ࡱ> ` 4bjbj .F, $ ' $hE6 66 6h  6 3N R"0'---( H | d(  '6666   Cystocele repair: A simplified, minimally invasive approach Source: Urology Times By: Serge P. Marinkovic, MD Originally published: October 1, 2005  INCLUDEPICTURE "http://www.urologytimes.com/urologytimes/data/articlestandard/urologytimes/422005/185567/i1.jpg" \* MERGEFORMATINET  Serge P. Marinkovic, MD Minimally invasive procedures for stress incontinence and pelvic prolapse now abound. In fact, surgeons have enjoyed a prominent 7- to 8-year history of worldwide success using tension-free vaginal tape and other, similar modifications in the treatment of stress incontinence. Although no prolapse procedure can claim this extended use and research history, minimally invasive options are slowly gaining ground. Most implement a fabricated, preconfigured soft polypropylene mesh to support the pubocervical fascia of the bladder (central defect) and its torn arcus tendineus fascia pelvis (paravaginal defect). Both conditions are very common and account for a nearly 40% to 50% failure rate in autologous repairs. New, minimally invasive cystocele and paravaginal approaches suspend the bladder from both obturator foramens, recapitulating the Delancey "bladder hammock" level 2 pelvic support. This article describes a simplified, minimally invasive approach to cystocele and paravaginal defects designed to reduce complication rates and facilitate convalescence. Material selection Polypropylene (Prolene) is a type 1 synthetic material whose weave width can be modified to facilitate bacterial opsonization in the event of infection. Bacteria are 1 mm in diameter, and macrophages are 20 mm. Anterior Prolift (Ethicon/Gynecare, Somerville, NJ) is 75 mm, allowing bacteria harboring in the interstices of infected mesh to be opsonified by macrophages. Meshes (type 3) with 1 mm to 5 mm weaves will not allow macrophage penetration; thus, bacteria may amplify in number. Once identified, most polypropylene mesh infections can be successfully treated with oral or intravenous broad-spectrum antibiotics, precluding the need for surgical intervention. Type 3 synthetic meshes may require surgical excision, however, because their small weave size prevents macrophage penetration. Mesh erosion may occur with the simple eroding of mesh through a vaginal epithelial layer (anterior or posterior vaginal wall) or, worse, it may become a complicated erosion when the mesh penetrates into an adjacent organ (eg, bladder, uterus, rectum, or small bowel).  HYPERLINK "http://sciencedaily.mediwire.com/main/Default.aspx?P=Content&ArticleID=185567" \l "#"  INCLUDEPICTURE "http://www.urologytimes.com/urologytimes/data/articlestandard/urologytimes/422005/185567/i3_t.jpg" \* MERGEFORMATINET  Figure 1. Mesh erosion may occur with the eroding of mesh through a vaginal epithelial layer or, worse, when the mesh penetrates into an adjacent organ. Figure 1a. A 2-cm anterior vaginal wall mesh erosion. Figure 1b. The erosion is excised and the anterior vaginal wall (AVW) is undermined for a 2-cm perimeter around the erosion so the reapproximation of the AVW edges can be tension free. Figure 1c. The AVW is closed using either absorbable or delayed absorbable suture. Once implanted, polypropylene is easily encapsulated, providing a protection mechanism and easier identification. In most studies, it has demonstrated 2% to 5% or lower simple and complicated erosion rates. Mesh erosions that are less than 1 cm can potentially be corrected by the application of estrogen cream, 2 grams three times weekly, with reassessment at 6 to 8 weeks. If the erosion is larger than 1 cm, it may be repaired by excising the protruding mesh, circumferentially undermining the anterior or posterior vaginal wall for 1 to 2 cm, then re-approximating (without tension) the edges (figure 1). Indications Surgical correction of prolapse is often indicated by symptom or grade. Overriding symptoms include incomplete emptying of the bladder secondary to urethral kinking, dyspareunia, bleeding from mucosal irritation, or difficulty ambulating. Most recently, surgeons have incorporated the use of a grading system developed by the International Continence Society (ICS) because of increased interobserver reproducibility. Many surgeons agree that symptoms with grade 2 prolapse (within 1 cm of the hymenal remnants) may warrant correction. Minimally invasive options are indicated or may be preferred over other methods when patients have health limitations or have a decided preference for a shorter, less-invasive surgery with comparatively good outcomes. Benefits include acceptable complication rates and more rapid convalescence. In addition, these procedures can be performed with or without concomitant hysterectomy or continence procedures. Surgical approach The patient is placed into Allen stirrups in the modified lithotomy position. Staple a Lingeman drape to the perineum covering the rectum, with side edges placed and stapled 2 to 3 cm lateral to both right and left inguinal folds.  