Laparoscopic Procedure >>
Posterior IVS (Intravaginal Slingplasty)
Posterior IVS Fig: 1
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As stated previously, many patients may not have a vaginal vault suspension completed at the time of their surgery even if they have vault prolapse because of the difficult and complex nature of the procedures reviewed above. This can lead to problems such as a shortened vagina, chronic 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) |
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Symptoms of vaginal vault NOT being suspended properly
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Urinary frequency, urgency |
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Difficulty emptying bladder |
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Constipation (straining to evacuate) |
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Vaginal pressure, pain |
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Painful intercourse |
Recent interest has focused on less invasive operations for vault suspension 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 has been 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. Miklos and Moore are some of the first surgeons in the United States offering this exciting new procedure.
Posterior IVS Fig: 2 Posterior IVS (Intravaginal Slingplasty)
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Posterior TVT sling for vaginal vault! |
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Minimally invasive vaginal vault suspension |
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10 minute vaginal outpatient procedure |
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Completed under local/regional anesthesia |
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One small vaginal incision, 2 tiny incision beneath buttocks |
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Safe and effective |
The procedure is called an infracoccygeal sacropexy, or more commonly known as Posterior IVS (Posterior Intravaginal Slingplasty). A piece of surgical mesh is 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 (uterosacral ligament) which suspends the top of the vagina in its normal anatomic position.
Advantages of Posterior IVS
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Minimally Invasive! |
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No abdominal incisions (vs. Sacral Colpopexy) |
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Decreased risk of bleeding (vs. SSLF) |
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Decreased risk of nerve injury (vs. SSLF) |
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No general anesthesia required (vs. Sacral Colpopexy) |
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Decreased recovery period |
Description of Procedure
The Posterior IVS Tunneler device (Tyco Healthcare, United States Surgical, Norwalk, CT) consists of a trocar that is very consistent in shape and size with the TVT sling trocar/needle, however it has a removable blunt tip, reversible plastic stylet into which a polypropylene multifilament tape can be threaded and brought up through the trocar. When utilized to suspend the apex of the vagina, the tape serves to create artificial uterosacral neoligaments to which the vaginal vault is reattached. Many repairs like Cystocele, rectocele and/or enterocele repair may be performed at the same time, with or without the use of graft or support materials.
The technique involves placing the tape through a very small buttock incision (5mm) lateral to the anus on one side, up along side the vagina to the apex, over the rectum at the top of the vagina, down along side the vagina on the other side and out a buttock incision lateral to the anus on the other side (Figure 1).
Posterior IVS Fig: 3 |
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. |
Surgical Technique
Dr. Miklos and Moore will begin the procedure just as they would with a posterior repair with dermal graft (link to that section). Most patients will have a rectocele and/or enterocele repair with their vault prolapse, therefore an incision will be made in the vaginal skin on the posterior wall. The rectovaginal fascia will be repaired first and then a dermal graft placed to augment the repair and repair any enterocele that is present near the top of the vagina. This will be repaired first and the dermal graft placed under the vaginal skin as previously described. The initial dissection is completed until the ischial spine is palpated on each side. However, unlike the SSLF (sacrospinous ligament) the ligament itself does not have to be isolated which can be a difficult and complex dissection.
A stab incision is made on each buttock 3cm lateral and 3cm inferior to the midline of the rectum (fig. 1). The surgeon then places a finger vaginally and palpates the ischial spine and the pelvic sidewall just distal to the spine (levator muscle). The surgeon then advances the trocar (figure 2) 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. The tape is then attached to the tip of the stylet and pulled out through the trocar and the tape left at the apex of the vagina. The procedure is completed on the other side in an identical fashion. The mesh tape is then attached to the apex of the graft and/or the vagina (figure 3) and 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.
Posterior IVS Fig: 4 |
Figure 4 - Posterior IVS tunneler (trocar) being advanced through small incision on buttock through the pararectal space to the top of the vagina. The mesh tape is then attached to trocar and pulled back through to the incision. |
Enterocele Repair Figure: 4 |
Figure 3. Side view of mesh tape going up around rectum (R) and attached to top of vagina (V) holding the vaginal apex in place. |
Results and Complications
Dr. Miklos and Moore have been experiencing excellent results using this new, minimally invasive technique for 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 Posterior IVS 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 Posterior IVS 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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