US20060229596A1 - Systems, devices, and methods for treating pelvic floor disorders - Google Patents

Abstract

Disclosed are single-incision surgical procedures for treatment of urinary incontinence and/or pelvic floor disorders and related uses, devices, kits, and methods. Implants are also disclosed for use in the exemplary procedures. In certain embodiments, soft tissue anchors are used to anchor the surgical implants to obturator membranes of a patient.

Description

CROSS-REFERENCE TO RELATED APPLICATIONS
• This application claims the benefit of U.S. Provisional Application No. 60/668,736, filed on Apr. 6, 2005, U.S. Provisional Application Nos. 60/702,539 and 60/702,540, both filed on Jul. 25, 2005, and U.S. Provisional Application No. 60/715,362, filed on Sep. 8, 2005, the contents of which are incorporated by reference herein in their entirety.
BACKGROUND
• Pelvic floor disorders are a class of abnormalities that effect the pelvic region of patients, and they afflict millions of women. The pelvic region includes various anatomical structures such as the uterus, the rectum, the bladder, and the vagina. These anatomical structures are supported and held in place by a complex collection of tissues, such as muscles and ligaments. When these tissues are damaged, stretched, or otherwise weakened, the anatomical structures of the pelvic region shift and in some cases protrude into other anatomical structures. For example, when the tissues between the bladder and the vagina weaken, the bladder may shift and protrude into the vagina, causing a pelvic floor disorder known as cystocele. Other pelvic floor disorders include vaginal prolapse, vaginal hernia, rectocele, enterocele, uterocele, and/or urethrocele.
• Pelvic floor disorders often cause or exacerbate female urinary incontinence (UI). One type of UI, called stress urinary incontinence (SUI), effects primarily women and is often caused by two conditions—intrinsic sphincter deficiency (ISD) and hypermobility. These conditions may occur independently or in combination. In ISD, the urinary sphincter valve, located within the urethra, fails to close (or “coapt”) properly, causing urine to leak out of the urethra during stressful activity. In hypermobility, the pelvic floor is distended, weakened, or damaged. When the afflicted woman sneezes, coughs, or otherwise strains the pelvic region, the bladderneck and proximal urethra rotate and descend. As a result, the urethra does not close with sufficient response time, and urine leaks through the urethra.
• UI and pelvic floor disorders, which are usually accompanied by significant pain and discomfort, are often treated by implanting a supportive sling or mesh in or near the pelvic floor region to support the fallen or shifted anatomical structures or more generally, to strengthen the pelvic region by promoting tissue in-growth. Often, treatments of stress incontinence are made without treating the pelvic floor disorders at all, potentially leading to an early recurrence of the stress incontinence.
• Existing systems, methods, and kits for treatment typically apply delivery devices to position a supportive surgical sling into a desired position in the pelvic region. However, some of these systems and methods require a medical operator to create multiple incisions and deliver the implant using complex procedures. Moreover, many existing surgical implants are not suitably sized or shaped to properly fit within a patient and treat pelvic floor disorders. Accordingly, medical operators and patients need improved systems, methods, and surgical kits for the treatment of pelvic floor disorders and/or urinary incontinence.
SUMMARY
• The invention generally pertains to systems and methods to treat pelvic floor disorders and/or UI through the use of a single incision surgical procedure. In a general single incision technique, the operator makes an incision in the vaginal wall of the patient and uses the single incision as the entry way into the patient's pelvic floor region to provide implants for supporting the urethra, bladderneck, and/or pelvic floor. As explained in more detail below, the single incision approach can be used to insert, position, tension, and secure the implant without the need to make additional incisions in the patient. In practice, the operator makes the single incision in the anterior vaginal wall of the patient and dissects bilaterally to the inferior pubic ramus on each side of the patient. The operator couples a surgical implant to a delivery device, and then guides the device through the single incision and to a target tissue region within the retropubic space on a first side of the pelvic region of the patient.
• The implant is secured within the retropubic space by soft tissue anchors, tangs on the implant, or both. In some implementations, the operator couples a first end of the surgical implant to the delivery device by first coupling the first end of the surgical implant to a soft tissue anchor, and then coupling the soft tissue anchor to the delivery device. The operator then secures the soft tissue anchor to the target tissue region and withdraws the delivery device, leaving the first end of the implant anchored to the target tissue region. In other implementations, the surgical implant is directly coupled to the delivery device, and includes tanged end portions that secure to the target tissue region. The operator then repeats this process on a second end of the implant to anchor the second end to a target tissue region to a contra-lateral location in the patient's retropubic space. In certain embodiments, the target tissue regions are located in the obturator membranes of the patient and the implant supports the urethra and/or bladderneck of the patient.
• In some configurations, the operator delivers implants that also extend to regions of the pelvic floor that are posterior to the bladderneck, and provides support to anatomical organs such as the bladder. In order to provide implants that provide both anterior and posterior support, the implant is secured to a plurality of target tissue regions on each side of the patient via a plurality of anchors or tanged portions on each side of the implant. In these configurations, the operator repeats the above-described process for each of the anchors or tanged portions. After delivering the implant to the patient's retropubic space, the operator may tension the surgical implant using a tensioning tool inserted through the vaginal incision. The systems and methods include surgical implants, soft tissue anchors that anchor the surgical implants to a desired anatomical location, delivery devices and methods that deliver the anchors and implants through the single incision to desired anatomical locations, and tensioning devices that reposition and/or tension the surgical implants after delivery.
• In one aspect, the systems and methods include surgical implants that are sized, shaped, and constructed to treat a variety of pelvic floor disorders. In certain embodiments, the implants are slings that are configured to extend under the urethra and/or bladderneck of the patient for the treatment of urinary incontinence. In other implementations, the implants are larger and configured to extend to and support regions posterior to the patient's bladderneck, including the base of the patient's bladder or further toward the posterior region of the pelvic floor to support other organs.
• In certain embodiments, the systems and methods include surgical implant assemblies for pelvic floor repair and/or for treatment of urinary incontinence in a patient. An exemplary assembly includes a surgical implant having a first end, a second end, and a central region adapted to extend to a position posterior to the bladderneck of the patient, and at least one soft tissue anchors coupled to an end of the surgical implant and adapted to secure the implant within the patient's pelvic floor. In certain embodiments, the implant has a first end adapted to extend to a first obturator membrane, a second end adapted to extend to a second obturator membrane, and first and second soft tissue anchors for coupling to respective ones of the first and second ends of the surgical implant and for securing to respective first and second obturator membranes. The implant, in various embodiments, is sized and shaped to support anatomical structures within the pelvic region such as the urethra, bladderneck, bladder, and uterus. The implants, in certain configurations, have anterior-to-posterior widths that allow the implant to extend to posterior regions of the pelvic floor region, including regions posterior to the bladderneck and, in some configurations, posterior to the bladder.
• The implant can couple to the soft tissue anchors in a variety of ways based at least in part on the target tissue region where the implant will be secured. In certain configurations, the implant directly couples to and physically contacts the soft tissue anchors. In others, the implant couples to soft tissue anchors by filaments which space the soft tissue anchors away from the implant. The orientation of the mesh with respect to the anchors may be varied to tension or loosen the implant.
• An exemplary surgical implant for use with the systems and methods includes a first set of strands and a second set of strands separate from the first set of strands. The first set of strands and the second set of strands are fixedly attached at a plurality of attachment points. An exemplary manufacturing technique includes extruding a first set of strands in a first direction, extruding a second set of strands in a second direction different from the first direction, and attaching the first set of strands and the second set of strands at attachment points.
• In one aspect, the systems and methods include implantable surgical sling assemblies for pelvic floor repair and/or for treatment of urinary incontinence in a patient. An exemplary implantable surgical sling assembly includes an implant for extending at least partially between a first obturator membrane and a second obturator membrane of the patient. The implant has a first strap end for aligning with the first obturator membrane, a second strap end for aligning with the second obturator membrane, a first plurality of soft tissue anchors for coupling to the first strap end of the implant and for securing the first strap end to a first soft tissue region, and a second plurality of soft tissue anchors for coupling to the second strap end of the implant and for securing the second end to a second soft tissue region. In certain embodiments, the first and second soft tissue regions are obturator membranes.
• In another aspect, the invention includes implantable surgical sling assemblies for pelvic floor repair and/or for treatment of urinary incontinence in a patient. An exemplary implantable surgical sling assembly includes a surgical implant having a first end for securing to a first obturator membrane of a patient and a second end for securing to a second obturator membrane of a patient. The assembly includes a first set of at least three soft tissue anchors for coupling to the first end of the implant and for securing to the first obturator membrane, and a second set of at least three soft tissue anchors for coupling to the second end of the implant and for securing to the second obturator membrane.
• The systems and methods also include sling end terminations that may optionally also be soft tissue anchors. In one aspect, the invention includes surgical sling assemblies for pelvic floor repair and/or for treatment of urinary incontinence in the patient. An exemplary assembly includes a surgical sling for supporting at least one of a urethra and a bladderneck of the patient, and a sling housing physically contacting and disposed about an end of the sling. The sling housing includes an aperture and tapers away from a distal end of the sling. In one feature, the sling housing is flexible. The aperture may be a ring, and the housing may include legs extending radially from the ring. In one application, the ring couples to a delivery device, and the legs engage with and anchor to soft tissue.
• In another aspect, an exemplary manufacturing technique for an implant is provided, comprising providing a mesh material, coupling the mesh material to a mold, injecting a curable material into the mold, allowing the curable material to cure, and removing the mesh material from the mold. The mesh material may have a pre-selected number of strands or a pre-selected length, width and/or thickness to allow the manufacture of a suitably sized implant.
• In another aspect, surgical techniques are disclosed for delivering an implant to a patient. In one implementation, the techniques include a single incision method for implanting a surgical implant in the pelvic floor region of a patient for pelvic floor repair. The exemplary method includes the steps of creating an incision in the vaginal wall of the patient, coupling the implant to a delivery device, inserting the delivery device through the vaginal incision via the external vaginal opening of the patient, and implanting and securing the implant within the pelvic floor region of the patient such that at least a portion of the sling extends to a position posterior to the bladderneck of the patient. The implant may be coupled to soft tissue anchors that anchor into respective soft tissue regions, such as obturator membranes, of the patient, and may additionally or alternatively include tanged portions that secure the implant to the soft tissue regions. The methods may optionally include tensioning the implant. In one feature, the methods include coupling the implant to a delivery device having a shaft and a slidable cannula disposed about the shaft, inserting the delivery device through the external vaginal opening, inserting the delivery device through the vaginal incision subsequent to inserting the delivery device through the external vaginal opening, aligning the shaft with a first obturator membrane, sliding the cannula distally along the shaft, and securing the implant to the first obturator membrane.
• In another aspect, the surgical implants are delivered through a single vaginal incision and are secured to the patient's obturator membranes. In particular, according to an illustrative technique, an operator creates a single incision in a vaginal wall of the patient, couples the implant to one or more soft tissue anchors, couples a soft tissue anchor to a delivery device, delivers the soft tissue anchor to an obturator membrane via the single vaginal incision, and anchors the soft tissue anchor to the obturator membrane. The operator repeats this process for any other anchors used, including an anchor for the patient's contra-lateral side, while using the same vaginal incision to insert the anchors and the implant. Either during delivery or subsequent to delivery, the operator optionally tensions the surgical implant. In one aspect, the implant is adjustably coupled to one or more soft tissue anchors, and the operator tensions the surgical implant by adjusting the implant's orientation with respect to its soft tissue anchors.
• In certain implementations, a method is provided for treating urinary incontinence in a patient. The method includes providing an implant having at least one tanged portion formed as a unitary body with the implant, creating an incision in the vaginal wall of the patient, coupling an implant to a delivery device, inserting the delivery device through the incision in the vaginal wall via the external vaginal opening of the patient, guiding the device to a location beneath the patient's epidermis, and securing, by the at least one tanged portion, the implant to the patient's soft tissue.
BRIEF DESCRIPTION OF THE DRAWINGS
• These and other features and advantages will be more fully understood by the following illustrative description with reference to the appended drawings, in which like elements are labeled with like reference designations and which may not be drawn to scale.
• FIG. 1A shows a lateral view of the female pelvic region and an exemplary positioning of a surgical implant.
• FIG. 1B shows an oblique view of the pelvic region and surgical implant ofFIG. 1A.
• FIG. 1C shows an anterior view of the pelvic region and surgical implant ofFIG. 1B.
• FIG. 2A shows a surgical implant having a central region and six extensions.
• FIG. 2B shows the surgical implant ofFIG. 2A having tanged portions on its extensions.
• FIG. 3 shows a surgical implant having a circular central region and four extensions.
• FIG. 4 shows a rectangular surgical implant sized and shaped for pelvic floor repair.
• FIG. 5 shows a trapezoidal surgical implant sized and shaped for pelvic floor repair.
• FIG. 6 shows a surgical implant that includes a plurality of apertures for promoting tissue in-growth.
• FIG. 7A shows a surgical implant having a first set of strands and a second set of strands attached at intersection points.
• FIG. 7B shows a close-up view of the surgical implant ofFIG. 7A.
• FIG. 8A shows the implant ofFIG. 7A with narrowed tanged portions.
• FIG. 8B shows a close-up view of the implant ofFIG. 8A.
• FIG. 9 shows an implant having tanged portions that include a single long strand and a plurality of short strands.
• FIG. 10 shows an implant having long strands and short strands, wherein the long strands are oriented at a non-perpendicular angle with respect to the short strands.
• FIG. 11A illustrates an exemplary extrusion technique for constructing a surgical implant similar to the surgical implant ofFIG. 10.
• FIG. 11B is a block diagram showing the steps of the exemplary technique illustrated inFIG. 11A.
• FIG. 12 illustrates a surgical implant having three sets of strands attached to each other at intersection points.
• FIG. 13 illustrates a surgical implant manufactured using a similar method as in the surgical implant ofFIG. 7A, but having a longer anterior-to-posterior length.
• FIG. 14A illustrates a circular surgical implant including a first set of strands and a second set of strands attached at intersection points, wherein the implant is sized and shaped to extend to posterior regions of the pelvic floor and to support anatomical structures such as the bladder.
• FIG. 14B shows the surgical implant ofFIG. 14A after selective removal of portions of the surgical implant.
• FIG. 15A shows an implant shaped to interfit below a urethra or bladderneck of a patient.
• FIG. 15B shows a clip used to shape the implant ofFIG. 15A.
