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Elevate – Anterior and Apical Support System

For Cystocele and Vault Prolapse

Cystocele is caused by a defect in the support tissue of the anterior vaginal wall (ie the pubocervical fascia) which causes the bladder to drop or "fall" down. In many cases the uterus (or top of vagina if the patient has had a hysterectomy) falls with the bladder. This is called vaginal vault prolapse. If this is not repaired at the same time as the cystocele, failure can occur. The use of a mesh graft to repair cystoceles has been shown by a recent Cochrane review to be beneficial and have a lower failure rate compared to when a graft is not used (for more detailed explanation of this see above in the Posterior Elevate section or click here for a more detailed background of the Anterior Elevate procedure).

The Perigee procedure was developed as a minimally invasive technique to place an anterior wall graft in cystocele repair. Dr Moore and Miklos have been performing this procedure for over five years and have taught the procedure throughout the world. They have also published multiple papers on the technique and their results and had excellent clinical results. However, procedures can always be improved. The Perigee procedure (as well as similar procedures such as the Prolift, Avaulta, etc) utilize needles that are passed through the groins and the transobturator space to help get the graft in place. The graft has 4 arms coming off of it that the needles are used to attached the arms/graft to the pelvic sidewalls. Complications can occur with this blind needle passage or in some patients the arms can heal too tight and this can cause pain. Several years ago, the Mini-sling was developed to help minimize risks of blind needle passes, ie a sling for urinary leakage could be placed through one small incision with no needle passes (click here for Dr Moore’s/Miklos recent paper on Minisling). Clinical cure rates for this procedure have been excellent, therefore the same technology has been utilized in the modification of the Perigee procedure and development of the Elevate procedure to treat cystocele and vault prolapse in one procedure.

Note: the needle passes through the groins required for the placement of the Perigee procedure above.

Anterior Elevate Procedure – Modification of Perigee

• Treats cystocele and vaginal vault w/one procedure
• ELIMINATES blind needle passes
• Improved Apical or Vault suspension
• Minimally invasive- only one small incision
• 20-30 minute vaginal outpatient procedure
• Completed under local/regional anesthesia
• One small vaginal incision
• Safe and effective- same mesh

Elevate Procedure

The Anterior Elevate procedure can be completed under spinal/epidural or general anesthesia and typically takes about 30 minutes to complete. It is an outpatient, vaginal approach with only one small incision in the vagina. Typically patients just stay overnight just one night (23 hour outpatient type surgery) and return home the following day. Most patients return to their normal activities within a few days, however lifting restrictions are in place for approximately 6 weeks.

Figure: A small incision is made vaginally and the bladder dissected away from the vagina. The sacrospinous ligaments are isolated and the apical arms are attached to the ligaments with the least invasive techology available to date.

Figure:Once the apical arms are in place, the bladder neck arms are attached to the sidewalls,
the upper portion of the graft slid over the arms attached to the sacrospinous ligaments and
adjusted into place. The excess mesh on the upper arms are excised and the vaginal incision closed.
A foley catheter and vaginal packing is placed and removed the next morning
prior to discharge from the hospital.

Elevate Graft in Position: Side-view of the pelvis showing the Elevate supporting the bladder and the top of the vagina (or uterus... which can be left in place and supported with the graft and hysterectomy avoided)

Results and Complications

Dr. Moore and Miklos have been experiencing excellent results using this modification of a minimally invasive technique for cystocele repair combined with vaginal vault suspension.  Of course as with any vaginal surgery there are risks associated with the procedure, even though the risks are low with the Elevate 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. Mesh is also permanent (which is one of the benefits, ie the support should stay there for the long term) however complications can occur with the mesh, that may require further surgery and there is no guarantee that further surgery will resolve these complications (as is true for any surgical complications or risks). Dr. Moore recently published the first long-term study in the world on the Anterior Elevate procedure in the International Urogynecology Journal and is also involved in the largest multicenter trial in the world evaluating the Anterior Elevate procedure with findings being reported at the Annual ICS Meeting in Scotland in August 2011.  Cure rates have been in the range of 90% and complications have been minimal.

For more information regarding a more detailed discussion of mesh risks in prolapse surgery, please click here to read the expanded section on the Anterior Elevate procedure.

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 Elevate procedure would be an appropriate procedure for your condition and review all alternatives including conservative methods such as doing nothing or using a pessary as well as non-mesh surgical approaches.  The Elevate procedure is not indicated in all patients, however Dr. Moore and Miklos strongly believe in its use when indicated and will discuss their recommendations with you and review why they feel it is indicated in your particular case.  As with all procedures, they tailor the surgery to the patient’s age, medical/surgical history, and physical findings.

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Posterior Elevate