Basic procedures in tension-free vaginal mesh operation for pelvic organ prolapse

Authors

  • Masami Takeyama

    Corresponding author
      Masami Takeyama M.D., Urogynecology Center, Senboku-Fujii Hospital, 3100-19 Izumitanaka, Minamiku, Sakai, Osaka 590-0126, Japan. Email: m-takeyama@me-medical.jp
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Masami Takeyama M.D., Urogynecology Center, Senboku-Fujii Hospital, 3100-19 Izumitanaka, Minamiku, Sakai, Osaka 590-0126, Japan. Email: m-takeyama@me-medical.jp

Abstract

A variety of tension-free vaginal mesh (TVM) systems are available for surgical treatment of pelvic organ prolapse (POP). These include Prolift, Apogee/Perigee and Avaulta, all of which vary in terms of mesh size, shape and surgical technique to such an extent that they cannot truly be considered the same operation for the purpose of evaluating results. I began carrying out self-made mesh cut out from Gynemesh PS in 2005. This system has four main characteristics: (i) the mesh is intended as a replacement for defective visceral pelvic fascia; (ii) it bridges between the left and right arcus tendineus fascia pelvis (white line, or ATFP); (iii) large-size mesh is held in place by passing cannulas through the obturator fascia (anterior wall) or the sacrospinous ligament (SSL) to attach the arms of the mesh graft; and (iv) the bladder neck is preserved. The mesh that I have used since then has been essentially similar to the Prolift System, developed by a French TVM group, in terms of size and shape of its central portion. Mesh grafts used for the anterior wall are quite large, so skillful execution will provide sufficient room between the left and right ATFP in almost all cases.

This video discusses the fundamental techniques necessary for skillful execution of the tension-free vaginal mesh (TVM) procedure using the Prolift System, focusing on the following points: (i) surgical separation of the correct layers of the vaginal wall, and the area separated, and effective hemostasis; (ii) precise puncture technique, especially the second puncture for the anterior TVM (TVM-A) procedure and the sacrospinous ligament (SSL) puncture in the posterior TVM (TVM-P) procedure; (iii) firmly securing the mesh to the vaginal wall or cervical canal; and (iv) careful mesh placement and formation of a bridge between the left and right arcus tendineus fascia pelvis (ATFP). Proper separation of the vaginal wall layers, in particular, is crucial for preventing unnecessary blood loss and mesh erosion. The second puncture in the TVM-A is the most important of the puncture maneuvers for the procedure. Penetrating the tough tissue near the ischial spine represents a significant challenge, and the SSL penetration in the TVM-P procedure is unexpectedly difficult for those without sufficient experience. In order to become proficient, the surgeon must have hands-on experience under the supervision of experts.

Finally, TVM is a relatively new procedure, so one must master the fundamentals before gaining true proficiency. The technique does not call for virtuosity on the part of the surgeon, but key points must be mastered to reduce the risk of complications and recurrences. With repeated hands-on training, surgical skills will gradually improve to the requisite level. This is a translated section of a video article originally published in Japanese as a DVD in the Audio-Visual Journal Vol.15 No.15. 2009 by The Japanese Urological Association.

Video images

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  • image(1)

[ Concept of the tension-free vaginal mesh (TVM) procedure. Before we describe the surgical techniques, let us confirm the concept of the TVM procedure. TVM uses a mesh to support and reinforce both the vaginal wall and vaginal canal. The mesh reinforces the anterior and posterior vaginal wall. In anterior TVM (TVM-A), four arms are passed through the obturator foramen to the arcus tendineus fascia pelvis (ATFP) to restore lateral support. In posterior TVM (TVM-P), two arms are passed to the sacrospinous ligament to reinforce the sacrouterine ligament. ]

  • image(2)

[ Correct separation of layers. This photograph shows the full-thickness incision of the vaginal wall following sufficient fluid separation. The vaginal wall adheres to the vaginal mucosa, and in conventional vaginoplasty the mucosal layer was separated from the muscle layer. In the tension-free vaginal mesh procedure, the adventitia layer between the full thickness of the vaginal wall and the bladder is separated. ]

  • image(3)

[ Properly securing the mesh to the vaginal wall and cervical canal (posterior TVM [TVM-P]). Properly securing the mesh is important for preventing recurrence and sufficient expansion of the mesh. In TVM-P, it is effective to (a) securely fix three points on the cervical canal with a non-absorbable suture, and (b) fix three points on the vaginal wall on the perineal side with an absorbable suture. ]

  • image(4)

[ Properly securing the mesh to the vaginal wall and cervical canal (anterior TVM [TVM-A]). In TVM-A, it is effective to (a) fix three points on the vaginal wall on the side of the bladder neck with an absorbable suture and (b) three points on the cervical canal with a non-absorbable suture. ]

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