Perineal approach to vascular anatomy during transobturator cystocele repair

Abstract

Objective To evaluate the risk of vascular injury during transobturator approach of cystocele repair.Design Dissection of the obturator area by perineal approach was performed after placement of mesh needles used for cystocele mesh repair.Setting Surgery school of Paris.Population or sample Twenty obturator regions in ten fresh female cadavers.Methods Transperineal dissection of the obturator area was conducted in ten fresh female anatomic subjects after inserting anterior Prolift Ò needles.Main outcome measures The vascular anatomy of the obturator region was mapped. Distances between needles and vascular structures of the obturator area were measured three times and averaged for each side.Results The anterior cannula-equipped needle perforated the gracilis and the adductor brevis muscles. The mean (SD) distance to the anterior obturator vessels was 21.2 (1.6) mm on the right side and 20.4 (1.5) mm on the left. The posterior needle perforated the adductor magnus. Its distance to the posterior division of the obturator vessels was 1.8 (1.0) mm on the right side and 1.1 (0.9) mm on the left.Conclusions During mesh cystocele repair by transobturator approach, the posterior obturator vessels division seems at risk of injury during the posterior needle insertion.

Vaginal mesh repair SYSTEMS for pelvic organ prolapse: Anatomical study comparing transobturator/trangluteal versus single incision techniques

“…This data is in line with a precedent anatomical study about cystocele repair by transobturator (out‐in) approach. This study concludes that the posterior obturator vessels division seems at risk of injury during the posterior needle insertion …”

“…This study concludes that the posterior obturator vessels division seems at risk of injury during the posterior needle insertion. 11 Another anatomical study 12 compared the specific risks of neurovascular injury resulting from two transobturator suburethral sling insertion approaches, the standard "outside-in" 13 versus the "inside-out." 14 This paper showed that the two techniques were not equivalent with a lower risk of vascular and neural injury with the outside-in insertion.…”

Determination of a Central Avascular Triangle within the Obturator Foramen: A Radioanatomic Study

“…The cadavers were prepared as described in our previous work[ 16 ]. Five cadavers were injected with intravascular blue dye to better identify and follow arteries.…”

“…Several cases of hemorrhagic complications following this procedure have been published [ 9 – 15 ]. In a previous anatomic study, we demonstrated that the posterior needle passes close to the obturator vessels [ 16 ]. However, the surgeon is unaware of the position of the needle as he/she is guided by palpation only.…”

Le foramen obturé : carrefour de tous les dangers ?

“…Après insertion transobturatrice des aiguilles selon la technique usuelle, nous avons procédé à l'étude anatomique de la région obturatrice par voie transpérinéale. Dans tous les cas, nous avons constaté une proximité préoccupante entre la trajectoire de l'ancillaire transobturateur inférieur et la branche inférieure du pédicule obturateur, prédictive de risque d'accident hémorragique [15]. D'autres travaux anatomiques similaires ont démontré l'existence d'un risque de lésion neurovasculaire lié aux passages transobturateurs [16].…”