UROGYNECOLOGY Anatomic study of prolapse surgery with nonanchored mesh and a vaginal support device Christl Reisenauer, MD; Thomas Shiozawa, MD; Markus Huebner, MD; Mark Slack, MD; Marcus P. Carey, MD OBJECTIVE: The purpose of this study was to evaluate the anatomic position and relations to neighboring neurovascular structures of polypropylene implants after vaginal repair with nonanchored mesh and a vaginal support device in a cadaver model. STUDY DESIGN: We undertook anatomic dissection of 6 cadavers, with and without prolapse after surgery. RESULTS: All polypropylene implants were positioned in accordance with the prescribed surgical technique. This surgery reconstructed the entire anterior and posterior pelvic floor compartments without exten- sion beyond the pelvic cavity. A safe distance between the implants and their neighboring neurovascular structures (obturator nerve and ves- sels, 2.8-3.3 cm; pudendal nerve and internal pudendal vessels, 1.8- 2.2 cm; sacral plexus, 2-2.2 cm) was observed. CONCLUSION: Anatomic cadaver dissection confirmed the accurate and safe placement of the polypropylene implants with the use of the prescribed surgical technique. Key words: anatomy, pelvic floor reconstruction, pelvic organ prolapse, polypropylene implant, vaginal support device Cite this article as: Reisenauer C, Shiozawa T, Huebner M, et al. Anatomic study of prolapse surgery with nonanchored mesh and a vaginal support device. Am J Obstet Gynecol 2010;203:590.e1-7. N ew procedures for pelvic organ prolapse require appropriate eval- uation to establish their safety and effec- tiveness before being marketed. Ana- tomic cadaver studies play an important role in the preclinical evaluation of new procedures. The success of prolapse surgery may be compromised by excessive movement of the healing vaginal tissues, with rises in intraabdominal pressure with coughing, straining, and physical activity in the early postoperative period. With aug- mentation of the surgery with polypro- pylene implants and support for the va- gina with a vaginal support device (VSD) for 3-4 weeks after surgery, the risk of recurrent prolapse may be reduced. Consistent with orthopedic wound heal- ing principles, the VSD acts as an in- travaginal splint to support both the vag- inal tissues and the positioning of the polypropylene implants. At 3 weeks, the polypropylene implants have become in- corporated into the body’s tissues as a result of tissue in-growth. By supporting the positioning of the polypropylene im- plants until they become incorporated, the VSD avoids the need for implant fix- ation by sutures or anchors or the use of trocars. This makes surgery simpler to perform and avoids the specific compli- cations that can occur with trocars or suture and anchor placement. The PROSIMA Pelvic Floor Repair System (Ethicon, Somerville, NJ) was developed to provide durable vaginal support by the use of polypropylene implants and splinting the healing vaginal tissues with the VSD with the use of a trocar-free technique. The balloon replaces the tra- ditional gauze vaginal pack. The balloon also serves to provide optimal contact between polypropylene implants and the fibromuscular layer of the vaginal epi- thelium during the first 24 hours when fibrin exerts its adhesive effect. Limited visualization often makes vaginal prolapse surgery technically dif- ficult to perform; therefore, a precise knowledge of the relevant pelvic anat- omy is essential. The aim of this cadaver study was to evaluate the anatomic position of polypropylene implants after recon- struction of the anterior and posterior compartments of the pelvic floor with this new surgical procedure. We also aimed to determine the relation of the mesh implants to important neighbor- ing neurovascular structures. MATERIALS AND METHODS Female cadavers, which were donated for medical education and research to the Institute of Anatomy, Tübingen, were studied. The anatomic specimens were preserved with an alcohol-glycerol solution. The injection solution con- From the Department of Obstetrics and Gynecology, University Hospital Tübingen (Drs Reisenauer and Huebner), and the Department of Anatomy, University of Tübingen (Dr Shiozawa), Tübingen, Germany; the Department of Obstetrics and Gynecology, Addenbrooke’s Hospital, University of Cambridge Teaching Hospital, Cambridge, England, UK (Dr Slack); and the Department of Obstetrics and Gynecology, Royal Women’s Hospital, Melbourne, VIC, Australia (Dr Carey). Presented at the 34th Annual Meeting of the International Urogynecological Association, Cernobbio, Italy, June 16-20, 2009. Received Feb. 22, 2010; revised June 3, 2010; accepted Aug. 9, 2010. Reprints: Christl Reisenauer, MD, Department of Obstetrics and Gynecology, University Hospital Tübingen, Calwerstrasse 7, 72076 Tübingen, Germany. christl.reisenauer@med.uni-tuebingen.de. Authorship and contribution to the article is limited to the 5 authors indicated. There was no outside funding or technical assistance with the production of this article. 0002-9378/$36.00 © 2010 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2010.08.005 Research www. AJOG.org 590.e1 American Journal of Obstetrics & Gynecology DECEMBER 2010