HYPERLINK "http://sciencedaily.mediwire.com/main/Default.aspx?P=Content&ArticleID=185567" \l "#"  INCLUDEPICTURE "http://www.urologytimes.com/urologytimes/data/articlestandard/urologytimes/422005/185567/i4_t.jpg" \* MERGEFORMATINET  Figure 2. Vaginal outline markings are used for four trocar placements. The two perineal marks are for a concomitant rectocele repair here, and can be ignored. Insert a 16F Foley catheter. Make indelible ink marks bilaterally at the level of the external urethral meatus, but lateral to the inguinal folds and just lateral to the right and left inferior pubic rami (figure 2). An additional mark is directed 2 cm inferiorly and 1 cm laterally. These four marks denote eventual placement of the four Prolift trocars through the skin, ipsilateral levator ani muscles and fascia (primarily iliococcygeus fascia), and the ipsilateral pubo-cervical fascia inferior to the arcus tendineus and inferior ramus of the pubis. Place two Alice clamps vertically on the anterior vaginal wall proximal to the bladder neck to avoid potential compression of the bladder neck with the large polypropylene mesh, well within the body of the bladder. The area between both Alice clamps should then be infiltrated with either 1% lidocaine with 1:100000 dilution of epinephrine or with injectable normal saline.  HYPERLINK "http://sciencedaily.mediwire.com/main/Default.aspx?P=Content&ArticleID=185567" \l "#"  INCLUDEPICTURE "http://www.urologytimes.com/urologytimes/data/articlestandard/urologytimes/422005/185567/i5_t.jpg" \* MERGEFORMATINET  Figure 3. The four trocars have been advanced and the blue loops placed. The open ends of the blue loops will be used to grab the individual arms of the polypropylene mesh and to advance them through the obturator foramen and out through the ipsilateral inguinal canal. Wait 3 to 5 minutes after the infiltration, then proceed with a longitudinal incision through the anterior vaginal wall and pubocervical fascia, mobilizing the cephalad and the lateral aspects of the bladder up to and including both arcus tendineus fascia pelvis components. Pierce through the right and left paravaginal defects with digital dissection to enter the retropubic space just medial to the arcus tendineus fascial pelvis. Once achieved, place the four Prolift trocars through the patient's right side markers beginning with the cephalad, then the inferior, both under fingertip guidance (figure 3). When a trocar is attached, place a finger on the ipsilateral side between the bladder and the pubocervical fascia, while advancing the trocar medially through the levator ani, but below the arcus tendineus and the inferior ramus. Use strict fingertip guidance of the trocar tip when advancing through the levators (iliococcygeus muscle and fascia) and the pubocervical fascia, but not through the vaginal wall, which would leave the polypropylene exposed in the vagina and could later present as mesh erosion.  HYPERLINK "http://sciencedaily.mediwire.com/main/Default.aspx?P=Content&ArticleID=185567" \l "#"  INCLUDEPICTURE "http://www.urologytimes.com/urologytimes/data/articlestandard/urologytimes/422005/185567/i6_t.jpg" \* MERGEFORMATINET  Figure 4. The polypropylene mesh is placed in front of the trocars and vagina for orientation prior to trocar loading. (Photographs and illustrations courtesy of Serge P. Marinkovic, MD) Place the preconfigured mesh in front of the vagina, oriented so the square trocar ends are superior to the round ends of the mesh (figure 4). As each trocar is placed with the thicker part adherent to the inguinal skin, carefully advance each blue loop so the non-looped end passes though the vaginal portion of the trocar. Proceed until the looped end is flush with the end of the trocar, then run the closed end through the loop and secure it to the Lingeman drape. When all four trocars and loops have been advanced, place the rounded mesh arms with 2-cm lips into the vaginal blue loop ends. Holding the thick trocar end by the inguinal side, bring the mesh through until it exits the thick trocar end at least 3 to 5 cm. Carefully advance the two cephalad trocar polypropylene mesh ends first, then the two inferior trocar ends. If the patient has a known paravaginal defect, use a cystoscope to gauge the reduction of the paravaginal defect (in this case, use only 100 mL of irrigation to demonstrate the defect). If the defect is not well reduced on either side or at any of the points, carefully place tension on the responsible mesh arm to adjust it, but avoid exerting too much tension on any one arm. Reduction should remain as free of tension as possible. When everything appears well adjusted, remove each trocar from the thick inguinal end and slowly place a Bonny on the corresponding side of the mesh to prevent unnecessary tangling. When the trocars are removed, the mesh should be well situated and should require no further suturing to bladder or pubocervical fascia. We do not recommend excision of the anterior vaginal wall or its pubocervical fascia to prevent mesh erosion. The redundant anterior vaginal wall involutes in time and does not represent as a prolapse. Close the anterior vaginal wall in two layers, with a deep layer of running, locking 2-0 Monocryl and a superficial layer of running, locking 3-0 Monocryl. Remove the Foley catheter the following morning. Proper coding Codes appropriate for this procedure include 57284 (paravaginal repair), 57282 (iliococcygeus hitch), 57240 (anterior repair), 57267 (once for an anterior repair; if a grade 2 vault prolapse also is being managed with this surgery, 57267 can be appropriately billed again). Medicare does not reduce the 57267 fee schedule with multiple uses up to and including all three pelvic compartments. The last code is 52000 for the cystoscopy to ascertain the repair of the paravaginal defect and to ensure that no cystotomy has been performed. Conclusion This new, minimally invasive approach may soon justify its use in primary and secondary cystocele repairs with and withoutparavaginal defects. The use of trocars to advance and load the large polypropylene mesh simplifies the procedure, clearly demonstrating usefulness in advanced prolapse. 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