edge of the sacrospinous ligament.
The posterior mesh is positioned by using techniques similar to those of an anterior repair. Again, I find that a dull curette is helpful for capturing the retrieval device.
After the mesh arms are placed, I examine the rectum to make sure there isn't any mesh perforating into the rectum or injury to the rectum. And just as with the anterior repair, the mesh must be placed loosely in the rectovaginal space to minimize erosion.
I often trim a bit of the mesh at the distal end and then place that end in the rectovaginal space to ensure its proximity to the apex of the perineal body. Again, I close the incision with a running interlocking stitch and use vaginal packing for 24 hours. I also often perform a perineorrhaphy to repair the perineal body and help with vaginal support.
When I first started using the Prolift transvaginal mesh kits, my erosion rate (when the mesh could be seen or felt through the vagina) was about 4%. Now, it is about 1%.
The Prolift mesh kit contains loosely woven polypropylene mesh, cannulas, a metal guide, and blue retrieval devices. ©ETHICON, INC.
Vaginal support anatomy: The pubocervical fascia is fused with the anterior vaginal wall and attached to each uterosacral ligament. The bladder passively rests on this “hammock.” ©Elsevier, Clinical Gynecology, Churchill Livingstone 2006
The surgeon's blue-gloved finger is near the right ischial spine; the white cannula traverses the obturator internus muscle. ©ETHICON, INC.
The mesh is placed in the vesicovaginal space and the arms are anchored through the obturator membranes. ©ETHICON, INC.
In the United States from 2005 to 2007, a reported total of 994,890 surgeries—363,000 procedures for pelvic floor prolapse and 631,890 procedures for stress urinary incontinence—utilized synthetic mesh. The impetus for mesh usage was based on the fact that conventional pelvic floor prolapse repair has an estimated failure rate of 30%–50%.
In October 2008, a Public Health Notification was issued by the Food and Drug Administration regarding complications with the transvaginal placement of surgical mesh for pelvic floor prolapse and stress urinary incontinence. Over a 3-year period, the FDA has received more than 1,000 reports of serious mesh-related complications from nine manufacturers. The most frequent complications included erosion through vaginal epithelium, infection, pain, urinary problems, and recurrence. Additional complications were noted due to bowel, bladder, and blood vessel perforation. In some cases, vaginal scarring and erosion led to decreased quality of life.
Because of the concerns noted above, I believe it is essential to review the proper technique that is involved with synthetic mesh placement for pelvic floor prolapse.
I have asked Dr. Robert M. Rogers to author this Master Class in Gynecologic Surgery. Dr. Rogers currently is in private practice in Kalispell, Mont. Committed to teaching, he serves as the chairman of the education committee of the Society of Gynecologic Surgeons. Not only is Dr. Rogers well known for his surgical prowess, especially in pelvic floor prolapse, but he also has lectured and written extensively on pelvic floor anatomy.
This Master Class will be a lesson not only in pelvic prolapse surgery, but in pelvic anatomy as well.