Abstract
Background
The aim of this study was to investigate the course of the transobturator posterior anal sling and its relationship to anatomical structures.
Methods
The transobturator anal sling procedure was performed in four fresh-frozen pelvises. The pelvises were dissected and the structures adjacent to the sling and the course of the sling were identified and measurements obtained.
Results
The transobturator posterior anal sling was inserted 2 ± 0.5 cm posteriorly to the anus, and 2.5 ± 0.5 cm caudal to the coccyx under the levator plate at the level of the puborectalis muscle. The tape was 3.5 ± 0.5 cm from the pubic symphysis and 2.3 ± 0.3 cm from the obturator canal at entry into the pelvic cavity. The tape passed 2.3 ± 0.3 cm inferior–medial to the obturator canal. At entry, the sling passed lateral to the ischiopubic ramus through the following structures: gracilis, adductor brevis, obturator externus, obturator membrane, and beneath the obturator internus muscle. The sling traveled 2–3 ± 0.5 cm over the iliococcygeus muscle and perforated the iliococcygeus fibers 0–2 cm medial to arcus tendinous levator ani. The posterior division of the obturator nerve was 2.8 ± 0.7 cm from the tape. The anterior division of the obturator nerve was 3.4 ± 0.8 cm from the tape. The device passed 1.1 ± 0.4 cm from the most medial branch of the obturator vessels.
Conclusions
The transobturator posterior anal sling travels mostly in the avascular area of the ischiorectal fossa and posterior to the puborectalis muscle as intended.
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References
C Norton (2009) Conservative and pharmacological management of faecal incontinence in adults. Incontinence 1321–1386
Macmillan AK, Merrie AE, Marshall RJ, Parry BR (2004) The prevalence of fecal incontinence in community-dwelling adults: a systematic review of the literature. Dis Colon Rectum 47(9):1341–1349
Brown H, Wexner S, Segall M, Brezoczky K, Lukacz E (2012) Accidental bowel leakage in the mature women’s health study: prevalence and predictors. Int J Clin Pract 66(11):1101–1108
Whitehead WE, Borrud L, Goode PS, Meikle S, Mueller ER, Tuteja A et al (2009) Fecal incontinence in US adults: epidemiology and risk factors. Gastroenterology 137(2):512–517 e2
Melville JL, Fan M-Y, Newton K, Fenner D (2005) Fecal incontinence in US women: a population-based study. Am J Obstet Gynecol 193(6):2071–2076
Markland AD, Goode PS, Burgio KL, Redden DT, Richter HE, Sawyer P et al (2010) Incidence and risk factors for fecal incontinence in black and white older adults: a population-based study. J Am Geriatr Soc 58(7):1341–1346
Wu JM, Vaughan CP, Goode PS, Redden DT, Burgio KL, Richter HE et al (2014) Prevalence and trends of symptomatic pelvic floor disorders in US women. Obstet Gynecol 123(1):141
Johanson JF, Lafferty J (1996) Epidemiology of fecal incontinence: the silent affliction. Am J Gastroenterol 91(1):33–36
Bliss DZ, Fischer LR, Savik K (2005) Managing fecal incontinence: self-care practices of older adults. J Gerontol Nurs 31(7):35–44
Landefeld CS, Bowers BJ, Feld AD, Hartmann KE, Hoffman E, Ingber MJ et al (2008) National institutes of health state-of-the-science conference statement: prevention of fecal and urinary incontinence in adults. Ann Intern Med 148(6):449–458
Miner PB Jr (2004) Economic and personal impact of fecal and urinary incontinence. Gastroenterology 126:S8–S13
Mellgren A, Matzel K, Pollack J, Hull T, Bernstein M, Graf W et al (2014) Long-term efficacy of NASHA Dx injection therapy for treatment of fecal incontinence. Neurogastroenterol Motil 26(8):1087–1094
Matzel K, Stadelmaie U, Gall F, Hohenfellner M (1995) Electrical stimulation of sacral spinal nerves for treatment of faecal incontinence. Lancet 346(8983):1124–1127
Wexner SD, Coller JA, Devroede G, Hull T, McCallum R, Chan M et al (2010) Sacral nerve stimulation for fecal incontinence: results of a 120-patient prospective multicenter study. Ann Surg 251(3):441
Wong WD, Congliosi SM, Spencer MP, Corman ML, Tan P, Opelka FG et al (2002) The safety and efficacy of the artificial bowel sphincter for fecal incontinence. Dis Colon Rectum 45(9):1139–1153
Hotouras A, Murphy J, Walsh U, Allison M, Curry A, Williams NS et al (2014) Outcome of percutaneous tibial nerve stimulation (PTNS) for fecal incontinence: a prospective cohort study. Ann Surg 259(5):939–943
Rosenblatt P, Schumacher J, Lucente V, McNevin S, Rafferty J, Mellgren A (2014) A preliminary evaluation of the TOPAS system for the treatment of fecal incontinence in women. Female Pelvic Med Reconstr Surg 20(3):155–162
Mellgren A, Zutshi M, Lucente VR, Culligan P, Fenner DE, Chern H et al (2016) A posterior anal sling for fecal incontinence results of a 152-patient prospective multicenter study. Am J Obstet Gynecol 214(3):349 e1–e8
DeLancey JO (1988) Structural aspects of the extrinsic continence mechanism. Obstet Gynecol 72(3 Pt 1):296–301
DeLANCEY JO (1986) Correlative study of paraurethral anatomy. Obstet Gynecol 68(1):91–97
Oelrich TM (1983) The striated urogenital sphincter muscle in the female. Anat Rec 205(2):223–232
Shobeiri SA, Gasser RF, Chesson RR, Echols KT (2003) The anatomy of midurethral slings and dynamics of neurovascular injury. Int Urogynecol J 14(3):185–190
Brochard C, Queralto M, Cabarrot P, Siproudhis L, Portier G (2017) Technique of the transobturator puborectal sling in fecal incontinence. Tech Coloproctol 21(4):315–318
Acknowledgements
We would like to acknowledge the assistance of the team at INOVA Advanced Surgical Technology and Education Center (ASTEC) and thank Mr. Larry Walker, the director of the program for his support of this study.
Author contributions
J. Alshiek: Project development, data collection, statistical analysis, manuscript writing. Peter Rosenblatt: Project development, manuscript review. S. A. Shobeiri: Project development, data collection, statistical analysis, manuscript writing.
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Dr. Peter Rosenblatt is the inventor of the transobturator posterior anal sling the other authors declare that they have no conflict of interest.
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This was an anatomical observational study that was approved as an exempt study at Inova Fairfax Hospital.
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Alshiek, J., Rosenblatt, P. & Shobeiri, S.A. The anatomy of Trans-Obturator Posterior Anal Sling (TOPAS) and dynamics of potential mechanism of action. Tech Coloproctol 23, 675–680 (2019). https://doi.org/10.1007/s10151-019-02042-6
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DOI: https://doi.org/10.1007/s10151-019-02042-6