Recurrent Prolapse Following Transvaginal Mesh Kit Repair – Anatomy and Correction The Perigee and Apogee are two widely available transvaginal mesh kits marketed for the repair of prolapse by American Medical Systems. The manufacturers state that the advantages to using these kits over conventional repairs for prolapse include they are minimally invasive, they are time-efficient, and their placement can be standardized and easily reproduced. Specifically, the manufacturers of Perigee claim that it can repair all types of anterior defects. It is designed to provide level 2 support by 4-point fixation along or near the Arcus tendineus fascia pelvis. This is accomplished via helical needles which allow the arms of the mesh to sit near the ischial spines. The Perigee, therefore, is aimed at supporting the entire anterior vaginal wall. The Apogee is a two-armed mesh system that is designed to provide apical support. The makers of the Apogee report that the arms of the mesh are able to support the apex of the vagina at the level of the ischial spines, thereby providing level 1 support. In the upper left-hand corner, the Apogee needle is depicted entering the pelvis immediately adjacent to the ischial spine. In this surgical video, we operate on a 58-year-old Paris female with prolapse of many years duration. She had had two previous surgeries for prolapse, both of which had failed. Most recently, she had undergone a repair with an Apogee and a Perigee. Due to her recurrent prolapse, she was seeking further surgical options. Her preoperative POPQ exam depicted here showed point BA to be 0, point C to be minus 3, and the total vaginal length to be 9 centimeters. Given these findings, she elected to undergo a laparoscopic sacral copalpexy. In this video, we demonstrate the following. First, dissection into the vesicovaginal space, exposing the proximal edge of the Perigee. Then, dissection into the rectovaginal space, exposing the proximal edge of the Apogee. And finally, placement of a new mesh for the sacral copalpexy. The laparoscopic ports are first placed, as shown here, with a 5-millimeter umbilical port, a 5-millimeter right lower quadrant port, an 11-millimeter left lower quadrant port, and a 5-millimeter left mid-location port. The peritoneum overlying the vaginal apex is tented up and entered sharply to begin the dissection. First, we demonstrate the anterior dissection into the vesicovaginal space. Gradually, the midsection, as well as the arms of the Perigee, are exposed. The distance from the arms to the apex is noted to be approximately 4 centimeters. The distance from the arms to the apex is noted to be approximately 4 centimeters. This leaves a significant portion of the anterior vaginal wall unsupported. One possible explanation for this is that the Perigee needle did not enter the pelvis as closely to the ischial spine as suggested by the manufacturers. In this cadaveric study of the Perigee trocar placement, the path of the trocar measures 5.2 centimeters from the ischial spine, a distance consistent with the anterior defect we see in our patient with recurrent prolapse. After completion of the anterior dissection, the posterior dissection is performed. In a similar fashion, the posterior dissection reveals the midsection and the most superior arms of the Perigee. It is sitting along the posterior vaginal muscularis. This mesh is estimated to sit approximately 6 centimeters from the apex of the vagina. In this drawing, the results of a cadaver study by Jalavsek et al. are summarized. Similar to our findings in this case study, the apex of the vagina was, on average, approximately 4 centimeters from where the trocar entered the vagina. They concluded that a posterior intravaginal slingplasty, such as the Apogee, appears to provide support to the mid-posterior vaginal wall and not to the vaginal apex. The mesh sacral colpopexy is then performed using a Y-shaped polypropylene mesh. Distally, the posterior arm of the mesh is secured to the existing Apogee mesh. With the posterior arm secured by 6 sutures, the anterior arm is then secured to the Apogee and secured to the anterior aspect of the vagina to support the length of the anterior vaginal wall. The mesh is also secured to the existing perigee. A total of 6 sutures are placed along the anterior vaginal wall. A tension is then turned to the sacral dissection. The sacral promontory is then identified and the superior aspect of the mesh secured to the sacrum with 2 sutures to the anterior longitudinal ligament. Finally, the mesh is re-peritonealized and the procedure is complete. Calling to mind the patient's pre-operative POPQ measurements, where point BA was at 0 and point C was at minus 3, we are able to compare these measurements to the POPQ measurements at her 6-week post-operative visit. Point BA is now at minus 3 and point C is now at minus 9. From this anatomical study, we conclude that the perigee insertion in both cadaveric and in vivo dissection does not appear to uniformly provide complete level 2 anterior vaginal wall support. Also, the Apogee insertion with needle placement per manufacturer instructions near the ischial spine does not appear to provide uniformly complete apical vaginal support. And even when placed properly by experienced hands, transvaginal mesh kits do not appear to render consistent anatomic outcomes.

transvaginal mesh kits

prolapse repair

minimally invasive

anatomical outcomes

laparoscopic sacral copalpexy