• FIG. 16A shows a sling assembly including an implant and end terminations for associating the implant to a delivery device and for anchoring the implant to soft tissue.
• FIG. 16B illustrates an exemplary manufacturing technique of the implant ofFIG. 16A.
• FIG. 17 shows an alternative configuration for an end termination having a top piece and a bottom piece.
• FIG. 18 shows an implant assembly including an implant and two end terminations, wherein each end termination includes a ring and no legs.
• FIG. 19A shows a flexible end termination in a collapsed state.
• FIG. 19B shows the end termination ofFIG. 19A in an expanded state and interfitted with a shaft of a delivery device.
• FIG. 20 shows an implant assembly including an implant and two alternative tab-shaped end terminations.
• FIGS.21A-D show exemplary barbed soft tissue anchors.
• FIG. 21E shows a barbed anchor coupled to a portion of a surgical implant and anchored to an obturator membrane.
• FIG. 22A shows a soft tissue anchor with a smooth outer surface and without barbs.
• FIGS. 22B-22C illustrate an exemplary technique for using the anchor ofFIG. 22A to anchor a surgical implant to an obturator membrane.
• FIG. 23 shows a soft tissue anchor shaped like an arrowhead.
• FIG. 24 shows the implant ofFIG. 2A and depicts alternative approaches to couple soft tissue anchors with straps of the implant.
• FIG. 25A illustrates a surgical implant coupled with soft tissue anchors via elastic rings.
• FIG. 25B shows the elastic rings ofFIG. 25A in stretched states.
• FIG. 26A shows an implant assembly including a surgical implant that couples with soft tissue anchors via filaments.
• FIG. 26B shows the implant assembly ofFIG. 26A anchored within the pelvic region of a patient.
• FIGS.26C-D show an exemplary technique to tension the implant ofFIG. 26A.
• FIG. 26E shows a corner of the implant ofFIG. 26A after an exemplary tensioning technique.
• FIG. 26F shows the implant assembly ofFIG. 26B anchored within the pelvic region of a patient after tensioning.
• FIG. 26G shows an exemplary technique for loosening the implant ofFIG. 26A.
• FIG. 27 shows a delivery device having a movable shaft and a fixed cannula for delivering an implant assembly to the pelvic region of a patient.
• FIG. 28 shows a delivery device having a fixed shaft and a moveable cannula for delivering an implant assembly to the pelvic region of a patient.
• FIG. 29 shows the delivery device ofFIG. 28 in an extended state.
• FIG. 30 shows the delivery device ofFIG. 28 having increment markings on its shaft.
• FIG. 31A illustrates a transobtural single vaginal incision procedure for delivering an implant sized and shaped to extend posterior to the bladderneck and support the base of the bladder.
• FIG. 31B shows a transobtural single incision procedure similar to the procedure depicted inFIG. 31A, for delivering an alternative implant sized and shaped for supporting the urethra and/or the bladderneck.
• FIGS. 32A-32C show a delivery device including a handle and a curved halo-shaped shaft.
• FIGS.33A-B show symmetric delivery devices similar to the device of FIGS.32A-C, but having the curved shaft lie in a plane that is non-orthogonal to a plane of the handle.
• FIG. 34A shows an exemplary technique for delivering an implant sized and shaped to extend posterior to the bladderneck and support the base of the bladder using a transobtural single vaginal incision procedure.
• FIG. 34B shows aspects of a transobtural single incision procedure similar to the procedure depicted inFIG. 34A for delivering an alternative implant sized and shaped for supporting the urethra and/or the bladderneck.
• FIG. 35A shows aspects of a transobtural single incision procedure for delivering a tanged implant without soft tissue anchors.
• FIG. 35B shows aspects of a transobtural single incision procedure similar to the procedure depicted inFIG. 35A for delivering an implant sized and shaped to treat pelvic floor disorders.
• FIG. 36 shows an exemplary placement of a surgical implant with straps secured to target tissue regions of obturator membranes, levator ani muscles, and sacrospinous ligaments.
DETAILED DESCRIPTION OF EXEMPLARY EMBODIMENTS
• The invention generally pertains to systems and methods to treat pelvic floor disorders and/or UI by using single vaginal incision surgical approaches to deliver surgical implants to the patient's pelvic floor and/or sub-urethral and retropubic space. The implants are secured to soft tissues within the patient's retropubic space by tanged portions of the implant, by one or more soft tissue anchors coupled to the implant, or both. The illustrative devices, systems, and methods of the invention are described below in the following order. First, surgical implants sized, shaped, and constructed for treating UI and/or pelvic floor repair are described. Second, soft tissue anchors are described that, in certain embodiments, secure the surgical implants to a desired anatomical location, such as obturator membranes, along with methods for coupling the soft tissue anchors to the surgical implants. Third, devices are described for delivering the anchors and implants to desired anatomical locations in the patient's retropubic space, such as obturator membranes, along with tensioning devices and methods that reposition and/or tension the surgical implant after delivery. Fourth, exemplary methods are described for implanting and positioning and securing exemplary implants within a patient's pelvic region by use of a single vaginal incision surgical technique.
• First, surgical implants sized, shaped, and constructed for treating UI and/or pelvic floor repair are described. The surgical implants described herein are adapted to be secured within the patient's retropubic space. The implants support anatomical structures in the pelvic region and more generally strengthen tissue of the pelvic region. In one aspect, the surgical implants physically support anatomical structures in the pelvic region by providing physical hammock-like support to anatomical structures such as the urethra, the bladderneck, the bladder, the uterus, and other vessels and structures. In order to physically support an anatomical structure, the surgical implants are sized and shaped to support that anatomical structure. In another aspect, surgical implants indirectly strengthen surrounding tissue by promoting tissue in-growth. The surgical implants can be constructed to include apertures or interstices in which tissue in-growth can occur, or may otherwise be constructed of a material that promotes tissue in-growth. Thus, surgical implants may be sized, shaped, and constructed to support anatomical structures and strengthen the tissue of the pelvic region.
• Turning to the Figures,FIGS. 1A-1C show an exemplarysurgical implant2 that is positioned within thepelvic region1 of a patient and secured therein through the use of the procedures described herein.FIGS. 1A-1C show thesurgical implant2 havinglateral edge2a,anterior edge2b, andposterior edge2c, and being sized, shaped and positioned to support the urethra4, thebladder6, and the bladderneck5 (the region that adjoins the urethra4 and the bladder6), of the patient by soft tissue anchors20a-20f. In particular,FIG. 1A shows a lateral view andFIG. 1B shows an oblique view of thepelvic region1. As shown, theimplant2 is located in the tissue region directly below the urethra4 and thebladderneck5 with the soft tissue anchors20a-fanchored into the patient's obturator membranes, thelateral edge2alocated on one side of the urethra4,bladderneck5, andbladder6, and theanterior edge2blocated under the urethra4 to help strengthen this tissue region in part to treat UI and/or urethrocele. Theposterior edge2cof the depictedsurgical implant2 also extends to a location that is posterior12 to thebladderneck5, to support the tissue near theposterior region6aof thebladder6 and theinferior region8aof theuterus8 to assist in treating other pelvic floor disorders including cystocele, uterine prolapse, enterocele, rectocele, and/or vaginal prolapse. However, because the various tissue regions of the pelvic region are interconnected, strengthening one tissue region often treats disorders afflicting other tissue regions.
• FIG. 1C shows an anterior view of thepelvic region1 with theanterior edge2bof theimplant2 as described above. The exemplarysurgical implant2 forms a hammock-like support below the urethra4, thebladderneck5, and thebladder6. Thesurgical implant2 is held in position by the six soft tissue anchors20a-fthat anchor torespective obturator membranes22aand22bwith three such anchors on each side. An obturator membrane is a thick fascial membrane and is located laterally on either side of the pelvic region. The obturator membrane is a convenient supporting structure for soft tissue anchors, such as soft tissue anchors20a-f, in part because it is strong, and in part because it is large and thus provides lateral, anterior, and/or posterior anchoring locations (in fact, the obturator membrane spans the obturator foramen, the largest foramen in the skeleton).
• In the depicted embodiment, the anchors20a-fcouple tosurgical implant2 and anchor directly into theobturator membranes22aand22b. However, in alternative embodiments, the anchors20a-fanchor into muscle tissue located laterally beyond theobturator membranes22aand22b. In other embodiments, theimplant2 does not span the full length between theobturator membranes22aand22b, known as the obturator-to-obturator length, but instead couples to the anchors20a-fvia filaments or rings that space theimplant2 away from the anchors20a-fand anchor into theobturator membranes22aand22b. In still other embodiments, theimplant2 does not anchor to theobturator membranes22aand22b, but instead anchors to other soft tissue regions in the retropubic space, such as the region of the tendinous arch of the levator ani muscle, as discussed below.
• Theimplant2 may be sized and shaped to achieve a desired patient fit.FIG. 2A shows an illustrativesurgical implant30 of the type shown inFIGS. 1A-1C having a trapezoidal shapedcentral region30aand six extension straps32a-f. In other embodiments thecentral region30ais rectangular. In certain embodiments, theimplant30, including straps32a-f, spans at least alength34 that extends between or beyond a first obturator membrane and a second obturator membrane of the patient, also known as the patient's obturator-to-obturator length. Thus, when the straps32a-fare delivered via the single vaginal incision, the straps32a-cattach to a first obturator membrane either directly or via soft tissue anchors directly coupled to the straps32a-c, and straps32d-fattach to the contralateral obturator membrane either directly or via soft tissue anchors directly coupled to thestraps32d-f, as illustrated with respect to FIGS.1A-C.
• In alternative implementations, the straps32a-fare secured to other target tissue regions in the patient's retropubic space, such as the patient's sacrospinous ligaments or levator ani muscles. By way of example, straps32aand32dmay extend to target regions of the sacrospinous ligament, straps32band32emay extend to target regions near the tendinous arch of the levator ani muscle, and straps32cand32fmay extend to target regions of the obturator membranes. Each of the straps32a-fmay have varying lengths in order to reach their respective target tissue regions.
• In certain embodiments, the straps32a-fof theimplant30 have tanged portions that directly secure one or more of the straps32a-fto a target tissue region.FIG. 2B shows theimplant30 ofFIG. 2A, with tanged portions at the end of each of the straps32a-f. In one exemplary technique, these portions are formed by first forming tangs around the edges of theimplant30, and then selectively melting portions of theimplant30 to form the non-tanged portions. More particularly, theimplant30 is first cut from a woven sheet which exposes fibrous protrusions, or the tangs, around the edges of theimplant30. The non-tanged portions are then formed by any process that smoothes, rounds or removes the protrusions, leaving the tangs around the ends of the straps32a-f. In one implementation, the edges of theimplant30 in the non-tanged portions are heat melted. In another exemplary technique, the tangs inimplant30 are formed from a non-tanged woven tape having the approximate dimensions of theimplant30 as depicted inFIG. 2B. The smooth sides of the tape are then trimmed to produce the frayed edges or fibrous protrusions of the tanged ends of straps32a-f. In either technique, the tangs are extremities of fibers of the implant, and the tanged ends of straps32a-fform a unitary body with theimplant30.
• FIG. 3 shows an alternative configuration of asurgical implant60 for use in supporting a pelvic region. As shown, theimplant60 has a circularcentral region62 and four radially extending extension straps64a-d. Thestraps64aand64care designed to extend to one obturator membrane of the patient, and thestraps64band64dare designed to extend to the contra-lateral obturator membrane of the patient. The circularcentral region62 is suitable for supporting various anatomical structures, including, for example, the base of the bladder. The straps64a-dcan couple with soft tissue anchors for anchoring into respective obturator membranes, as will be discussed below. The depictedimplant60 is a woven mesh; however, a similarly shaped non-woven implant with tanged straps for anchoring to target tissue regions is discussed below.
• As noted in connection with theimplant30 ofFIG. 2A, the straps64a-64dmay also be configured to extend to and secure to other target tissue regions in the patient's retropubic space. In one implementation, straps64c-64dextend to target tissue regions of the patient's obturator membranes, and straps64a-64bextend to target tissue regions near the patient's tendinous arch of the levator ani muscle.
• The implants ofFIGS. 2 and 3 described above have extensions/straps that can span the obturator-to-obturator length of patients so that the extensions/straps can directly secure to respective obturator membranes, either alone (using, for example, tangs) or in combination with soft-tissue anchors.FIG. 4 illustrates an alternative strapless embodiment of asurgical implant70, havinglateral length72 and, in various embodiments, spanning varying distances between or beyond a first obturator membrane and the contra-lateral obturator membrane of the patient. In certain embodiments the depictedsurgical implant70 does not span the full obturator-to-obturator length of many patients, but, as discussed below, couples to soft tissue anchors via long filaments that attach to the implant. The depictedimplant70 has alateral length72 of between about 5 centimeters and about 8 centimeters. Alternatively, the implant25 can have alonger lateral length72, such as greater than about 7 cm, greater than about 9 cm, or greater than about 10 cm, and thus be sized to span the patient's full obturator-to-obturator length and directly couple to soft tissue anchors that anchor in respective obturator membranes with no intervening filament.
• The depictedimplant70 has an anterior-to-posterior length74 of between about 2.5 centimeters and about 8 centimeters, which allows thesurgical implant70 to extend under and provide hammock-like support to posterior regions of the pelvic region, including, for example, the base of the bladder. In general, thesurgical implant70 can have any desired anterior-to-posterior lengths74 to support other anatomical regions of the pelvic floor. For example,surgical implant70 can have an anterior-to-posterior length74 of between about 0.5 cm and about 2 cm and may be suitable to support one or both of the patient's urethra and bladderneck. Alternatively,surgical implant70 can have an anterior-to-posterior length74 of greater than about 3 cm, greater than about 5 cm, greater than about 7 cm, or greater than about 10 cm to support the patient's urethra, bladderneck, and/or bladder.
• Thesurgical implant70 is a woven mesh and has interstices between constituent fibers in which tissue in-growth can occur. Thesurgical implant70 can be made of a wide variety of materials, and can be treated with a variety of therapeutic materials, which are discussed in more detail in the references cited herein.
• The implants can also be configured to have other desired shapes.FIG. 5 shows a trapezoidal shapedsurgical implant90 similar to theimplant30 ofFIG. 2A, but without extension straps. The depictedsurgical implant90 has aposterior base length92 of between about 8 cm and about 11 cm, ananterior base length94 of between about 5 cm and about 7 cm, and an anterior-to-posterior length96 of between about 5 cm and about 10 cm. Thesurgical implant90 is shaped to have awider posterior region90athananterior region90bbecause theposterior region90aof thesurgical implant90 supports larger posterior anatomical structures, such as the bladder, whereas theanterior region90bof theimplant90 supports smaller anterior anatomical structures, such as the urethra and/or bladderneck.
