Pelvic Floor Reconstruction - Anterior Repair

Healthcare Professionals

by: Mark Swierzewski, M.D.

Overview
Anterior Repair with Repliform® Tissue Regeneration Matrix is indicated in patients presenting with cystocele and/or stress urinary incontinence. An anterior defect is the protrusion or herniation of the anterior vaginal wall. The degree of protrusion may vary from patient to patient. The severity of cystocele may range from minimal protrusion to protrusion of the anterior vaginal wall beyond the level of the introitus. Contributing factors may include weakening or tearing of the pubocervical or endopelvic fascia. Common presenting complaints may include the feeling of a vaginal bulge, urinary retention or incontinence. Cystocele is often not an isolated change. Posterior compartment prolapse and enterocele may be concomitant. Individual defect and symptomatology will influence procedure selection.

Pre-Operative Procedure

1. The patient is prepped and draped.
2. A 16F Foley catheter is placed.
3. Two Alice clamps are placed on either side of the urethra for retraction and are held from above.
4. With a marking pen, a mid-line mark approximately 4-5cms long is made on the anterior vaginal wall

Steps of the Procedure
- Arcus to Arcus Graft: The Simplified 5-Step Approach
Dr. Goldberg.
Steps:

1. Start with a Standard Colporrhaphy Dissection. Dissect the the vaginal epithelium away from the bladder and its surrounding endopelvic connective tissue, just like an anterior colporrhaphy. For graft placement, blunt dissection will be carried further laterally on both sides, beyond the descending pubic ramus which can be easily palpated. The obturator internus (OI) is now exposed. The OI muscle surface is the anatomic insertion point for the pubocervical fascia, the physiologic ‘hammock’ of connective tissue support beneath the bladder – and also the insertion point for your graft. These structures are readily accessible, and are associated with no major blood vessels. Figure 1 illustrates this simple and safe anatomic area.
2. Palpating Simple Bony Landmarks. Two easily palpable bony ‘notches’ are your most reliable fixed reference points for confirming the position of the OI and arcus tendineus. These are the ischial spine, and pubic tubercle. Between these bony notches lies the soft muscular surface of the OI, where your stitches will be placed to anchor the graft. The connective tissue remnant of the arcus tendineus fascia pelvis can often be seen or palpated overlying this portion of the obturator internus; however for cases involving pronounced paravaginal defect, the arcus may be absent, as this connective tissue remnant has been completely attenuated or detached. Whether the arcus is well defined or absent, the surgeon should be aware that graft sutures rely upon the tensile strength of the OI muscle and not the overlying arcus tendineous connective tissue remnant for their support. Palpation of the bony landmarks, and their relation to the OI, ATFP, and Repliform® graft sutures, are illustrated in Figure 2.
3. Placing the Sutures. The Capio® suturing device is now used to anchor sutures into the OI. This most commonly involves 3 sutures on each side (although at physician discretion 2 may be used), anchoring the graft to the (1) proximal, (2) mid and (3) distal areas of the OI and overlying arcus tendineous fascia pelvis. Place a finger on the desired target site and advance the Capio device head to your finger. The push-and-catch Capio system delivers suture placement with controlled depth, requiring minimal dissection and a trocarfree approach. 3A.Colporrhaphy. At the discretion of the physician, standard colporrhaphy is now performed at this time.
4. Preparing the Graft. Repliform acellular tissue grafts are available in several sizes – including 5x10cm and 6x12cm. This allows the surgeon to customize according to patient dimensions, avoiding ‘one size fits all’ mismatches. The graft should be immersed in sterile saline solution for approximately 20 minutes before placement into the surgical site. A typical trapezoidal shape appropriate for most anterior compartment repairs, along with dimensions, is illustrated in Figure 4.
5. Securing the Graft. The free ends of each anchoring suture are now carried through the graft corners, using an ordinary free tapered suture needle, 1cm from each corner. Sutures are sequentially tied, fastening the graft into place. Excessive tension and laxity should be avoided, the graft should lay flat. As the graft is being fixed into position, it can be further tailored to the patient’s anatomy by trimming excess width or by repositioning the site of suture placement. A safety stitch can be used by placing a free suture between the knot and graft, before final tie down, to release the knot if necessary. Figure 5 illustrates final graft placement. Standard closure of the vaginal incision is now performed. Given the incidence of stress urinary incontinence associated with prolapse repair, a sling procedure may now be performed.

Post-Operative Procedures

1. Patients typically receive antibiotics and pain medication post-operatively. Percocet® (Oxycodone and Acetaminophen), Levaquin® (Levofloxacin) and Quinolone are typically prescribed.
2. The Foley catheter is discontinued once the patient is ambulatory. This is typical before the patient is discharged from the hospital.
3. Patients typically stay in the hospital less than 23 hours and go home the next day.

Footnotes:
Repliform® Tissue Regeneration Matrix is regulated by the FDA as human tissue for transplantation and complies with US regulations in 21CFR part 1270 and 1271. The product is exclusively distributed in the USA by Boston Scientific Corporation.

Accordingly for medical devices:
Caution:
Federal (USA) law and governing law outside the USA restrict these products to sale by or on the order of a physician.

This reference text contains information about a Boston Scientific product and is provided by Boston Scientific Corporation for reference only. The content reflects the experiences of the author. Please refer to the Instructions for Use enclosed with the product for complete instructions for use, indications, contraindications, warnings, potential adverse effects and cautions.

See Prescriptive Information regarding specific Boston Scientific product indications, contraindications, precautions and warnings. Please refer to Directions for Use for more complete information.
Repliform is a trademark of LifeCell Corporation.
Capio are trademarks of Boston Scientific Corporation or its affiliates.
Percocet is a trademark of DuPont Merck Pharmaceutical Company.
Levaquin is a trademark of Daiichi Pharmaceutical Company, Ltd.