Perigee >>
Advantages of Transobturator Approach
- Safer, faster, more efficient
- Decreased risk of:
-Bowel Injury
-Bladder Injury
-Major Bleeding
- No Retropubic Needle Passage
- No Abdominal Incisions
- More Anatomic Position of Graft
In Dr. Moore’s and Miklos’ initial travels to France and Italy, where they operated with the developers of these techniques for stress incontinence (ie Dargent, Mellier, Courtieau, Von Theobold and others) they also observed their work in utilizing this same space to pass needles through it, to be able to attach an anterior wall graft up high on the pelvic sidewalls in a very time efficient and minimally invasive approach to treat cystoceles. At the same time, the Australians (who developed Posterior IVS system for vault prolapse), specifically Professor AJ Rane, were also investigating this same space as a potential space to be able to reach a point on the white line up near the ischial spine to have a strong attachment point for an anterior wall graft for cystocele repair. Modifications of some of these techniques have been made to make the approach easier and safer since that point in time. After evaluating the procedure in Europe and completing many cadaver studies, Dr. Moore was the first US surgeon to utilize the Perigee system (the first Transobturator system released in the US) to place an anterior wall graft for repair of cystocele. Since that point in time, he has also become the lead investigator in the United States clinical trial of the Perigee and presented (in conjunction with Dr. Miklos) one of the first papers and videos in the world on the procedure at the International Urogynecology Meeting in Copenhagen in 2005. Dr. Moore has worked with other world wide leaders to help develop this product in the United States and is directing other centers such as Harvard, Cleveland Clinic and others in the current US study.
Perigee Figure: 1 |
Figure 1 The original incisions of the TOT sling are used to attach the bladder neck portion of the graft under the bladder. One more incision is made on each side lower in the groins to pass the superior needle through the obturator space to attach the superior portion of the graft.
The transobturator approach to graft placement is subfascial, ie the needles or the mesh arms NEVER enter the retropubic space
Very small incisions are placed in the groins (two on each side) and a small incision is made in the vagina under the bladder, allowing the graft to be placed under the bladder in the correct position without having to pass needles blindly through the retropubic space and the abdominal wall or down to the sacrospinous ligaments. The space that the needle passes through has been extensively studied (Dr. Moore and Miklos have done numerous cadaveric dissections to study the anatomy of the space) and has been found to be a very safe space to work in. There is very minimal risk of major bleeding (no major blood vessels),bowel, bladder or nerve injury. Many physicians are concerned of the route of the obturator and/or pudendal nerves, however we have completed dissections showing that if done correctly, the obturator and pudendal nerves are nowhere near the surgical tract of the needles (see anatomy below). The needle is also guided by a finger placed vaginally throughout its tract, therefore there is minimal blind passage of the needle.
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