• As mentioned above, the surgical implants are generally made of mesh materials having interstices that promote tissue in-growth.FIG. 6 illustrates asurgical implant120 that, additionally or alternatively, includes a plurality ofapertures122 that can be of varying sizes and that promote tissue in-growth. This and other exemplary surgical implants are further discussed in U.S. Pat. No. 6,197,036, incorporated herein by reference in its entirety.
• As noted, the mesh surgical implants described above may be woven. The implants may also be protected with a protective cover or sleeve, as described in U.S. patent application Ser. No. 11/202,554, the contents of which are incorporated by reference herein in their entirety, to help prevent the woven implants from unraveling, stretching, and/or otherwise becoming damaged by stresses applied to the implant during delivery. The sleeve covers and protects the implant during delivery of the implant through tissue, and is removed after delivery. Alternatively, the implant may be configured in non-woven arrangements that prevent unraveling, stretching, and/or damaging during delivery and tensioning of the implant.
• FIGS. 7A-14B illustrate various exemplary surgical implants constructed in such a non-woven configuration. In particular,FIG. 7A shows asurgical implant140 having afirst end140a, asecond end140b, a set oflateral strands142, and a set oftransverse strands144, whileFIG. 7B shows a close-up view of theimplant140. Theimplant140 includes attachment points146, wherein thelateral strands142 intersect with and fuse or otherwise fixedly attach to thetransverse strands144, andopenings148 defined by thestrands142 and144 and attachment points146. Theimplant140 can be sized to suit a particular application. For example, the depictedimplant140 has alateral width150 of between about 6 cm and about 11 cm to extend laterally between both of the patient's obturator foramen, and an anterior-to-posterior width153 of between about 0.5 cm and about 2 cm to support the urethra and/or bladderneck.
• As shown inFIG. 7B, in this illustrative embodiment, thelateral strands142 are parallel to thelongitudinal axis158 of the implant, and thetransverse strands144 are substantially perpendicular to thelateral strands142. Thelateral strands142 and thetransverse strands144 can be made of a wide variety of materials, including any of the biocompatible materials described herein or in the references cited herein. Thelateral strands142 and thetransverse strands144 may be made of monofilament fibers and/or multifilament fibers. Thestrands142 and144 may include different respective materials which provides, for example, different tension and/or elasticity along alongitudinal axis158 compared to aperpendicular axis156. In certain embodiments, thelateral strands142 prevent theimplant140 from stretching laterally. In certain configurations, thelateral strands142 and thetransverse strands144 have different respective colors. This may help an operator visually determine the orientation of thesurgical implant140 as he delivers and/or tensions theimplant140.
• As mentioned above, theimplant140 includes attachment points146 wherein thelateral strands142 attach to and intersect with thetransverse strands144. In one embodiment, the attachment is formed by a biocompatible adhesive. Alternatively, the attachment is formed by fusingstrands142 and144. In other embodiments, the attachment of thestrands142 and thestrands144 is formed by molding, stamping, and/or laser cutting.
• Theimplant140 also includesopenings148, defined by thestrands142 and144, that promote tissue in-growth. Theopenings148 may be of substantially similar size and shape. The depictedopenings148 are substantially rectangular, but they may have other shapes, and in certain embodiments are parallelogram-shaped. Theopenings148 may also be of varying sizes and shapes to encourage the formation of varying tissue in-growth patterns along varying regions of theimplant140 according to a medical operator's preference.
• The implants described herein are configured to be secured within soft tissues within the patient's retropubic space. In one aspect, theimplant140 includestanged portions152aand152b, in which thetransverse strands144 extend beyond the span of thelateral strands142 along theperpendicular axis156, and adetanged portion162 in which the length of thetransverse strands144 is substantially equal to the span of thelateral strands142 along theperpendicular axis156. As shown inFIG. 7B, thetanged portions152aand152bare formed from a plurality oftangs160. Thetangs160 interact with surrounding tissue to resist, and optionally prevent, movement of the implant and thereby secure theimplant140 in place until tissue in-growth occurs through theopenings148. For example,tanged portions152aand152bmay be placed directly within obturator foramen, thus securing the implant within the obturator foramen without requiring the use of anchors on the ends of the implant. Each of thetangs160 may extend beyond a span of thelateral strands142 by between about 0.5 mm and about 1 mm, by between about 1 mm and about 2 mm, by between about 2 mm and about 3 mm, by between about 3 mm and about 4 mm, by between about 4 mm and about 5 mm, or by between about 5 mm and about 1 cm. In certain embodiments, thetangs160 are substantially rigid. For example, they may be made of monofilament or multifilament strands with sufficient rigidity to secure theimplant140 to target soft tissue regions without requiring the use of soft tissue anchors.
• Theimplant140 also includes adetanged portion162 in which the length of thetransverse strands144 is substantially equal to the span of thelateral strands142 along theperpendicular axis156. Thedetanged portion162 provides a wide support area for an anatomical structure. In certain implementations, an operator positions thedetanged portion162 under sensitive anatomical structures such as the urethra, bladderneck and/or bladder, while thetanged portions152asecure theimplant140 in place, resulting in lessened irritation to the supported structures.
• In one exemplary technique, a manufacturer forms theimplant140 by first attaching thestrands142 and144 using one or more attachment methods described above, then forming the tanged portions152a-b, and then forming thedetanged portion162. To form the tanged portions152a-b, the manufacturer first manufactures theimplant140 with two additional lateral strands, depicted by dashedlines142aand142b, that are configured as the outermost strands in the set oflateral strands142. The manufacturer then shortens thetransverse strands144 to the outerlateral strands142aand142band removes the outerlong strands142aand142bto expose thetangs160. Thetangs160 are thus extremities of thetransverse strands144 that make up theimplant140, and theimplant144 and itsstrands144 withtangs160 form a unitary body. In one exemplary method, thetransverse strands144 are shortened by heat melting, and in others they are shortened by trimming or cutting. Next, to form thedetanged portion162, a manufacturer heat melts, cuts, trims, or otherwise shortens thetransverse strands144 to theoutermost strands142cand142dof the remaininglateral strands142. Because thestrands142 and144 are individually attached, thestrands142 and144 can be cut as desired without causing the implant to unravel.
• The tanged and untanged portions of an implant can be sized to achieve a desired anatomical fit and to reduce the level of invasiveness caused by implantation.FIGS. 8A and 8B show theimplant140 ofFIGS. 7A and 7B with thetanged portions152aand152bhaving been narrowed along theperpendicular axis156 by cutting or otherwise shortening the tanged portions152a-bto reduce the delivery profile of theimplant140. A delivery profile refers to the maximum cross-sectional area of a passageway through the patient's anatomy that is required for delivery of theimplant140. The delivery profile may be effected by one or more of a number of factors, including the diameter of the delivery needles, shafts, and/or dilators, implant width, and protective sleeve width.
• Smaller delivery profiles can be beneficial because they may result in less invasive implant delivery procedures. An implant having the smaller profile illustrated in FIGS.8A-B may be delivered using a delivery device with smaller dimensions, such as a smaller shaft or needle, which may reduce trauma to the patient and damage less tissue. However, implants with larger profiles, such asimplant140 as shown inFIGS. 7A and 7B, may more securely anchor within the patient's anatomy and provide an operator with more control during delivery, and the operator can select an implant having a delivery profile that is suitable for the patient. The anterior-to-posterior width of thedetanged portion162 has not been narrowed and thus provides a wide support area for an anatomical structure.
• FIG. 9 shows an alternative implant embodiment with a still further reduced delivery profile. As shown each of thetanged portions152aand152bincludes a singlelateral strand170 havingend portions170aand170b. The tangs are formed fromtransverse strands172 attached to thelateral strand170 in a perpendicular orientation. In one exemplary application, an operator uses a delivery device with a fork-shaped tip to deliver, position, and/or adjust the placement of theimplant140. The operator interfits the prongs of the fork-shaped tip around the long strand nearend portion170a, for example, atregions174aand174b. The fork-shaped tip abuts one of the transverse strands172aand the operator pulls or drags theimplant140 in a desired direction. In this embodiment, if one or both of thetanged portions152aand152btwist about thelongitudinal axis158 during delivery or placement, tissue in-growth in surrounding tissue regions may be substantially unaffected. Thus, the operator does not need to prevent twisting of theimplant140 during delivery.
• The implants may also be shaped as needed to achieve desired elasticity and elongation properties.FIG. 10 shows anexemplary implant180 havinglateral strands182 andtransverse strands184,tanged portions186aand186band anon-tanged portion188. Theimplant180 is similar to implant140 ofFIG. 7A, except that thetransverse strands184 are oriented at an opposing andnon-perpendicular angle190 with respect to thelateral strands182, so that theimplant180 includesopenings192 that are substantially diamond shaped. Orienting thetransverse strands184 in this manner allows theimplant180 to stretch in thetransverse direction194 without damaging theimplant60. More particularly, during implantation or use, when transverse stress or tension is applied along the anterior-to-posterior width194, thetransverse strands184 shift and orient themselves perpendicularly to thelateral strands182. This increases the anterior-to-posterior width194 which allows theimplant180 to absorb the transverse stress without damaging theimplant180.
• FIG. 11A illustrates an exemplary extrusion technique for constructing asurgical implant210 similar tosurgical implant180 ofFIG. 10, andFIG. 11B illustrates a block diagram of the technique. In the technique, a manufacturer first extrudes and fuses two sets of strands, and then cuts the resulting structure to size and shape theimplant210.
• More particularly, a manufacturer first extrudes the first set of strands212 (step230) at a first angle with respect to thelongitudinal axis214. To do so, in one implementation, the manufacturer pushes and/or draws a feedstock of the implant material through an extrusion die that includes respective apertures for each of the first set ofstrands212. The apertures are arranged in a circular configuration and oriented at the first angle with respect to thelongitudinal axis214 so that the first set of strands form a tube of parallel strands.
• Next, the manufacturer extrudes a second set of strands216 (step232) at a second angle with respect to thelongitudinal axis214. To do so, in one implementation, the manufacturer pushes and/or draws a feedstock of the implant material through a second extrusion die that includes respective apertures for each of the second set ofstrands216. These apertures are also arranged in a circular configuration and oriented at the second angle with respect to thelongitudinal axis214, so that the second set of strands forms a tube of parallel strands and intersects with the first set ofstrands212 at a plurality of attachment points218. The manufacturer then fuses the first set ofstrands212 to the second set of strands216 (step234) at the attachment points218, and thus forms a substantially continuous tube.
• Next, the manufacturer cuts theimplant210 to an appropriate length along longitudinal axis214 (step235) and cuts theimplant210 longitudinally along one lateral wall of the tube (step236) to open the tube into a flat shape. In certain embodiments, the cuts in the lateral wall allow the first set ofstrands212 or the second set ofstrands216 to be oriented parallel to thelongitudinal axis214 of the implant. This results in a configuration similar to that shown inFIG. 10, where thelong strands182 are parallel to the longitudinal axis181 of theimplant180. As mentioned, such an orientation helps reduce stretching in the lateral direction during delivery of theimplant210. In other embodiments, the number of strands is increased or decreased to alter the diameter of the tubular shape in order to vary the size of the final configuration of the implant. Finally, the operator optionally cuts the implant to a desired size and shape (step238), and optionally forms tangs as described above (step240). The operator may also optionally couple the implant to one or more soft tissue anchors, as described herein.
• The implants described above in relation toFIGS. 7A-11B include two sets of strands, which in the illustrated embodiments include a first set of long strands and a second set of short strands. In alternative embodiments, additional sets of strands may be included to provide additional strength, tension, or elasticity properties.FIG. 12 illustrates a portion of any exemplarysurgical implant250 having three sets of strands—a firsttransverse set252, a second lateral set254, and a thirdcross-oriented set256. The strands within each set are substantially parallel and in certain embodiments lie in different respective layers. Each layer is oriented at a different angle with respect to thelongitudinal axis257 and is fixedly attached to at least one other layer. As shown, the strands of each ofsets252,254, and256 attach to strands in one or both of the other two sets to form a plurality of intersection points258 having strands of two or more of the sets fused, melted, or otherwise attached using methods discussed above.
• The implants described with respect toFIGS. 7A-12 are sized and shaped to support anatomical structures such as the urethra and/or the bladderneck of the patient. Similarly constructed implants can be sized and shaped to support other anatomical structures and extend to other pelvic regions.FIG. 13 illustrates asurgical implant280 constructed similar to theimplant140 ofFIG. 7A, but sized and shaped similar to theimplant70 ofFIG. 4. In particular, theimplant280 has a longer anterior-to-posterior length282 than does implant140, which allows theimplant280 to support posterior regions of the pelvic region, such as tissue regions posterior to the patient's bladderneck and under the base of the patient's bladder. Additionally, the depictedsurgical implant280 has asmaller lateral length284 than the lateral length of thesurgical implant140 ofFIG. 7A, such that theimplant280 does not span the full obturator-to-obturator length of the patient. Instead, as discussed below, thesurgical implant280 couples to soft tissue anchors that are spaced from theimplant280 bylong filaments286 which span the remainder of the obturator-to-obturator length when the soft tissue anchors anchor to respective obturator membranes. Although not shown, one or more of the edges ofsurgical implant280 may include tangs as described above. In any of the exemplary embodiments, tangs are optional, particularly when soft tissue anchors are used to anchor the surgical implants to respective obturator membranes.
• FIGS.14A-B illustrate exemplary alternativesurgical implants300 and310 that are sized and shaped to extend to posterior regions of the pelvic floor and to support anatomical structures such as the bladder. Theimplant310 depicted inFIG. 14B is sized and shaped similar to theimplant60 ofFIG. 3, but is manufactured according to the non-woven configuration described above in connection withFIGS. 7A-12. Theillustrative implant300 inFIG. 14A is circular and has acenter302, a first set ofstrands304 formed as concentric circles of increasing radii aboutcenter302, and a second set ofstrands306 that extend radially from thecenter302. Theimplant300 includestangs308, but in alternative embodiments, portions of the implant may be detanged as described above.
