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Apogee Procedure: New minimally invasive vaginal approach for Vault Prolapse, Rectocele and Enterocele.
As stated previously, many surgeons may not complete a vaginal vault suspension at the time of prolapse surgery, even if the patient has vault prolapse, because of the difficult and complex nature of the procedures reviewed above. This can lead to problems such as a shortened vagina, pelvic pain, painful intercourse, urinary symptoms (urgency, frequency, nocturia, difficulty emptying) that can occur post-operatively if the vaginal vault wasn’t properly suspended (Posterior Fornix Syndrome).
Symptoms of vaginal vault
NOT being suspended properly
Recent interest has focused on less invasive operations for vault suspensions such as laparoscopic procedures, however as Dr Bruce Farnsworth, a well known Urogynecologist from Australia, recently quoted, “Laparoscopic procedures require a high degree of skill and extensive specialized training. As a result, only a minority of surgeons achieve competence in these methods”. Additionally, as reviewed above, bleeding or nerve damage are potential risks of the sacrospinous ligament suspension.
Because of this, recently a new minimally invasive approach for vault prolapse was developed and studied in Australia and Europe that is an outpatient procedure that applies the tension-free vaginal tape principle to the posterior part of the vagina. Dr Moore and Miklos were some of the first surgeons in the United States offering this new vaginal procedure in patients that they feel are candidates for a vaginal approach.
The Apogee procedure is a modification of the original work done by Petros in Australia which was called the Posterior IVS procedure. It offers many advantages over the original IVS procedure as we detail below.
Figure1: The above figure depicts the original Posterior IVS tape procedure for vaginal vault suspension. The Apogee procedure is a modification of this procedure that adds a posterior wall graft in addition to the tape at the vault so that the entire posterior compartment can be treated, in addition to the vault.
The original tension-free vault suspension procedure was called an infracoccygeal sacropexy, or more commonly known as Posterior IVS (Posterior Intravaginal Slingplasty). A piece of surgical mesh was placed at the top of the vagina, in a tension free manner (described below), through the pelvic sidewalls to support the top of the vagina. A fibrous reaction occurs around the tape, which acts to strengthen and replace the weakened pelvic ligaments (cardinal/uterosacral ligaments) which suspends the top of the vagina in its normal anatomic position.
The Apogee procedure is a modification of the original IVS approach and has several advantages over the original IVS procedure. It adds a central posterior wall mesh that repairs rectocele and enterocele in one procedure, in addition to the mesh arms that support the apex of the vagina. With the original IVS procedure, Dr Moore and Miklos always attached the tape that supported the vault to a posterior wall graft that repaired the rectocele. Now this is done for them with the Apogee system. The Apogee needles are also smaller diameter than the IVS needles, which makes it less risky, and the Apogee needles are shaped in a way that achieves higher vault suspension. Addtionally, the Apogee utilizes Type I macroporous, monofilament mesh which has less complications than the original multifilament mesh tape that IVS used.
Apogee Figure: 2 - The Apogee System with posterior wall mesh that treats rectocele and enterocele, and apical arms designed to suspend the vault of the vagina.
Advantages of Apogee Procedure
Description of Procedure
The Apogee Procedure system (American Medical Systems, Minnetonka, MN) consists of a needle that is very consistent in shape and size with the Sparc sling trocar/needle, that is used for the vault suspension portion of the procedure. The system also has a macroporous Type I mesh with 2 apical arms attached to the graft near its apex to support the vault. When utilized to suspend the apex of the vagina, the mesh arms serve to create artificial cardinal/uterosacral neoligaments to which the vaginal vault is reattached. Rectocele and enterocele are treated with the body of the graft and cystocele repair may also be performed at the same time, with or without the use of graft or support materials.
