Posterior Elevate Procedure
New Minimally Invasive Vaginal Approach to Treat Vault Prolapse at Same Time as Rectocele and/or Cystocele
As stated previously, many surgeons may not complete a vaginal vault suspension at the time of prolapse surgery, even if the patient has vault prolapse, because of the difficult and complex nature of the procedures reviewed above. This can lead to problems such as a shortened vagina, pelvic pain, painful intercourse, urinary symptoms (urgency, frequency, nocturia, difficulty emptying) that can occur post-operatively if the vaginal vault wasn’t properly suspended (Posterior Fornix Syndrome).
Symptoms of vaginal vault NOT being suspended properly
- Urinary frequency, urgency
- Difficulty emptying bladder
- Constipation (straining to evacuate)
- Vaginal pressure, pain
- Painful intercourse
Recent interest has focused on less invasive operations for vault suspensions such as laparoscopic procedures, however as Dr Bruce Farnsworth, a well known Urogynecologist from Australia, recently quoted, "Laparoscopic procedures require a high degree of skill and extensive specialized training. As a result, only a minority of surgeons achieve competence in these methods." Additionally, as reviewed in the sacrospinous ligament suspension section, bleeding or nerve damage are potential risks of the traditional sacrospinous ligament suspension.
Because of this, a less invasive approach for vault prolapse was developed and studied in Australia and Europe that was an outpatient procedure that applied the tension-free vaginal tape principle to the posterior part of the vagina called the Posterior IVS procedure. Dr Moore and Miklos were some of the first surgeons in the United States to evaluate this system and did some of the first research in the modifications of the system. This ultimately led to the vaginal mesh procedure kits that have become more popular over the past several years such as the Apogee/Perigee (http://www.ncbi.nlm.nih.gov/pubmed/20087573) system, Prolift, Avaulta, etc. These kits utilized mesh placed in the anterior (bladder) or posterior (rectocele) vaginal compartments with needled passed through the groins or buttock cheeks to get them in place. The posterior graft kits had arms coming off the top of them that would be attached to the pelvic sidewalls in an attempt to support the top or vault of the vagina.
Fig 1 The above figure depicts the original Posterior IVS tape procedure for vaginal vault suspension. The Apogee procedure was a modification of this procedure that adds a posterior wall graft in addition to the tape at the vault so that the entire posterior compartment can be treated, in addition to the vault.
Fig 2 The original Apogee System with posterior wall mesh that treats rectocele and enterocele, and apical arms designed to suspend the vault of the vagina.
The traditional approach with the vaginal mesh kits was to utilize the posterior approach to place a graft to treat the rectocele and enterocele and then utilize arms at the top portion of the mesh to support the vault or the apex of the vagina. The mesh arms at the top of the graft were designed to be attached to the pelvic sidewall muscles by passing needles blindly through two incisions in the buttock cheeks and ischiorectal fossa and penetrating the pelvic sidewall muscles up near the ischial spines. The arms at the top of the graft were attached to the needles and pulled back through the incisions in the buttock cheeks. (see Apogee procedure below). This supported the top of the vagina at the level of the ischial spines and the body of the graft repaired the rectocele and enterocele. The Prolift procedure arms could also be placed like this or were sometimes taken up through the sacropinous ligaments from below, which Dr Moore and Miklos did not believe in as they felt it was a very dangerous blind pass.
There has been some controversy over these type of procedures because of complications that have been reported. Dr. Moore and Miklos recently published an extensive review of the procedures including complications. Many studies have been completed that have shown increased cure rates compared to traditional repairs without mesh with low rate of complications, but risks such as vaginal or pelvic floor pain, pain with intercourse, mesh extrusions into the vagina or erosion into the rectum have been reported. Dr Miklos and Moore do feel that many of these complications may be secondary to inadequate experience by the implanting surgeons and/or the wrong patient selection. They have used these techniques in select patients and had very good results and were involved in several studies involving the Apogee (Rectocele and Vault) and Perigee (Cystocele) systems. Dr Moore is actually one of the leading investigators in the US in the Perigee system and is Principal Investigator in an ongoing multicenter US trial on the system that will continue to follow patient for 5 yrs. He recently reported on the results of the trial at the 2009 International Urogyn Meeting in Italy. Cure rates in the range of 90% have been seen with minimal complications in this predominantly (over 85%) postmenopausal age group.
Fig 3a,b. The Apogee procedure involves the blind passage of a needle through the buttock cheek and then it penetrates the pelvic sidewall muscle near the ischial spine. The lateral mesh arm at the top of the mesh is then attached to the needle and pulled back through the muscle and the incision. The arms support the top of the vagina and the body of the graft treats the rectocele and enterocele. These arms, if too tight, may pull and cause pain.
Some of the complications that have been reported, may also be secondary to the blind needle passes through the buttock cheeks (in the posterior compartment) causing rectal injury and/or bleeding issues, or secondary to the apical mesh arms healing under tension through the pelvic sidewall muscles up near the ischial spines. If the arms are too tight, it can pull on the muscles or create a tight "band" in the vagina. If this happens then this can cause generalized pelvic and/or vaginal pain and also pain with intercourse aka dyspareunia. (In 2011 the FDA issued a Communication regarding some of these complications which seemed to be occurring mostly in these “First Generation” mesh kits. This is covered in more detail in the next sections). Typically these complications can be handled, however in many cases the patient must go to an advanced pelvic surgeon with experience in these type of complications to get adequate treatment. Additionally many surgeons also felt the support of the top of the vagina at the level of the ischial spines was not adequate for higher grade or more severe prolapse. Because of this, and of course because we are always seeking improvements in our procedures, improvements and modifications have been made to the systems to help reduce or eliminate some of these risks.
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