• In one exemplary manufacturing technique, a manufacturer selectively removes portions of thesurgical implant300 depicted inFIG. 14A to construct thesurgical implant310 ofFIG. 14B. In particular, portions303a-303dare removed by cutting, trimming, melting, laser cutting, or using other like methods. The removal of the portions303a-303dshortens some of theradial strands306a-306dand, optionally leaves them detanged. Similarly, the removal of portions303a-303dleaves the concentriccircular strands304 insegments304a-304d, which are depicted as being tanged. The resultingimplant310 thus includes acentral untanged portion314 with multiple radially extending tanged extensions316a-d. The depicted centraluntanged portion314 is circular for supporting various anatomical structures including, for example, the base of the bladder. The radially extending tanged portions316a-dcan extend to and anchor to respective obturator membranes either alone or in combination with soft tissue anchors, as will be discussed below.
• The implants discussed above generally lie flat when not in use. However, in one aspect, the implants described herein may be pre-shaped to curve and fit around desired anatomical locations. For example,FIG. 15A shows animplant320 that is sized and pre-shaped to fit under and support a urethra and/or a bladderneck. Theimplant320 includes anindented portion322 that is designed to interfit under the bladderneck and/or the urethra, to impede theimplant320 from exerting excessive stress on the bladderneck and/or urethra.
• In one exemplary technique, theindented portion322 is formed by gathering and compressing theportion322 of theimplant320 using aclip324 shown inFIG. 15B that is aligned along the anterior-to-posterior direction328 of theimplant320. In particular, the operator squeezes together levers326aand326band opens theclip324, then places theportion322 of theimplant320 in theclip324, releases thelevers326aand326bto close the clip, and then folds theends320aand320boverrespective levers326aand326b. After waiting for a sufficient period of time for theimplant320 to maintain its folded configuration upon removal of theclip324, the operator opens the clip and releases theimplant320, which is then shaped as illustrated inFIG. 15A.
• Larger pelvic floor implants described above, including those sized and shaped to extend to and support a patient's bladder, can be similarly pre-shaped usinglarger clips324, or by usingmultiple clips324 or multiple uses of asingle clip324 at various locations along theimplant320. The depictedindented portion322 extends in the anterior-to-posterior direction328, but in other implementations theindented portion322 may also extend in alateral direction330. This can be done by, after forming theindented portion322 as described above, gathering and compressing a portion of theimplant320 with theclip324 aligned along thelateral direction330 of theimplant320.
• The implants described above can be constructed from a variety of materials. There are many possible mesh materials, and the implant may, in the alternative or in combination, be made of other types of materials. Exemplary mesh materials include, for example, synthetic materials, natural materials (e.g., biological) or a combination thereof. The mesh may be fabricated from any of a number of biocompatible materials, such as nylon, silicone, polyethylene, polyester, polyethylene, polyimide, polyurethane, polypropylene, fluoropolymers, copolymers thereof, combinations thereof, or other suitable synthetic material(s). The material may be, for example, a biodegradable synthetic material. The term “biodegradable,” as used herein, refers to the property of a material that dissolves in the body. Such materials may also be absorbed into the body, i.e., bioabsorbable.
• Suitable bioabsorbable synthetic materials include, without limitation, polylactic acid (PLA), polyglycolic acid (PGA), poly-L-lactic acid (PLLA), human dermis and decellularized animal tissue. Human tissues may be derived, for example, from human cadaveric or engineered human tissue. Animal tissues may be derived, for example, from porcine, ovine, bovine, and equine tissue sources. The material may be an omnidirectional material, a material that has equivalent tensile strength from any direction, such as pericardium or dermis. Alternatively, the material may be an oriented material, a material that has a single direction where the tensile strength of the material is the highest. Oriented materials may include rectus fascia and/or facia lata, as well as oriented synthetic materials.
• Exemplary biodegradable polymers, which may be used to form the tubular mesh100, in addition to those listed above, include, without limitation, polylactic acid, polyglycolic acid and copolymers and mixtures thereof, such as poly(L-lactide) (PLLA), poly(D,L-lactide) (PLA), polyglycolic acid [polyglycolide (PGA)], poly(L-lactide-co-D,L-lactide) (PLLA/PLA), poly(L-lactide-co-glycolide) (PLLA/PGA), poly(D,L-lactide-co-glycolide) (PLA/PGA), poly(glycolide-co-trimethylene carbonate) (PGA/PTMC), poly(D,L-lactide-co-caprolactone) (PLA/PCL), and poly(glycolide-co-caprolactone) (PGA/PCL); polyethylene oxide (PEO); polydioxanone (PDS); polypropylene fumarate; polydepsipeptides, poly(ethyl glutamate-co-glutamic acid), poly(tert-butyloxy-carbonylmethyl glutamate); polycaprolactone (PCL), poly(hydroxy butyrate), polycaprolactone co-butylacrylate, polyhydroxybutyrate (PHBT) and copolymers of polyhydroxybutyrate; polyphosphazenes, poly(phosphate ester); maleic anhydride copolymers, polyiminocarbonates, poly[(97.5% dimethyl-trimethylene carbonate)-co-(2.5% trimethylene carbonate)], cyanoacrylate, hydroxypropylmethylcellulose; polysaccharides, such as hyaluronic acid, chitosan, alginates and regenerate cellulose; poly(amino acid) and proteins, such as gelatin and collagen; and mixtures and copolymers thereof.
• The systems, devices and methods described herein may be combined with other techniques for treating UI and/or pelvic floor disorders. For example, while the implants described herein are suitable for use in the single vaginal incision procedure, such implants may also be used in multi-incision procedures such as those described in US Patent Publications 2005/0245787, 2005/0250977, 2005/0075660, U.S. Pat. No. 6,911,003, and other systems. In certain implementations, the meshes used to support the urethra and/or pelvic organs may, either as a whole or on a fiber-by-fiber basis, include an agent for release into the patient's tissues. One illustrative agent is a tissue growth factor that promotes, when applied to the patient's tissues in a pharmaceutically acceptable amount, well-organized collagenous tissue growth, such as scar tissue growth, preferably, in large quantities. According to one feature, the agent may or may not block or delay the dissolvability of the biodegradable materials. This may be controlled by selecting differing methods for loading the agent onto the implant. The tissue growth factor may include natural and/or recombinant proteins for stimulating a tissue response so that collagenous tissue such as scar tissue growth is enhanced. Exemplary growth factors that may be used include, but are not limited to, platelet-derived growth factor (PDGF), fibroblast growth factor (FGF), transforming growth factor-beta (TGF-beta), vascular endothelium growth factor (VEGF), Activin/TGF and sex steroid, bone marrow growth factor, growth hormone, Insulin-like growth factor 1, and combinations thereof. The agent may also include a hormone, including but not limited to estrogen, steroid hormones, and other hormones to promote growth of appropriate collagenous tissue such as scar tissue. The agent may also include stem cells or other suitable cells derived from the host patient. These cells may be fibroblast, myoblast, or other progenitor cells to mature into appropriate tissues. Besides applying active pharmaceutical agents, passive agents may be applied to promote tissue in-growth. For example, titanium sputtering or chrome sputtering can be used.
• In various illustrative embodiments, the agent may include one or more therapeutic agents. The therapeutic agents may be, for example, anti-inflammatory agents, including steroidal and non-steroidal anti-inflammatory agents, analgesic agents, including narcotic and non-narcotic analgesics, local anesthetic agents, antispasmodic agents, growth factors, gene-based therapeutic agents, and combinations thereof.
• Exemplary steroidal anti-inflammatory therapeutic agents (glucocorticoids) include, but are not limited to, 21-acetoxyprefnenolone, aalclometasone, algestone, amicinonide, beclomethasone, betamethasone, budesonide, chloroprednisone, clobetasol, clobetasone, clocortolone, cloprednol, corticosterone, cortisone, cortivazol, deflazacort, desonide, desoximetasone, dexamethasone, diflorasone, diflucortolone, difluprednate, enoxolone, fluazacort, flucloronide, flumehtasone, flunisolide, fluocinolone acetonide, fluocinonide, fluocortin butyl, fluocortolone, fluorometholone, fluperolone acetate, fluprednidene acetate, fluprednisolone, flurandrenolide, fluticasone propionate, formocortal, halcinonide, halobetasol priopionate, halometasone, halopredone acetate, hydrocortamate, hydrocortisone, loteprednol etabonate, mazipredone, medrysone, meprednisone, methyolprednisolone, mometasone furoate, paramethasone, prednicarbate, prednisolone, prednisolone 25-diethylaminoacetate, prednisone sodium phosphate, prednisone, prednival, prednylidene, rimexolone, tixocortal, triamcinolone, triamcinolone acetonide, triamcinolone benetonide, triamcinolone hexacetonide, and pharmaceutically acceptable salts thereof.
• Exemplary non-steroidal anti-inflammatory therapeutic agents include, but are not limited to, aminoarylcarboxylic acid derivatives such as enfenamic acid, etofenamate, flufenamic acid, isonixin, meclofenamic acid, mefanamic acid, niflumic acid, talniflumate, terofenamate and tolfenamic acid; arylacetic acid derivatives such as acemetacin, alclofenac, amfenac, bufexamac, cinmetacin, clopirac, diclofenac sodium, etodolac, felbinac, fenclofenac, fenclorac, fenclozic acid, fentiazac, glucametacin, ibufenac, indomethacin, isofezolac, isoxepac, lonazolac, metiazinic acid, oxametacine, proglumetacin, sulindac, tiaramide, tolmetin and zomepirac; arylbutyric acid derivatives such as bumadizon, butibufen, fenbufen and xenbucin; arylcarboxylic acids such as clidanac, ketorolac and tinoridine; arylpropionic acid derivatives such as alminoprofen, benoxaprofen, bucloxic acid; carprofen, fenoprofen, flunoxaprofen, flurbiprofen, ibuprofen, ibuproxam, indoprofen, ketoprofen, loxoprofen, miroprofen, naproxen, oxaprozin, piketoprofen, pirprofen, pranoprofen, protizinic acid, suprofen and tiaprofenic acid; pyrazoles such as difenamizole and epirizole; pyrazolones such as apazone, benzpiperylon, feprazone, mofebutazone, morazone, oxyphenbutazone, phenybutazone, pipebuzone, propyphenazone, ramifenazone, suxibuzone and thiazolinobutazone; salicylic acid derivatives such as acetaminosalol, aspirin, benorylate, bromosaligenin, calcium acetylsalicylate, diflunisal, etersalate, fendosal, gentisic acid, glycol salicylate, imidazole salicylate, lysine acetylsalicylate, mesalamine, morpholine salicylate, 1-naphthyl salicylate, olsalazine, parsalmide, phenyl acetylsalicylate, phenyl salicylate, salacetamide, salicylamine o-acetic acid, salicylsulfuric acid, salsalate and sulfasalazine; thiazinecarboxamides such as droxicam, isoxicam, piroxicam and tenoxicam; others such as ε-acetamidocaproic acid, s-adenosylmethionine, 3-amino-4-hydroxybutyric acid, amixetrine, bendazac, benzydamine, bucolome, difenpiramide, ditazol, emorfazone, guaiazulene, nabumetone, nimesulide, orgotein, oxaceprol, paranyline, perisoxal, pifoxime, proquazone, proxazole and tenidap; and pharmaceutically acceptable salts thereof.
• Exemplary narcotic analgesic therapeutic agents include, but are not limited to, alfentanil, allylprodine, alphaprodine, anileridine, benzylmorphine, bezitramide, buprenorphine, butorphanol, clonitazene, codeine, codeine methyl bromide, codeine phosphate, codeine sulfate, desomorphine, dextromoramide, dezocine, diampromide, dihydrocodeine, dihydrocodeinone enol acetate, dihydromorphine, dimenoxadol, dimepheptanol, dimethylthiambutene, dioxaphetyl butyrate, dipipanone, eptazocine, ethoheptazine, ethylmethylthiambutene, ethylmorphine, etonitazene, fentanyl, hydrocodone, hydromorphone, hydroxypethidine, isomethadone, ketobemidone, levorphanol, lofentanil, meperidine, meptazinol, metazocine, methadone hydrochloride, metopon, morphine, myrophine, nalbuphine, narceine, nicomorphine, norlevorphanol, normethadone, normorphine, norpipanone, opium, oxycodone, oxymorphone, papaveretum, pentazocine, phenadoxone, phenazocine, pheoperidine, piminodine, piritramide, proheptazine, promedol, properidine, propiram, propoxyphene, rumifentanil, sufentanil, tilidine, and pharmaceutically acceptable salts thereof.
• Exemplary non-narcotic analgesic agents that may be combined with the implants of the invention include, but are not limited to, aceclofenac, acetaminophen, acetaminosalol, acetanilide, acetylsalicylsalicylic acid, alclofenac, alminoprofen, aloxiprin, aluminum bis(acetylsalicylate), aminochlorthenoxazin, 2-amino-4-picoline, aminopropylon, aminopyrine, ammonium salicylate, amtolmetin guacil, antipyrine, antipyrine salicylate, antrafenine, apazone, aspirin, benorylate, benoxaprofen, benzpiperylon, benzydamine, bermoprofen, brofenac, p-bromoacetanilide, 5-bromosalicylic acid acetate, bucetin, bufexamac, bumadizon, butacetin, calcium acetylsalicylate, carbamazepine, carbiphene, carsalam, chloralantipyrine, chlorthenoxazin(e), choline salicylate, cinchophen, ciramadol, clometacin, cropropamide, crotethamide, dexoxadrol, difenamizole, diflunisal, dihydroxyaluminum acetylsalicylate, dipyrocetyl, dipyrone, emorfazone, enfenamic acid, epirizole, etersalate, ethenzamide, ethoxazene, etodolac, felbinac, fenoprofen, floctafenine, flufenamic acid, fluoresone, flupirtine, fluproquazone, flurbiprofen, fosfosal, gentisic acid, glafenine, ibufenac, imidazole salicylate, indomethacin, indoprofen, isofezolac, isoladol, isonixin, ketoprofen, ketorolac, p-lactophenetide, lefetamine, loxoprofen, lysine acetylsalicylate, magnesium acetylsalicylate, methotrimeprazine, metofoline, miroprofen, morazone, morpholine salicylate, naproxen, nefopam, nifenazone, 5′ nitro-2′ propoxyacetanilide, parsalmide, perisoxal, phenacetin, phenazopyridine hydrochloride, phenocoll, phenopyrazone, phenyl acetylsalicylate, phenyl salicylate, phenyramidol, pipebuzone, piperylone, prodilidine, propacetamol, propyphenazone, proxazole, quinine salicylate, ramifenazone, rimazolium metilsulfate, salacetamide, salicin, salicylamide, salicylamide o-acetic acid, salicylsulfuric acid, salsalte, salverine, simetride, sodium salicylate, sulfamipyrine, suprofen, talniflumate, tenoxicam, terofenamate, tetradrine, tinoridine, tolfenamic acid, tolpronine, tramadol, viminol, xenbucin, zomepirac, and pharmaceutically acceptable salts thereof.
