A THREE-YEAR EXPERIENCE WITH ANTERIOR TRANSOBTURATOR MESH (ATOM) AND POSTERIOR ISCHIORECTAL MESH (PIRM)

Abstract

Background. Use of alloplastic mesh implantates allow a new urogynecologycal surgical techniques achieve a marked improvement in pelvic organ static and pelvic floor function with minimally invasive needle transvaginal intervention like an anterior transobturator mesh (ATOM) and a posterior ischiorectal mesh (PIRM) procedures.

Methods. In three years, between April 2006 and May 2009, we performed one hundred and eightyfour operative corrections of female pelvic organ prolapse (POP) and pelvic floor dysfunction (PFD) with mesh implantates. The eighty-three patients with surgical procedure TVT-O or Monarc as solo intervention indicated by stress urinary incontinence without POP, are not included in this number. In 97 % of mesh operations, Gynemesh 10 × 15 cm was used. For correction of anterior vaginal prolapse with ATOM procedure, Gynemesh was individually trimmed in mesh with 6 free arms for tension-free transobturator application and tension-free apical collar. IVS (Intravaginal sling) 04 Tunneller (Tyco) needle system was used for transobturator application of 6 arms through 4 dermal incisions (2 on right and 2 on left). Minimal anterior median colpotomy was made in two separate parts. For correction of posterior vaginal prolapse with PIRM procedure Gynemesh was trimmed in mesh with 4 free arms and tension-free collar. Two ischiorectal long arms for tension-free application through fossa ischiorectale – right and left, and two short arms for perineal body also on both sides. IVS 02 Tunneller (Tyco) needle system was used for tension-free application of 4 arms through 4 dermal incisions (2 on right and 2 on left) in PIRM.

Results. All 184 procedures were performed relatively safely. In 9 cases of ATOM we had perforation of bladder, in 5 by application of anterior needle, in 3 by application of posterior needle and in one case with pincette when collar was inserted in lateral vesico – vaginal space. In 2 cases of PIRM we had perforation of rectum. In all 11 cases correction was performed during the operation, mesh was kept in place and postoperative course of treatment went without complications. Mean hospitalization time for mesh operation was 4 to 5 days. Short term results, 2 to 3 months after the operation, are very good both for pelvic organ static, and for pelvic function. In 14 cases we had small vaginal erosion in place of upper vaginal incision by ATOM. All erosions were cured spontaneously after removing of unresorptive suture (Etibond 1/0; Ethicon) and/or excision of small denudated mesh part (< 1 mm2) without any anesthesia and vaginal sutures.

Conclusions. New methods and materials allow return of pelvic floor integrity to physiological condition without hysterectomy of otherwise healthy uterus also in state of totally uterine prolapse. Corrections of POP with mesh procedures and without hysterectomy present a minimally invasive surgery with short hospitalization and reconvalescence. Quality of life markedly improved after operation because the preoperative problems were eliminated. Our and foreign experiences on these field1–8 give us a promise for long duration of good results which we also expect for women after needle implanted mesh in ATOM and/or PIRM procedure.9, 10