TOTAL ANTERIOR VAGINAL WALL REPAIR VIA A TRANSOBTURATOR SYSTEM:  A PILOT STUDY

A.M. Rane, A.K. Naidu, C.L. Barry, A.C. Corstiaans

James Cook University, Townsville, Queensland, Australia

OBJECTIVES: To evaluate a simple transobturator synthetic mesh system developed for total repair of anterior vaginal wall prolapse.

MATERIALS AND METHODS: Eleven patients with large cystoceles underwent the transobturator (TO) procedure (Perigee, American Medical Systems, Inc., Minnetonka, MN, U.S.A.) with follow-up at 6 weeks, 3, 6, 9 and 12 months.  Institutional Ethics Committee approval was obtained for this prospective study. A midline incision was made and dissection followed superiorly to the vaginal vault and laterally to each inferior pubic ramus. Four helical needles were passed from outside to in, through the obturator foramen and levator ani muscles: two at the level of the vaginal vault, two at the level of the bladder neck.  A large-pore polypropylene mesh with four, self-fixating arms covered in plastic sheaths restored the support to the cystocele.

RESULTS: Cystocele defects found included lateral (7), central (2), both (1), and unknown (1).   5 (45%) had prior anterior repairs.  Perigee operative time averaged 18.4 minutes (11-26 min); total O.R. time averaged 45.3 minutes (31-80 min).  Nine had concomitant procedures and cystoscopy:  Monarc (4), SPARC (1), rectocele repair (7: VYPRO II(3), defect-specific(4)), hysterectomy (1), bladder bulge reduction (5), culdoplasty (1), and urethral dilation (1).  No urethral or bladder perforations, bowel, vessel or nerve injuries were noted.  One small bladder tear (< 0.5 cm) occurred during dissection and was repaired with 2-0 vicryl.  At 6 weeks: one UTI  and temporary pain down both legs for five days; at 3 months one sore left hip; at 6 months one constipation with bowel strain and digital support, one poorer stream, and one late menses coital pain. POP-Q prolapse: pre-op stage III/IV (10); at 6-months stage 0 (11).  For POP-Q Aa and Ba, all follow-up visits showed significant improvement by LS Means compared to pre-op (p < 0.001) and there was no statistical difference between the 6-week, 3-month, or 6-month visit results.

CONCLUSIONS: This pilot study has demonstrated that A TO system provides a safe and effective means for restoring anterior vaginal wall support.

Key Words: cystocele, transobturator, transvaginal surgery, mesh, polypropylene

Disclosure - Grant/Research: A.J. Rane, AMS, Inc.; Speakers Bureau: A.J. Rane, AMS, Inc.