• Exemplary local anesthetic therapeutic agents include, but are not limited to, ambucaine, amolanone, amylocalne hydrochloride, benoxinate, benzocaine, betoxycaine, biphenamine, bupivacaine, butacaine, butaben, butanilicaine, butethamine, butoxycaine, carticaine, chloroprocaine hydrochloride, cocaethylene, cocaine, cyclomethycaine, dibucaine hydrochloride, dimethisoquin, dimethocaine, diperadon hydrochloride, dyclonine, ecgonidine, ecgonine, ethyl chloride, beta-eucaine, euprocin, fenalcomine, fomocaine, hexylcaine hydrochloride, hydroxytetracaine, isobutyl p-aminobenzoate, leucinocaine mesylate, levoxadrol, lidocaine, mepivacaine, meprylcaine, metabutoxycaine, methyl chloride, myrtecaine, naepaine, octacaine, orthocaine, oxethazaine, parethoxycaine, phenacaine hydrochloride, phenol, piperocaine, piridocaine, polidocanol, pramoxine, prilocalne, procaine, propanocaine, proparacaine, propipocaine, propoxycaine hydrochloride, pseudococaine, pyrrocaine, ropavacaine, salicyl alcohol, tetracaine hydrochloride, tolycaine, trimecaine, zolamine, and pharmaceutically acceptable salts thereof.
• Exemplary antispasmodic therapeutic agents include, but are not limited to, alibendol, ambucetamide, aminopromazine, apoatropine, bevonium methyl sulfate, bietamiverine, butaverine, butropium bromide, n-butylscopolammonium bromide, caroverine, cimetropium bromide, cinnamedrine, clebopride, coniine hydrobromide, coniine hydrochloride, cyclonium iodide, difemerine, diisopromine, dioxaphetyl butyrate, diponium bromide, drofenine, emepronium bromide, ethaverine, feclemine, fenalamide, fenoverine, fenpiprane, fenpiverinium bromide, fentonium bromide, flavoxate, flopropione, gluconic acid, guaiactamine, hydramitrazine, hymecromone, leiopyrrole, mebeverine, moxaverine, nafiverine, octamylamine, octaverine, oxybutynin chloride, pentapiperide, phenamacide hydrochloride, phloroglucinol, pinaverium bromide, piperilate, pipoxolan hydrochloride, pramiverin, prifinium bromide, properidine, propivane, propyromazine, prozapine, racefemine, rociverine, spasmolytol, stilonium iodide, sultroponium, tiemonium iodide, tiquizium bromide, tiropramide, trepibutone, tricromyl, trifolium, trimebutine, n,n-ltrimethyl-3,3-diphenyl-propylamine, tropenzile, trospium chloride, xenytropium bromide, and pharmaceutically acceptable salts thereof.
• Having described various surgical implants sized, shaped, and constructed for UI and/or pelvic floor repair, and exemplary methods of construction, we next describe soft tissue anchors that may optionally be used to secure the surgical implants to a desired anatomical location, such as obturator membranes, and methods for coupling the soft tissue anchors to the surgical implants. In use, as mentioned above, the surgical implants are inserted and positioned in a desired location within the pelvic region of the patient through a single incision in the patient's vaginal wall and then anchored to soft tissue regions such as obturator membranes.
• In general, soft tissue anchors are biocompatible structures that are fixed to or interoperationally connected to an implant and are adjusted to anchor to patient's pelvic tissue. In certain embodiments, the soft tissue anchors are sling housings directly formed and/or fitted as end terminations around ends of the implant, and in others the soft tissue anchors and the implant are separate elements that can be assembled to form an implant assembly. Moreover, the anchors may be directly coupled to a surgical implant, or indirectly coupled to the implant via, for example, filaments or rings that space the anchors away from the surgical implant. The soft tissue anchors may adjustably couple to the surgical implant to allow an operator to tension the implant after anchoring in the patient. The soft tissue anchors can include barbs that anchor to the obturator membrane, or can be smooth, in which case the operator positions the anchor to act as a mechanical stop and prevent disengagement from the obturator membrane. The soft tissue anchors may also be bioabsorbable and absorb into surrounding tissue after being implanted into the pelvic region of the patient.
• FIGS. 16A-16C depict animplant assembly400 having soft tissue anchors that are configured as housings around ends of asurgical implant401 to anchor the implant and couple the implant with delivery devices.
• More particularly as shown inFIG. 16A, theimplant assembly400 includeshousings402 and404 which are end terminations formed and/or fitted around the end of themesh implant401 that taper away from the end of theimplant401 about which they are formed and/or fitted. Theend termination402 includes a ring oraperture416 and first andsecond legs412 and414 that extend radially from theaperture416. Theaperture416 is sized and shaped to engage with a delivery device, such as, for example, the distal end of a shaft, needle or dilator of any of the delivery devices described below. Theassembly400 also includes anend termination404 that is similar to endtermination402. In particular,end termination404 includeslegs406 and408 extending radially fromaperture410. In operation, an operator places the aperture416 (or410) over the tip of a delivery device shaft and slides theaperture416 down the tip until theaperture416 abuts against a step, shoulder, or other stopping mechanism, as will be discussed in more detail below. Theapertures410 and416 include inner surfaces410aand416athat, in certain embodiments, are tapered to inter-fit with the tip of a delivery device.
• The depictedapertures410 and416 are coplanar with theimplant401. As a result, theimplant assembly400 has a low delivery profile. As mentioned above, a delivery profile refers to the maximum cross-sectional area of a passageway through the patient's anatomy that is required for placement of the implant, and smaller delivery profiles are beneficial at least in part because they may reduce tissue damage during implant delivery. Moreover,apertures410 and416 may be any shape, including square, triangular, oval, or other preferred shapes. Theapertures410 and416 may also be any size, and in particular may be configured to couple with shafts or needles of varying dimensions.
• The legs on theend termination402 and404 are sized and shaped to engage with and attach to theimplant401 to help anchor theimplant401 inside the patient. More particularly, referring to theend termination402, thelegs412 and414 extend radially from therespective aperture416 and adjoin atangle418. In certain embodiments, theend termination402 is flexible such that theangle418 can be increased or decreased upon application of appropriate mechanical pressure. By way of example, if theimplant401 passes through tissue in aforward direction420, thelegs412 and414 interact with the tissue to reduce theangle418. If theimplant401 passes through tissue in aretrograde direction422, thelegs412 and414 are pushed outward by the tissue to increase theangle418. The varyingangle418 thus facilitates movement of theimplant401 in theforward direction420, and impedes movement of themesh strap401 in theretrograde direction422. In certain embodiments, theangle418 can vary from between about 0 degrees to about 90 degrees, and in other embodiments can vary to more than about 90 degrees. Theangle418 formed between thelegs412 and414 can vary, as can the flexibility of theend termination402. These properties are generally chosen to suit the particular delivery path and location for anchoring the implant, as well as the condition being treated.
• Additionally, the V-shaped configuration oflegs412 and414 acts to engage with patient tissue to resist removal once theimplant assembly400 is implanted. The depictedlegs412 and414 extend beyond thewidth401aofimplant401 to provide additional engagement with tissue, but in other illustrative embodiments may be of any length, and may not extend beyond thewidth401aof theimplant401. The features described herein with regard to endtermination402 may also apply to endtermination404.
• The end termination may be connected to the implant by gluing, stapling, soldering, molding, or other methods.FIG. 16B shows an embodiment in which theend terminations402 and404 are molded to theimplant401. In an exemplary manufacturing technique, a manufacturer inserts anend401bof theimplant401 into a mold (not shown) that has passages or cavities shaped like end termination402 (i.e., including cavities shaped likering416 and legs412 and414). Next, the manufacturer injects a curable material, such as a curable biocompatible plastic, into the mold. After the curable material cures, the manufacturer decouples the mold and theimplant401, and then trims, melts, or otherwise removesexcess molding material419. The process is repeated for theother side401cof theimplant401 to formend termination404, the manufacturer then trims, melts, or otherwise removesexcess mesh corners401d,401e,401f, and401gof theimplant401.
• FIG. 17 illustrates an end termination similar to theend terminations402 and404, but which does not need to be molded directly on an implant. This end termination includes atop piece420 and abottom piece422. Thebottom piece422 includes twolegs424 and426 that form a V-shape and anaperture428 located between the V-shapedlegs424 and426. Thetop piece420 is shaped to align with thebottom piece422, and in particular includes twolegs429 and430 that form a V-shape and anaperture432 located between the V-shapedlegs429 and430. Thetop piece420 further includes a plurality of apertures or cavities (not shown) that align with a plurality ofprojections434 that are designed to interfit within the apertures or cavities. In operation, a manufacturer secures animplant401 between thetop piece420 and thebottom piece422 by disposing an end of theimplant401bbetween thetop piece420 and thebottom piece422. Theprojections434 pass through interstitial spaces between filaments of theimplant401 and snap-fit into the corresponding apertures or cavities (not shown) in thetop piece420. In addition to or as an alternative to using theprojections434 and the corresponding apertures or cavities, a manufacturer may secure thetop piece420 and thebottom piece422 by gluing, heat-bonding, molding, or otherwise attaching thetop piece420 and thebottom piece422 to each other and/or to theimplant401.
• In alternative configurations, the end terminations are provided without radially extending legs.FIG. 18 shows animplant assembly440 including animplant442 and twoend terminations444 and446 formed as respective apertures with no legs. A manufacturer affixesend terminations444 and446 to theimplant442 using any of the methods described above. In the depictedimplant assembly440, the corners of theimplant442 are trimmed atlocations442a,442b,442c, and442d.
• FIGS. 19A and 19B show analternative end termination450 that is flexible and made of a softer material, such as a soft durometer biocompatible material, than the previously described end terminations. Theend termination450 can couple to a surgical implant using any of the methods described herein with respect to other end termination embodiments. As shown inFIG. 19A, theend termination450 includes anaperture452, afirst leg454, and asecond leg456. Thefirst leg454 and thesecond leg456 form a V-shape, and theaperture452 lies in a plane that is perpendicular to the plane extending through the first andsecond legs454 and456. This perpendicular orientation results in the distal end of theshaft458 aligning with the implant (not shown), and may be preferred by an operator for delivery of an implant. Since theend termination450 is made of a relatively soft material, thering452 is in a collapsed state when theend termination450 is at rest, as shown inFIG. 19A. In use, an operator couples theend termination450 to a delivery device (not shown) by sliding theaperture452 around ashaft458 of the delivery device as depicted inFIG. 19B. Theaperture452 expands as theshaft458 is pushed within theaperture452, expanding theaperture452 into a substantially circular configuration. The operator delivers theend termination450 to a target tissue region, and retracts theshaft458 to decouple theshaft458 from theend termination450. After the operator retracts theshaft458, theaperture452 returns to the collapsed state illustrated inFIG. 19A. The collapsed state provides a lower profile for theend termination450 after theend termination450 is implanted. As mentioned above, low profile implant assemblies may lessen damage to surrounding tissues.
• FIG. 20 shows another embodiment of animplant assembly460 having alternative lowprofile end terminations463 and464 that lie substantially in the plane of theimplant466.End termination464 includes a tab shapedregion468, anaperture470 disposed within the tab shapedregion468, andlegs472 and474 extending radially from theaperture470. The depictedaperture470 is small (i.e., in certain embodiments having a diameter of less than about 2 mm), and is sized to couple with a narrow needle of a delivery device. In other embodiments, theaperture470 is sized to allow an operator to thread a filament therethrough. The filament may couple to a separate soft tissue anchor as described in connection with other embodiments herein. Similar to the legs described in connection withFIG. 16A above, thelegs472 and474 anchor theimplant466 to soft tissue. In an exemplary manufacturing technique, a manufacturer dips theimplant466 in a curable plastic to form theend termination468. The manufacturer then trims the plastic to create thetab shape468 and theoptional legs472 and474, and punches a hole through the plastic to create theaperture470. However, in alternative embodiments, the manufacturer may pre-form theend termination464 and subsequently snap-fit, glue, stitch, or otherwise attach it to theimplant466.
• Alternative end termination463 also includes a tab-shapedregion473 but does not include an aperture. Instead, endtermination463 includes aconical projection475. Theconical projection475 is designed to interfit about the distal end of a delivery device shaft, such as theneedle477. In operation, an operator interfits theneedle477 with theprojection475 and drags theimplant466 towards a target tissue region. Theprojection475 need not be conical, and in certain embodiments it is pyramidal.
• As mentioned above, in certain embodiments, the soft-tissue anchors and the implant are separate elements that are assembled as an implant assembly. FIGS.21A-D illustrate exemplary barbed soft tissue anchors that can be used for this purpose. InFIG. 21A, theanchor500 includes a through-aperture502, abody504 and two rows of radial projections, orbarbs506. The through-aperture502 couples to a shaft of a delivery device by fitting around the shaft, as will be discussed below. The depicted through-aperture502 extends axially entirely through thebody504 of theanchor500. In other embodiments, thebody504 includes a passage extending axially from theproximal end500bof theanchor500 only part way to thedistal end500aof theanchor500.
• Thebarbs506 are relatively short (e.g., less than about 2 millimeters in length) and relatively wide (e.g., between about 1 millimeter and about 2 millimeters in width/diameter). Additionally, they have relatively flat terminal ends508. Thebarbs506 are also flexible. When an operator inserts theanchor500 into an obturator membrane, thebarbs506 flex and compress against thebody504 of theanchor500 to allow passage at least partially through the obturator membrane. After insertion within the obturator membrane, thebarbs506 expand radially from thebody504 and thereby resist retrograde motion back through the obturator membrane, thereby impeding theanchor500 from disengaging from the obturator membrane.
• FIG. 21B shows an alternative embodiment of ananchor510, having a through-aperture512, abody514 and two rows ofradial projections516. Theprojections516 are relatively long (e.g., greater than or equal to about 2 millimeters in length) and relatively wide (e.g., between about 1 millimeter and about 2 millimeters in width/diameter), as compared withanchor500 ofFIG. 21A.
