Prolapse Repair with Mesh
Pelvic reconstruction with mesh has seen a resurgence in the last few years with many surgeons adopting new techniques of surgery. Dr Farnsworth has developed a number of mesh techniques since 2001. A rigorous quality assurance program has been instigated with the approval of the Sydney Adventist Hospital Ethics Committee and retrospective data analysis of all surgical techniques used by Dr Farnsworth has been reported and presented at a number of international meetings since 2001. At the Centre for Pelvic Reconstructive Surgery at Sydney Adventist Hospital regular peer review meetings are held to document and discuss any surgical complications.
Dr Farnsworth regularly performs workshops to demonstrate his original techniques at Sydney Adventist Hospital and around the world. A schedule of current workshops is available for interested surgeons.
Dr Farnsworth's initial interest in this type of surgery began in 1997 when he spent time with Professor Peter Petros in Perth, Western Australia and then began performing the anterior and posterior intravaginal sling procedures. The Posterior Intravaginal Slingplasty (PIVS) was an exciting new concept in Pelvic Surgery. During 1998-1999 Dr Farnsworth performed over 100 PIVS cases and reported the results with 1-2 years follow-up in the International Urogynecology Journal in 2002.
Whilst the PIVS proved to be an effective treatment for vault prolapse it was found to be associated with development of a secondary cystocoele or bladder prolapse in up to 30% of patients. A mesh repair of the fascial layers in the vaginal walls proved to be the next step in the evolution of this technique.
Dr Farnsworth began performing Synthetic Mesh Reconstruction procedures in 1997 when he first performed the Posterior IVS procedure. In 2001 after working with Dr Armin Fischer in Weisbaden, Germany and Professor Peter Von Theobald of Caen in France Dr Farnsworth introduced the use of Mesh into his practice for vaginal fascial repair using Surgipro SPMM monofilament polypropylene mesh. A brief outline of the development of these techniques is outlined below.
The Honda Repair 2001-2004
The Honda Repair was an original idea developed by Dr Farnsworth in an effort to recreate the anterior pubocervical fascia and its' attachments to the pelvic sidewall.
It was developed to recreate lateral vaginal support of a prosthesis with attachment of the mesh to the white line (or Arcus Tendineous Fascia Pelvis) using an Endostitch device. The mesh consisted of a central body with lateral arms secured to the arcus ligament and distal arms placed in the Obturator Fossa as outlined in the diagram below.
Viewed from above the "H" shape of the mesh is evident. The lateral view below demonstrates how the mesh protects the vagina from the abdominal pressure above.
The lateral margin of the mesh is attached to the pelvic sidewall at the obturator fossa (1) along the arcus ligament (2,3) and the sacrospinous ligament (4). The mesh is configured so as to allow passage of the urethra (U) and rectum (R).
Results of this procedure were presented by Dr Farnsworth at the International Continence Society Meeting in Paris 2004. The Honda Repair was a big advance but prone to failure of the distal lateral attachments in 5-10% of cases. This problem was solved by the introduction of lateral transobturator slings in 2004.
Anterior Mesh with Transobturator Slings 2004-2005
Transobturator slings revolutionised the lateral support of anterior mesh operations when they were introduced during 2004 following original work by French Pelvic Surgeons. Adding lateral transobturator slings to the Honda Repair meant that there was a dramatic improvement in the lateral support of the prosthesis as shown in the diagram below.
Dr Farnsworth developed this original technique in which the posterior edge of the mesh is attached to the sacrum at (1) to restore posterior support of the bladder. The attachment of the mesh to the cervix at (2) corrects any uterine prolapse while the body of the mesh passes form one side of the pelvis to the other to correct any central defect at (4). Lateral transobturator slings at (3) and (6) correct and prevent any lateral defect. The distal edge of the mesh provides support to the bladder neck (5).
Similar prostheses have been released by a number of companies since 2004. These include the Perigee from American Medical Systems and the Anterior Prolift Device by Ethicon Women's Health and Urology.
Posterior Mesh with Posterior IVS 2002-2005
These techniques have developed from the Posterior IVS which was originally performed in conjunction with a fascial repair. The PIVS reconnects the vaginal vault to the sacrum by fixing it to the levator muscle. A mesh can then be added to strengthen the fascia in the posterior vaginal wall.
This technique was originally performed using Pelvicol biological mesh or Surgipro. The mesh was laid between the posterior vaginal wall and the rectum and secured to the levator muscle using a Posterior IVS sling.
This diagram shows a Posterior IVS sling is being placed into position with a Vipro2 mesh.
In recent years much better meshes have become available. The first mesh designed specifically for vaginal surgery was Gynemesh from Ethicon Women's health and Urology. Similar meshes have been developed by a number of companies and a number of pre-cut Prolapse Repair Mesh Kits have been developed including the Apogee, Posterior Prolift and Avaulta.
Total Vaginal Reconstruction with Mesh
This technique involves a comprehensive reconstruction which addresses anterior and posterior fascial replacement as well as reattachment of the entire system to the bony pelvis. It was originally reserved for only the most severe and recurrent cases.
Click here for further information about Total Vaginal Reconstruction with Mesh
Click here for further information on Complications of Mesh
Click here for further information on Dr Farnsworth's latest mesh technique