Posterior Intravaginal Slingplasty Vaginal Vault Suspension

The posterior IVS (Tyco/US Surgical) procedure was initially described as a means of enhancing posterior pelvic floor support as a component of the "Integral Theory" described by Petros. As initially described, this procedure entails placing a piece of multifilament Prolene mesh through the pararectal space onto the vaginal apex to help provide apical support. The tape is inserted along the medial aspect of each buttock approximately 2 to 3 cm posterior and lateral to the anus using a blunt tunneler. In our initial experience, and in cadaveric dissections, we have

Figure 8-2.2. The tape from the posterior IVS procedure lies from pelvic sidewall to pelvic sidewall, allowing the vaginal cuff to be supported by neo-"Cardinal"lig-aments. (Reprinted with the permission of The Cleveland Clinic Foundation.)

found the procedure, as originally described, to result in significant vaginal foreshortening. Therefore, we have modified the technique to place the tape further lateral along the pelvic sidewall in order to attain more cephalad support of the vaginal apex. We guide the IVS tunneler through the pararectal space and direct the tip along the lateral pelvic sidewall with the resultant placement immediately anterior to the ischial spine deep to the arcus tendineus. Once this is performed bilaterally, the tape essentially lies from ischial spine to ischial spine, analogous to Cardinal ligaments. The vaginal apex is then sutured to the tape to restore vaginal vault support. The ends of the tape are then pulled at their perianal ends, elevating the tape (and attached cuff) to the desired position. The dissection required is less than that for a sacrospinous fixation, and the resultant vaginal axis is more physiologic because it is anterior to the ischial spines, and not as horizontal as after a sacrospinous fixation (Figure 8-2.2).

The surgical procedure is performed via a near identical procedure to a sacrospinous fixation. One of the most attractive features of this procedure is the fact that the tape serves as an attachment site for the endopelvic fascia along the anterior and posterior vaginal walls. Fascia can be sutured to the tape such that when the tape is adjusted by pulling the ends of the tape paraanally, the vaginal apex and its fascial attachments are then elevated to their physiologic position. The presence of the tape also prevents the development of a central enterocele, which can occur after a bilateral sacrospinous fixation. In our current series of 77

Figure 8-2.2. The tape from the posterior IVS procedure lies from pelvic sidewall to pelvic sidewall, allowing the vaginal cuff to be supported by neo-"Cardinal"lig-aments. (Reprinted with the permission of The Cleveland Clinic Foundation.)

patients treated with a posterior IVS, we have not had any vaginal vault prolapse recurrences and have only had one vaginal mucosal erosion of the tape.4 Resultant anatomy includes a vaginal length of 7.6 cm (range, 5-11) and a mean POP-Q point C of 7.0 cm.

Radiographic evaluation of these patients has demonstrated that the vaginal axis is less horizontal than that found with a sacrospinous fixation and approximates more the axis resultant from an abdominal sacrocolpopexy.

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