• FIG. 21C shows another embodiment of ananchor520 having abody522, an axially extending through-aperture524 andradial projections526. Theanchor520 is similar toanchors500 and510 ofFIGS. 21A and 21B, respectively, except that theradial projections526 have pointed rather than flat terminal ends, in contrast to theprojections506 and516. The pointedprojections526 impede retrograde forces that may be applied to theanchor520, since theprojections526 more firmly incise into and engage with the tissue of the obturator membrane and thereby prevent disengagement of theanchor520 from the obturator membrane. In particular, the projections have an initial width at a base530 comparable to the width of theprojections506 and516, and have a length similar to that of theprojections506.
• FIG. 21D shows anotherillustrative anchor540, including a relatively long (e.g., between about 2.5 centimeters and about 3.5 centimeters)body542 and five rows of relatively long (e.g., greater than about 5 millimeters)radial projections544. As in the case of the above described examples, theanchor540 includes a radially extending through-passage546.
• FIG. 21E shows thebarbed anchor540 coupled to a portion of asurgical implant550 and anchored to anobturator membrane552. In operation, an operator drives theanchor540 partially (as illustrated) or entirely through theobturator membrane552 using a delivery device and/or method that will be discussed below. Thebarbs544 on theanchor540 engage with theobturator membrane552 and inhibit theanchor540 from retracting out of themembrane552 after insertion. An operator then optionally drives theanchor540 further into theobturator membrane552 to tension the associatedsurgical implant550. Thelong body542 is beneficial in part because the operator can drive theanchor540 various distances through theobturator membrane552, corresponding to various tensions ofimplant550. When the operator drives theanchor540 entirely through theobturator membrane552, thesurgical implant550 is driven through theobturator membrane552. Theimplant550 may have tangs to engage with and anchor to theobturator membrane552. The operator can then extend or retract a portion of theimplant550 through theobturator membrane552 to tension theimplant550. In certain embodiments, theimplant550 is not coupled tosoft tissue anchor540 and anchors itself to theobturator membrane552.
• FIG. 22A illustrates asoft tissue anchor560 without barbs. In particular, thesoft tissue anchor560 has a smoothouter surface562. Like the anchors depicted in FIGS.21A-E, theanchor560 includes a through-aperture564 that fits around the shaft of a delivery device, as will be discussed below. The depicted through-aperture564 extends axially entirely through theanchor560. In other embodiments, theanchor560 includes a passage extending axially from theproximal end560bof theanchor500 only part way to the distal end560aof theanchor560.
• FIGS. 22B-22C illustrate an exemplary technique for using theanchor560 to anchor asurgical implant566 to anobturator membrane568. In particular, an operator forms anaperture570 within theobturator membrane568 using, for example, a needle or dilator. Next, the operator couples theanchor560 to animplant566 using methods discussed below. The operator then drives theanchor560 through theaperture570. When retrograde tension is applied to theimplant566, theanchor560 pivots to a horizontal orientation, depicted inFIG. 22C, and aligns with theobturator membrane568, and this horizontal orientation prevents theanchor560 from disengaging from theobturator membrane568.
• FIG. 23 illustrates an alternativesoft tissue anchor570 shaped like an arrowhead. More particularly, theanchor570 includes apoint572 at a distal end, acylindrical shaft574 at a proximal end, andwings576aand576bat a distal end of thecylindrical shaft574. Theanchor570 further includes aslot578 disposed longitudinally along thecylindrical shaft574 and across bar580 bridging theslot578. In one exemplary technique, an operator couples theanchor570 to a filament by interfitting the filament throughslot578 and threading the filament around thecross bar580.
• As mentioned above, the soft tissue anchors couple to surgical implants in a variety of ways. In certain embodiments, such as with pelvic floor repair implants that have long lateral widths or laterally extending legs or extension regions, they directly couple to the surgical implant. In others, they are spaced away from the surgical implants. In any case, the anchors may be fixedly coupled, or adjustably coupled so that an operator can tension the implant.
• FIG. 24 illustrates asurgical implant580, similar to thesurgical implant30 depicted inFIG. 2A, with soft tissue anchors582-587 coupled directly to respective ones of the straps590-595. In certain embodiments, the anchors are fixedly coupled to the respective straps, as depicted with respect to soft tissue anchors582-584. The ends582a,583a, and584aof the anchors582-584 are affixed torespective ends590a,591a, and592aof the straps590-592 by gluing, heat bonding, tying, or other permanent affixation methods.
• In other embodiments, the anchors are adjustably coupled to respective straps, as depicted with respect to soft tissue anchors585-587. As shown, the mesh straps593-595 are threaded through buckles or apertures of the anchors585-587, which exposes free ends593a,594a, and595aof the mesh straps that have threaded entirely through the anchors585-587. The operator can pullfree end595ato thread more ofmesh strap595 throughanchor587 and increase the length of the exposedfree end595a. As a result, the tension applied bystrap595 to thesurgical implant580 will increase. The operator can similarly tension theimplant580 by adjusting the other mesh straps.
• As mentioned above, certain exemplary surgical implants may be used that do not extend the full obturator-to-obturator length of the patient. In such instances, soft tissue anchors can indirectly couple to the surgical implant via, for example, filaments or rings which space the anchors away from the surgical implant to extend the anchoring points.FIG. 25A illustrates asurgical implant600 coupled with soft tissue anchors602 and604 viaelastic rings606 and608. Therings606 and608 couple their respective anchors to the implant by a set of through-apertures. More particularly, thering606 couples withanchor602 by threading through theapertures614 and616 insoft tissue anchor602, and couples withsurgical implant600 by threading through theapertures610 and612 insurgical implant600. Similarly, thering608 couples tosoft tissue anchor604 by threading through theapertures622 and624 insoft tissue anchor604, and couples to thesurgical implant600 by threading through theapertures618 and620 in thesurgical implant600. As mentioned above, woven surgical implants may stretch and damage due to stresses during delivery of the implant. Theelastic rings606 and608 stretch to absorb lateral stresses, thereby preventing damage to theimplant600 during delivery.
• Additionally, theelastic rings606 and608 adjust to short term and/or long term changes in the patient's changing anatomy to prevent damage to thesurgical implant600. For example, when the patient sneezes, coughs, or jumps, muscles in the pelvic region can contract and anatomical structures may shift. Anatomical structures may also shift over long periods of time because of the patient's changing anatomy due to, for example, weight gain or weight loss. In such cases, theelastic rings606 and608 stretch to absorb the stresses caused by these short-term and long-term changes, thereby preventing the changes from damaging thesurgical implant600.FIG. 25B shows theelastic rings606 and608 in stretched states.
• FIGS.26A-G illustrate an alternative embodiment of animplant assembly630 having asurgical implant632 that is spaced away from and couples with soft tissue anchors634,636,638, and640 viafilaments642,644,646, and648. As will be discussed, the spacing of the soft tissue anchors634,636,638, and640 from theimplant632 can be adjusted to tension the implant, and to allow the soft tissue anchors634,636,638, and640 to reach various target tissue regions in the patient's retropubic space.
• The depictedsurgical implant632 is similar to thesurgical implant70 ofFIG. 4, and the depicted soft tissue anchors634,636,638, and640 are similar to thesoft tissue anchor570 ofFIG. 23. More particularly, as shown inFIG. 26A, thefilament642 threads through afirst aperture650 of theimplant632, through anaperture652 in theanchor634, and through asecond aperture654 of theimplant632. Two ends642aand642bof thefilament642 are cinched by a slidablefilament locking mechanism656 into an adjustable size loop. Similarly, theimplant632 couples to thesoft tissue anchor636 viafilament644,filament locking mechanism660, andapertures666,668, and670, tosoft tissue anchor640 viafilament648,filament locking mechanism662, andapertures672,674, and676, and tosoft tissue anchor638 viafilament646,filament locking mechanism664, andapertures678,680, and682.FIG. 26B shows theimplant632 after anchoring the soft tissue anchors634,636,638, and640 toobturator membranes639 and641. Instead offilament locking mechanisms660,662,664, and656, other adjustable cinching elements can be used, such as slip knots.
• Thefilaments642,644,646, and648 along withfilament locking mechanisms660,662,664, and656 allow an operator to adjustably tension theimplant632 within the pelvic region of the patient. More particularly, once an operator delivers theimplant632 to a target tissue region, such as the obturator membranes as depicted inFIG. 26B, the operator tensionssurgical implant632 and/or adjusts its length or width usingfilament locking mechanisms660,662,664, and656 by drawingimplant corners632a,632b,632c, and632dtowardsrespective anchors634,636,638, and640. In particular, as depicted in FIGS.26C-D, an operator grasps atensioning tool700 with one hand and one or both filament ends642aand642bwith another hand. Thetensioning tool700 includes ahandle700a, ashaft700bextending distally from the handle, and a curved, looped, or hookedtip700cat a distal end of theshaft700boriented at an angle to theshaft700b. Thetip700cof thetensioning tool700 is sized and shaped to hook onto and engage with thefilament locking mechanism656 and to slide thefilament locking mechanism656 along thefilament642 to adjust the distance from theimplant corner632ato the anchor634 (secured to a target tissue region) and thereby tension and/or adjust the length and/or width of the implant assembly.
• In an exemplary technique, the operator abuts thetip700cof thetensioning tool700 against theproximal end656aof thefilament locking mechanism656. Thefilament locking mechanism656 may be external to the patient, within the vaginal canal, or beyond the vaginal incision and within the pelvic region of the patient. When thefilament locking mechanism656 is beyond the vaginal incision, the operator inserts thetensioning tool700 through the same vaginal incision. Next, as shown inFIG. 26D, the operator pushes thetensioning tool700 in adistal direction706 towards theimplant corner632awhile pulling one or both filament ends642aand642bin aproximal direction708 away from theimplant corner632a. The filament ends642aand642bmay lie exterior to the patient, within the vaginal canal, or beyond the vaginal incision. If the filament ends642aand642bare inaccessible by hand, the operator may use forceps or other suitable instruments to grasp the filament ends642aand642b. Thefilament locking mechanism656 then slides in adistal direction706 along thefilament642 and towards theimplant corner632a. In certain embodiments, thefilament locking mechanism656 is configured to slide in one direction (i.e., distally706) and not in a retrograde direction (i.e., proximally708). The same may apply if slip-knots are used (i.e., the slip knots may be one-way slip knots).
• Thefilament locking mechanism656 then abuts againstimplant corner632aand drawsimplant corner632atowards theanchor634 which increases the tension of theimplant632.FIG. 26E depicts theimplant corner632a, theanchor634, thefilament locking mechanism656, and thefilament642 after such an exemplary tensioning technique. The operator then repeats this process forimplant corners632b,632c, and632duntil theimplant632 is properly tensioned.FIG. 26F depicts theimplant632 after the operator has tensioned all fourcorners632a-d. While the depictedimplant632 couples to four anchors atrespective corners632a-d, theimplant632 may also couple to anchors at sides or edges of theimplant632 that are spaced away from thecorners632a-d.
• The operator can also loosen theimplant632 usingfilament locking mechanisms660,662,664, and656. An exemplary technique is depicted inFIG. 26G, in which an operator grasps thetensioning tool700 and abuts thetip700cagainst theproximal end656bof thefilament locking mechanism656. The operator pulls the tensioning tool in aproximal direction708, and as a result thefilament locking mechanism656 slides proximally along thefilament642. Theimplant corner632ais then free to slide in aproximal direction708 along thefilament642. The operator then repeats this process forimplant corners632b-duntil theimplant632 is properly loosened to a desired tension.
• Although the depicted tensioning and loosening technique was described in connection with theanchors634,636,638, and640 anchoring torespective obturator membranes639 and641, theanchors634,636,638, and640 can also couple to other target tissue regions in the patient's retropubic space. For example, in one alternative implementation, theanchors634 and636 anchor to target tissue regions of the patient's sacrospinous ligament or levator ani muscle, while theanchors638 and640 anchor to target tissue regions of the patient'sobturator membranes639 and641.
• Having described various exemplary surgical implants, and systems and methods for anchoring the implants within the patient and tensioning the implants once the implants are anchored, various exemplary devices are now described for use in inserting the surgical implants through a single vaginal incision. In certain embodiments, the delivery devices include a handle and a shaft extending distally from the handle to couple with a soft tissue anchor. In certain configurations, the delivery devices include movable parts that allow an operator to control the release of the soft tissue anchor from the delivery device, measure the delivery location of the soft tissue anchors, and/or measure appropriate lengths of an implant for use in a particular patient. The delivery devices are generally shaped so that an operator can guide a distal end of the delivery device through the patient's vaginal opening, through the vaginal incision, and towards a patient's obturator membrane. In certain embodiments, the delivery device is also shaped to extend through the vaginal incision to the contra-lateral obturator membrane, and in others the operator is provided with a second device having an opposite curvature to extend through the vaginal incision and to the contra-lateral obturator membrane. In certain exemplary techniques, soft tissue anchors secure the implant to target tissue regions, whereas in others, tanged portions of the implant secure the implant to the target tissue regions.
• More particularly,FIG. 27 shows adelivery device800 for delivering a implant assembly to the pelvic region of a patient. Thedelivery device800 includes ahandle802, acannula804 extending distally from thehandle802, and amovable shaft806.
• Thehandle802 includes aproximal end808 and adistal end810. Thehandle802, as depicted, is substantially straight and tapers inward from theproximal end808 to adistal location812. Thedistal portion810 of thehandle802 tapers outward from thedistal location812 to prevent a medical operator's hand from slipping distally while grasping thehandle802.
• Thecannula804 has aproximal end804aanddistal end804b, and extends distally from a distalmost end814 of thehandle802. Thecannula804 is substantially straight, but this need not be the case. In alternative embodiments, it may include any combination of curved sections and straight sections, and may extend into one, two or more planes. Theshaft806 interfits within thecannula804 and mechanically couples at a proximal end to aslider816 on/within thehandle802. An operator may slide theslider816 axially within the slot to retract and extend theshaft806 in and out of thecannula804. With theshaft806 extended, a distalmost end820 of thecannula804 forms ashoulder822.