The technique involves placing the needles through very small buttock incisions (5mm) lateral to the anus on each side, up along side the vagina to the apex and grasping the lateral mesh arms on each side through the ileococcygeus fascia at the level of the ischial spines and pulling the arms through the buttock incisions to elevate the vaginal vault (the top of the mesh is attached to the top of the vagina prior to adjusting the arms). The posterior wall mesh is then attached to the top of the vagina and also laterally along the pelvic sidewalls down to the opening of the vagina, which allows the procedure to treat the entire posterior compartment from the opening of the vagina up to the apex. Figure 1 illustrates the concept of a posterior wall graft with lateral arms supporting the apex at the level of the ischial spines.
Figure 3. Location of small buttock incisions and path of IVS tunneler and mesh. Note the mesh comes out at the top of the vagina and is attached at that point to suspend the vault.
Apogee Surgical Technique
Dr. Moore and Miklos will begin the procedure just as they would with a posterior repair with graft (link to that section). Most patients will have a rectocele and/or enterocele with their vault prolapse, therefore an incision will be made in the vaginal skin on the posterior wall. The rectovaginal fascia will be identified and may be repaired prior to placing the system. The central graft will be used to treat the rectocele and enterocele present. The initial dissection is completed until the ischial spine is palpated on each side. However, unlike the SSLF the ligament itself does not have to be isolated which can be a difficult and complex dissection. The incision on the posterior wall is kept very small and the dissection is completed by tunneling under the vaginal skin, to help decrease complications of a large incision having to heal over the mesh graft. Additionally, very little or no vaginal skin is cut off prior to closing the incision as this has been found to help decrease risk of mesh extrusion as well.
A stab incision is made on each buttock 3cm lateral and 3cm inferior to the midline of the rectum (fig. 4). The surgeon then places a finger vaginally and palpates the ischial spine and the pelvic sidewall just distal to the spine (levator muscle) fig . The surgeon then advances the trocar (figure 5) through the stab incision, into the ischiorectal fossa (pararectal space) and advances it toward the dissecting finger in the vagina and and into the vagina at the apex guided by the dissecting finger (fig 6). The apical arm of the graft is then attached to the needle and pulled back through the buttock incision. This is completed on each side. The central graft is then attached to the apex of the vagina (usually 2cm of graft is used above the level of the arms as to not shorten the vagina) and the body of the graft attached out laterally to the pelvic sidewalls down to the level of the perineal body (figure 3) then the vaginal incision closed. The excess mesh is cut off at the buttock incisions and these are closed with steri-strips. There is evidence that tissue ingrowth into the mesh begins within 24 hours.
Figure 4 . Apogee needle being advanced through small incision on buttock through the pararectal space to the top of the vagina. The apical mesh arm coming off the graft is then attached to needle and pulled back through to the incision. This is done on both sides.
Figure 5 . Needle gets passed through the ischiorectal fossa, lateral to the levator ani muscles to the level of the ischial spine
Figure 6 :The needle is then perforated through the ileococcygeus fascia at the level of the ischial spine to attach to the apical mesh arm of the graft. This supplies the apical suspension of the procedure. The central graft is then attached to the apex of the vagina and the pelvic sidewalls down to the perineal body, giving the entire posterior compartment support.
Fig 7. Lateral View of final position of the Apogee procedure with posterior wall graft treating rectocele and enterocele and lateral apical arms attached through the ileococcygeus fasci and muscle supporting the apex of the vagina.
Results and Complications
Dr. Moore and Miklos have been experiencing excellent results using this new, minimally invasive technique for rectocele combined with vaginal vault suspension. Success rates in the literature have been reported at approximately 90%. Dr. Miklos and Moore have combined this procedure with their other innovative approaches to reconstructive surgery to continue to provide their patients with the best technology available to achieve higher cure rates, but not to jeopardize patient safety. Of course as with any vaginal surgery there are risks associated with the procedure, even though the risks are low with the Apogee procedure. These risks include: bleeding, infection, rejection or erosion of the mesh material, failure of the procedure, bowel or rectal injury, vaginal scar tissue formation and/or pain.
No single surgery is the answer for all patients, so Dr Miklos and Moore will evaluate your history and findings and discuss with you whether or not the Apogee procedure would be an appropriate procedure for your condition. As with all procedures, they tailor the surgery to the patients age, medical history, and physical findings.
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