• In operation, an operator slides theslider816 distally and thereby extends theshaft806 to an extended position. Next, the operator interfits a tissue anchor, such as the tissue anchors described above, onto the distal end of theshaft806. The operator then inserts the distal end of thedelivery device800 with the tissue anchor into the body of the patient, for example, via the incision in the vaginal wall according to the illustrative procedure. The operator advances the device until the anchor is placed at a target tissue region such as an obturator membrane. Next, the operator retracts theslider816 to retract theshaft806 into thecannula804 and out of the tissue anchor. In certain implementations, the tissue anchor abuts against theshoulder822 of thedelivery device800 and thereby disengages from theshaft806 when theshaft806 retracts into thecannula820. The operator removes thedelivery device800 from the patient and thereby leaves the tissue anchor placed and anchored at the target tissue region. The anchor may be coupled to an implant that is coupled to one or more other soft tissue anchors. The operator may repeat the procedure for the other soft tissue anchors with the same or a different delivery device.
• According to the illustrative embodiment, when theshaft806 is in an extended position, the exposed distal section of theshaft806 is between about 2 centimeters and about 4 centimeters long. In other illustrative embodiments, it is between about 1 centimeter and about 3 centimeters long. In further illustrative embodiments, the narrowed distal section of theshaft806 has an outside diameter of between about 0.03 inches and about 0.05 inches. In one illustrative embodiment, it has an outside diameter of about 0.04 inches. According to other configurations, the outside diameter of thecannula804 at thedistal end820 is between about 0.07 inches and about 0.1 inches. In one implementation, the outside diameter of this portion of the cannula is about 0.09 inches. According to one configuration, the total distance from thedistal end814 of thehandle802 to the distal most tip806aof theshaft806, with the shaft extended is between about 7 centimeters and about 20 centimeters. In other configurations, the total distance is between about 8 centimeters and about 12 centimeters.
• Alternatively, delivery devices may include a fixed shaft and a movable cannula disposed about the fixed shaft.FIG. 28 shows such adelivery device900 and animplant assembly920. Thedelivery device900 includes ahandle902, a needle/shaft910 extending distally from thehandle902, apusher button904 distal to thehandle902, and acannula906 disposed about theshaft910 and extending distally from thepusher button904.
• Theshaft910 is generally linear at itsproximal end910a, and curves towards itsdistal end910b. However, in other embodiments theshaft910 may be straight, may include any combination of curved sections and straight sections, and/or may extend into one, two or more planes. When inserting thedelivery device900 through the vaginal incision and towards an obturator membrane, a straight shaft may facilitate access for an operator to more posterior regions of an obturator membrane, whereas a shaft with more curvature may facilitate access to more anterior regions of an obturator membrane. In certain embodiments, the shaft may be shorter in length than the depictedshaft910 which may provide an operator with better control. In certain embodiments, theshaft910 has a diameter of between about 0.075 inches and about 0.2 inches, and in certain embodiments is about 0.107 inches. Theshaft910 includes atip916. Thetip916 can be sharp and suited to incise and/or dissect human tissue, or blunt and suited for blunt dissection and/or dilation of human tissue. In certain embodiments, the tip is blunt so as to avoid damaging sensitive structures such as organs, nerves, and arteries, as will be discussed below.
• Thepusher button904 comprises polymeric materials and is mechanically coupled to thecannula906. Thecannula906 is shorter in length than theshaft910, and when thebutton904 is in a retracted state, as depicted inFIG. 28, theshaft910 is exposed at itsdistal end910b. In certain implementations, the exposed portion of theshaft910 is slightly longer than about half the length of theimplant assembly920 so theimplant assembly920 remains external to the body during initial placement of theshaft910.
• Theimplant assembly920 includes animplant928 and anchors926 and922 coupled to theimplant928. Theanchors926 and922 are similar to anchor560 ofFIG. 22A, but can be similar to any of the anchors described herein. Theanchors926 and922 include respective axial through holes. The inner diameter of theanchor926 is preferably sized and shaped to fit around and slide against the outer diameter of theshaft910. Theanchor926 slides proximally along theshaft910 and abuts the distal end of thepusher cannula906. The outer diameter of theanchor926 can be smaller, larger, or equal to the outer diameter of thepusher cannula906. Theimplant928 further includes acenter mark924 indicating the center, or “half-length,” of theimplant924. In one usage ofdevice900, thecenter mark924 of the implant is placed directly underneath the urethra. However, in other implementations,device900 is used with larger meshes that include marks which are placed under other anatomical structures, such as, for example, the base of the bladder.
• Thecannula906 includes apusher mark908 that indicates where thecenter mark924 of theimplant928 will be positioned after theimplant928 has been placed using thedelivery device900. In one exemplary mode of operation, when an operator delivers theimplant928 using thedelivery device900 with thepusher button904 and thecannula906 retracted, the operator positions thepusher mark908 underneath the urethra such that when the operator advances the pusher, thecenter mark924 of theimplant928 lies about or directly underneath the urethra. However, in embodiments wherein implants include marks indicating placement of the implant with respect to another anatomical structure, such as the base of the bladder, the operator accordingly positions thepusher mark908 underneath that anatomical structure.
• In operation, an operator couples ananchor926 of theimplant assembly920 to theshaft910. Theanchor926 slides proximally along theshaft910 and abuts the distal end of thepusher cannula906. The operator inserts theshaft910 into the body of the patient and guides thetip916 towards a target region while thebutton904 is retracted. In certain implementations, the operator advances the tip past the target region. The operator optionally gauges his proximity to the target region buy aligning thecannula mark924 with an anatomical landmark such as the urethra. The operator advances thebutton904 distally, and thereby advances the distal end of thecannula906 towards thetip916 of theshaft910.FIG. 29 shows thedelivery device900 ofFIG. 28 with thepusher904 in an extended state. As will be described below, in certain implementations the operator advances theanchor926 to a target region with the anatomy of the patient without pushing theanchor926 off of theshaft910. Instead, after placement of theanchor926, the operator retracts thedevice900 in a retrograde direction, which decouples theanchor926 from theshaft910.
• In addition to thecannula mark908, thedevice900 may include other marks that guide the operator. In order to measure how far to advance thebutton904 andcannula908, in certain embodiments theshaft910 includes increment/measurement markings910a. The operator can use the measurement markings to gauge the distance from thetip916 of the shaft to the distal end of thecannula908.FIG. 30 shows an alternate view of thedevice900 ofFIG. 29 withincrement markings910aetched into theshaft910. Themarkings910acan be disposed using other methods, such as disposing a biocompatible ink or stain on theshaft910.
• As described above, the exemplary meshes, anchors and delivery devices access target soft tissue regions, such as the obturator membranes, via single vaginal incisions. Exemplary surgical techniques for implanting the meshes will now be described. As illustrated herein, the procedure can be applied with meshes that are configured to support the urethra or bladderneck for the treatment of UI, and also with meshes that have longer anterior-to-posterior widths for supporting the bladder, uterus, and/or other organs located within the patient's pelvic region.
• FIG. 31A illustrates an exemplary single vaginal incision procedure for usingdelivery device900 to deliver animplant assembly981 for the treatment of a pelvic floor disorder. Theexemplary implant assembly981 is similar toimplant assembly630 ofFIG. 26A, and in particular includes animplant980 similar toimplant632 ofFIG. 26A. Theimplant assembly981 also includes three soft tissue anchors982,984, and986 on one side of the implant, and three soft tissue anchors988,990, and992 on a contralateral side. Theanchors982,984,986,988,990, and992 are similar to anchor500 ofFIG. 21A, and couple to theimplant980 using filaments and filament locking mechanisms similar to those described in connection withFIG. 26A.
• In the exemplary technique, the patient is placed on an operating table in a position to provide access to the pelvic region. The operator may subject the patient to local anesthesia, regional anesthesia, and/or general anesthesia or sedation according to his preference. Next, the operator makes a transverse incision (not shown) in the anterior vaginal wall of the patient and dissects the incision bilaterally according to his preference using, for example, surgical scissors. In certain implementations, the operator dissects bilaterally to the inferior pubic ramus on both sides of the patient. The operator then identifies a path of delivery of the implant by palpating tissue of the pelvic region. The operator may palpate by inserting his finger through the vaginal incision and may identify anatomical structures such as the obturator foramen.
• Next, the operator accesses the patient's pelvic region via the single incision to insert the implant into the patient's pelvic region and secure the implant within the region so that at least a portion of the implant is located posterior to the bladderneck. To accomplish this, the operator first couples anchor982 to thetip916 of theshaft910, inserts the distal end of theshaft910 into the body through the externalvaginal opening987 and then guides the distal end of theshaft910 through the vaginal incision towards anobturator membrane950. The operator may palpate during delivery as preferred. The operator may also use the posterior portion of the patient's pubic bone as an anatomical landmark to assist in guiding the needle. The operator optionally secures theimplant980 against theshaft910 during delivery so that theimplant980 does not obstruct the operator's vision or the path of delivery using any suitable sterile securing means, such as a sterile elastic band or tie.
• The operator then punctures theobturator membrane950 with thetip916 but stops short of extending a portion of thetip916 orshaft910 through the surface of the patient's skin in the groin. The location of the puncture within theobturator membrane250 depends on the anchor being delivered. For example, the operator deliversanchor982 through a sufficientlyposterior region950bof theobturator membrane950 so that theimplant assembly981 extends to posterior regions of the patient's pelvic floor and provides posterior support, while he deliversanchor986 through ananterior region950aof theobturator membrane950 so that theimplant assembly981 extends to and supports anterior regions of the patient's pelvic floor (e.g., so that at least a portion of theimplant981 extends to a location that is posterior to the patient's bladder neck). In certain implementations, the operator generally delivers theimplant980 along a path that avoids certain pelvic structures, such as the internal pudendal artery, the pudendal canal, the perineal nerve, the labial nerve, and other vascular and nerve structures.
• The operator may hear and/or feel a pop indicating that he has pierced theobturator membrane950. The operator gauges the length from the vaginal incision to theobturator950 by using the markings or indications (not shown) on theshaft910, by using the mark908 (not shown in this figure) on thecannula906, and/or by visually gauging the length from the proximal edge of theanchor982 to the vaginal incision to assure that the length of theimplant980 is suitable for the patient. As mentioned above, in certain implementations, theimplant980 includes a visual marking that the operator places under a predetermined anatomical landmark, such as the urethra or the bladder.
• If needed, the operator further advances theshaft910 to be near, contact, apply pressure to, poke (“tent-up”), or, in certain uses, pierce the epidermis (not shown) just beyond theobturator membrane950, without penetrating entirely through the skin, until theshaft910 is in an appropriate position to deliver theanchor982. The operator may externally palpate the epidermis proximal to the obturator membrane to feel theshaft910 poke the epidermis and confirm its location. In certain embodiments the operator stops extending thetip916 when it reaches a position that is beneath the patient's stratum corneum, while in other embodiments the operator stops thetip916 from extending to the epidermis. In certain embodiments the operator stops thetip916 in the subcutaneous tissue or beneath the subcutaneous and does not extend thetip916 to the dermal layer
• In certain implementations, the incision is made in the vagina so as to allow the inserted shaft to be near, contact, apply pressure to, or poke the skin at a position that is generally in line with the urethral meatus. The operator anchors theanchor982 to the obturator membrane, and retracts theshaft910, thereby decoupling theshaft910 from theanchor982, using methods discussed above.
• The operator repeats this process foranchors984 and986, in each instance delivering the anchors through the same vaginal incision. Next, the operator repeats the process on the contralateral side, deliveringanchors988,990, and992 to theobturator membrane951 through the same vaginal incision. The operator also inserts theregion981 of theimplant980 through the vaginal incision. In certain implementations theregion981 is inserted after the operator inserts theanchors982,984 and986 on one side of the patient but before insertinganchors988,990 and992 on the other side. Once all of theanchors982,984,986,988,990, and992 are delivered through the vaginal incision in the anterior vaginal wall and extended torespective obturator membranes950 and951, theentire implant980 will have been delivered through thevaginal opening987 and through the vaginal incision, and thus lie in a region anterior to the vaginal canal and supporting the urethra, bladder, and/or bladderneck.
• The order in which the operator delivers theanchors982,984,986,988,990, and/or992 can vary. In certain implementations, the operator delivers anchors in a posterior-to-anterior order so that anterior portions of the implant do not obstruct or get in the way of the operator when delivering posterior anchors. Although cystoscopies are not required with the above-described procedure, the operator may perform a cystoscopy to check for bladder damage after delivering any or all of the anchors. Also during delivery, the operator optionally uses a pair of forceps or another suitable medical instrument to space theimplant980 from the urethra (not shown) during delivery of one or more of the anchors to prevent excessive tension or stress on the urethra. When completed, the operator reviews theimplant980 to confirm that it is properly placed under the organ needing support, then sutures the vaginal incision.
• For certain patients, the lateral length of theimplant980 may be longer than the obturator-to-obturator length of that patient. In these cases, the operator may leave equal lengths of the implant displaced on external sides of theobturator membranes950 and951. By way of example, if theimplant980 has a lateral length of about 10 cm, then the patient with obturator to obturator length of about 7 cm will have about 1.5 cm of implant displaced on each side beyond theobturator membranes950 and951. Alternately, the manufacturer can supply implants with various lateral lengths to suit various patients.
• Thedevice900 and a similar delivery technique can be used to deliver non-woven implants discussed above (i.e.,implant140 ofFIG. 7A), and/or implants that do not extend to posterior regions of the patient's anatomy and are instead sized and shaped for treating urinary incontinence.FIG. 31B illustrates the use ofdevice900 to deliver animplant994 with a narrower anterior-to-posterior width994athat is designed to underlie and support the urethra and/or bladderneck of the patient. Theimplant994 is directly coupled toanchors500 ofFIG. 21A. The operator uses a delivery method similar to that described in connection withFIG. 31A, except that the operator only delivers two soft tissue anchors500. In any event, the operator extends the soft tissue anchors500 within the patient's soft tissue but stops short of extending a portion of the device through the surface of the patient's skin, as described above.
• The surgical methods described above are non-limiting examples. Others will be apparent upon review of this disclosure. In certain alternative implementations, devices used to insert the implants are set forth inFIGS. 32A-34B. FIGS.32A-C shows anotherillustrative delivery device1060 that is sized and shaped for transobtural placement of an implantable implant through the single vaginal incision, and employable, without limitation, with any of the illustrative embodiments described herein. More particularly, thedelivery device1060 includes ahandle1062 with first1062aand second1062bsubstantially straight sections located substantially in a first plane and angled relative to each other, atransitional portion1065 extending out of adistal end1063 of thehandle1062 which interfits and extends axially out of thedistal end1063 of the secondstraight handle section1062b, and a halo-shapedcurved shaft1064 extending from a distal end of thetransitional portion1065. Thecurved shaft1064 includes a reduceddiameter section1064aat a distal end of theshaft1064 and an increaseddiameter section1064bat a proximal end of theshaft1064. The increaseddiameter section1064band the reduceddiameter section1064aadjoin to form a shoulder/ledge1064c. In use, an operator couples a soft tissue anchor to thedevice1060 by interfitting the reduceddiameter section1064aof theshaft1064 through a through-aperture of the soft tissue anchor. The increaseddiameter section1064 should have a cross-section with a larger diameter than the diameter of the through-aperture, and thus theshoulder1064cprovides a mechanical stop that prevents the anchor from sliding proximally along theshaft1064. In certain embodiments, the increaseddiameter section1064band the reduceddiameter section1064aare manufactured from a unitary body. However, in other embodiments, the increased diameter section comprises a flexible sheath or covering that an operator slides over the reduceddiameter section1064aand around theshaft1064.
• In this embodiment, the first substantiallystraight section1062ahas alongitudinal axis1067 that is normal to the plane of thecurved shaft1064. However, thelongitudinal axis1067 can form any suitable angle with respect to the plane of the curved shaft (e.g., about 10, 20, 30, 45, 60, 70 or 80 degrees). By way of example, FIGS.33A-B show twosymmetric devices1040 and1041 similar todevice1060 of FIGS.32A-C, but having alternativeflat handles1043, taperedtips1046aat distal ends of thecurved shafts1046, and havinglongitudinal axes1042 that form angles1044 of about 60 degrees with respect to the planes of thecurved shafts1046.
• FIG. 34A shows an exemplary technique for delivering animplant using device1041. Theimplant1120 is similar to implant30 ofFIG. 2A, except thatimplant1120 includes acentral region1120athat is rectangular rather than trapezoidal.Anchors1122,1124,1126,1128,1130, and1132, similar toanchor500 ofFIG. 21A, directly couple tostraps1120b,1120c,1120d,1120e,1120f, and1120gofimplant1120.
• In the exemplary technique, first the patient is placed in a position to provide access to the pelvic region. The operator may subject the patient to local anesthesia, regional anesthesia, and/or general anesthesia or sedation according to his preference. Next, the operator makes a transverse incision (not shown) in the anterior vaginal wall of the patient and dissects the incision bilaterally according to his preference using, for example, surgical scissors. In certain implementations, the operator dissects bilaterally to the inferior pubic ramus on both sides of the patient. The operator then (optionally) identifies a path of delivery of the implant by palpating tissue of the pelvic region. The operator may palpate by inserting his finger through the vaginal incision and may identify anatomical structures such as the obturator foramen.
• Next, thesoft tissue anchor1122 is interfitted over the taperedtip1046a(not shown in this figure) of thedelivery device shaft1064. The operator grasps thehandle1043 and inserts the deliverydevice shaft portion1046 with theanchor1122 through the vaginal incision. With a lateral motion, the medical operator passes thecurved shaft1046 behind theischiopubic ramus1140 and pierces theobturator membrane1142.
• Thedelivery device shaft1046 is then withdrawn through the vaginal incision with a retrograde motion by the operator, leaving theanchor1122 implanted in or through theobturator membrane1142 and, optionally, fixed to theobturator membrane1142 as described above. The operator implants theanchor1122 in a sufficientlyposterior region1142aof theobturator membrane1142 so that theimplant1120 provides support to posterior anatomical structures and regions, such as the base of the bladder, in each instance delivering the anchors through the same vaginal incision.
• This process is repeated foranchors1124 and1126. Next, the process is repeated foranchors1128,1130, and1132 to thecontralateral obturator membrane1146 with the same or a second delivery device (i.e., thesymmetric delivery device1040 withopposite shaft1064 curvature). As described above in connection with other exemplary techniques, the operator can perform cystoscopies during the procedure to check for bladder damage.
• The halo-shapedcurved shaft1046 is beneficial at least in part in that the operator can navigate thetip1046aabout the ischiopubic ramus with lessened movement of his arm, wrist, and/or hand to provide a more accurate placement of the anchors. The operator may palpate during delivery as preferred. The operator may also use the posterior portion of the patient's pubic bone as an anatomical landmark to assist in guiding the needle. The halo-shapedcurved shaft1046 is also beneficial in part because it is shaped to avoid sensitive nerves and vascular structures that may be located in or near certain regions of theobturator membrane1142. In some patients, these sensitive structures are more concentrated in superior regions of theobturator membrane1142. Thus, in certain implementations, the operator delivers theanchors1122,1124,1126,1128,1130, and1132 to regions in the vicinity of theobturator membranes1142 and1146 that are proximal to inferior pubic bone structures, such as the inferior ramus of the pubis and the ramus of the ischium.
• As was the case withdelivery device900,delivery devices1040,1041, and1060 can be used to deliver non-woven implants discussed above (i.e.,implant140 ofFIG. 7a), and/or implants that do not extend to posterior regions of the patient's anatomy and are instead sized and shaped for treating urinary incontinence.FIG. 34B illustrates the use ofdevice1041 to delivery amesh implant1048 with a relatively narrow anterior-to-posterior width1048athat is designed to underlie and support the urethra and/or bladderneck of the patient. The operator uses a delivery method similar to that described in connection withFIG. 34A, except that the operator only delivers two soft tissue anchors500 coupled to theimplant1048. Additionally, thedevice1041 includes analternative handle configuration1043athat includes grooves to provide the operator with a better grip of thedevice1041.
• FIG. 31A-B and FIGS.34A-B illustrate exemplary techniques for delivering implants that are secured to respective obturator membranes with soft tissue anchors. However, as mentioned above, in certain embodiments the implants are secured directly to target tissue regions of the retropubic space using tangs that are of unitary body with the implant. FIGS.35A-B depict exemplary tanged implants and techniques for delivering and securing the implants.
• In the exemplary techniques involving soft tissue anchors discussed above in connection with FIGS.31A-B and FIGS.34A-B, the implant couples to soft tissue anchors, which are then coupled to a delivery device. However, when no soft tissue anchors are used, the implant couples directly to the delivery device.FIG. 35A depicts animplant1102 directly coupled to thedelivery device1060 that was shown inFIGS. 32A-32C. Theimplant1102 includestanged portions1104aand1104bat respective ends of theimplant1102, and anon-tanged portion1104cbetween thetanged portions1104aand1104b. Thetanged implant1102 can be manufactured using a technique similar to that described in connection with thetanged implant30 ofFIG. 2B.
• In use, the operator couples theimplant1102 directly to thedelivery device1060 by sliding the reduceddiameter portion1064athrough one of theinterstices1110 of theimplant1102. In order for the reduceddiameter portion1064ato fit through one of the interstices, in certain embodiments the reduceddiameter portion1064ahas a diameter of less than about 1 mm. The operator then follows the same steps as those described in connection withFIG. 34B to guide the distal end of thedelivery device1060 to the obturator membrane112b. However, instead of piercing a soft tissue anchor through the obturator membrane, the operator drives the reduceddiameter portion1064aof thedevice1060 with at least part of the tangedportion1104bthrough theobturator membrane1112b. Thedelivery device1060 is then withdrawn through the vaginal incision leaving thetanged portion1104bimplanted in or through theobturator membrane1112b. The operator then repeats this process to anchor the contra-lateraltanged portion1104ato the contra-lateral obturator membrane1112a.
• Thetanged implant1102 is sized and shaped to treat urinary incontinence by supporting the patient's urethra and/or bladderneck. Tanged implants can also be used for treating other pelvic floor disorders.FIG. 35B shows an oblique view of thepelvic region1128 of a patient with animplant1130 similar to theimplant30 ofFIG. 2, but having tangedstraps1130a-f. To deliver theimplant1130, the operator uses a similar method as that described in connection withFIG. 35A to deliver each of the tanged ends1130a-cto afirst obturator membrane1132 and to then deliver each of thetanged straps1130d-fto a contra-lateral obturator membrane1134.
• As noted above, after placing a surgical implant, the operator tensions the implant to provide the proper support to anatomical structures of the pelvic region using methods described above.
• In addition to the obturator membranes, in certain alternative implementations an operator anchors the implant to other anatomical structures. These structures include posterior or lateral tissues or muscles, such as the sacrospinous ligament and the levator ani muscle. The sacrospinous ligament is a thin and triangular tissue that is attached by its apex to the spine of the patient's ischium, and medially, by its broad base, to the lateral margins of the sacrum and coccyx in front of the sacrotuberous ligament. The sacrospinous ligament is a convenient location to anchor mesh straps in the posterior regions of the pelvic floor in order to provide posterior support. The levator ani muscle is a broad, thin muscle situated generally on the side of the pelvis that is attached to the inner surface of the lesser pelvis. It is a convenient location to anchor mesh straps in order to provide lateral and/or posterior support and tension for a surgical implant.
• More particularly,FIG. 36 shows an exemplary position of asurgical implant1142 in thepelvic region1140 of a patient. The implant includes three sets of straps. The anterior set ofstraps1142a-banchor to respective obturator membranes as discussed above in connection with other exemplary implant positions, and provide anterior support to theimplant1142. The lateral set ofstraps1142b-canchor to respectivetarget tissue regions1144aand1144babout the tendinous arch of the levator ani muscle and provide lateral support to theimplant1142. The posterior set ofstraps1142e-fanchor to respectivetarget tissue regions1146aand1146bof the sacrospinous ligament and provide posterior support to theimplant1142. Each of thestraps1142a-fanchors to a respective target tissue region via asoft tissue anchor500 discussed in connection withFIG. 21A. However, in other embodiments thestraps1142a-fhave tangs that anchor to respective target tissue regions.
• One exemplary implantation technique is performed in three phases. In a first phase, the operator inserts and secures theposterior straps1142e-finto the sacrospinous ligament. In a second phase, the operator inserts and secures thelateral straps1142c-dinto the levator ani muscle. In a third phase, the operator inserts theanterior straps1142a-bthrough the obturator foramen and secures the straps in either obturator membranes or in the patient's tissues proximal to the obturator canals.
• More particularly, in the first phase, to insert the strap1142e, a medical operator creates an incision in a patient's anteriorvaginal wall1148. The incision can be dissected or extended as required to facilitate access of a delivery device to targetregion1146b. Next, the operator couples, preferably external to the body, mesh strap1142ewithdelivery device900 described above in connection withFIG. 28 via the soft tissue anchor500 (not shown) described in connection withFIG. 21A.
• The operator then inserts thedevice900 and the coupled mesh strap1142ethrough the vaginal opening, into the vaginal canal, and through the vaginal incision. The operator guides thetip916 of the device towards thetarget region1146aof the sacrospinous ligament, and pierces and drives the mesh strap1142ethrough thetarget region1146a. The operator then retracts the device, leaving the strap1142eanchored to thetarget region1146a. For strap1142e, as well as theother straps1142a-dand1142f, the operator may use other devices having varying shaft lengths and curvatures in order to reach the appropriate target tissue region via the vaginal incision.
• The operator then delivers themesh strap1142fthrough the vaginal opening and through the vaginal incision in a similar manner as1142e. The vaginal incision may be dissected or extended as necessary to facilitate access ofdelivery device900 to targetregion1146b. The operator may use thesame delivery device900 for delivery ofstrap1142f, or alternatively may use asecond delivery device900.
• In the second phase, the operator inserts thestraps1142d-eintotarget regions1144aand1144bof the levator ani muscle. To insertstrap1142c, the operator first couplesdelivery device900 to themesh strap1142cusing asoft tissue anchor500, then inserts thedevice900 into the vaginal canal, and through the vaginal incision. The operator then pierces and drives themesh strap1142cthrough thetarget region1144aof the levator ani muscle, and retracts thedelivery device900 using methods discussed above. The operator similarly deliversmesh strap1142dto targetregion1144bof the tendinous arch of the levator ani muscle contra-lateral to targetregion1144ausingdelivery device900.
• In a third phase, the operator inserts theanterior straps1142aand1142bthrough the obturator foramen and secures the straps to respective obturator membranes or to the patient's tissues proximal the obturator canals using any of the exemplary methods and devices discussed above.
• In alternative embodiments, the implants can be stitched or sutured to the target tissue regions. Moreover, the operator may use any operative combination of the above-described techniques. For example, the operator may anchor any of the implants described herein on one side of the patient's retropubic space using soft tissue anchors, while anchoring the same implant to the contra-lateral side of the patient's retropubic space using tanged portions of the implant. According to another feature, the implants of the invention may include any suitable end portions, such as tissue dilators, anchors, and association mechanisms for associating the implant with the delivery devices of the invention. The implants and other features described herein may be adapted for use in multi-incision procedures, such as, for example, US 2005/0245787, 2005/0250977, 2003/0220538, and 2004/0249473. They may also include other implants (i.e., slings), sling assemblies, sling delivery approaches, sling assembly-to-delivery device association mechanisms, and sling anchoring mechanisms. These and other features with which the delivery devices, implants, methods, and kits of the invention may be employed are disclosed in U.S. Pat. No. 6,042,534, entitled “Stabilization sling for use in minimally invasive pelvic surgery,” U.S. Pat. No. 6,755,781, entitled “Medical slings,” U.S. Pat. No. 6,666,817, entitled “Expandable surgical implants and methods of using them,” U.S. Pat. No. 6,042,592, entitled “Thin soft tissue surgical support mesh,” U.S. Pat. No. 6,375,662, entitled “Thin soft tissue surgical support mesh,” U.S. Pat. No. 6,669,706, entitled “Thin soft tissue surgical support mesh,” U.S. Pat. No. 6,752,814, entitled “Devices for minimally invasive pelvic surgery,” U.S. Ser. No. 10/918,123, entitled “Surgical Slings,” U.S. patent application Ser. No. 10/641,376, entitled “Spacer for sling delivery system,” U.S. patent application Ser. No. 10/641,192, entitled “Medical slings,” U.S. Ser. No. 10/641,170, entitled “Medical slings,” U.S. Ser. No. 10/640,838, entitled “Medical implant,” U.S. patent application Ser. No. 10/460,112, entitled “Medical slings,” U.S. patent application Ser. No. 10/631,364, entitled “Bioabsorbable casing for surgical sling assembly,” U.S. Ser. No. 10/092,872, entitled “Medical slings,” U.S. patent application Ser. No. 10/939,191, entitled “Devices for minimally invasive pelvic surgery,” U.S. patent application Ser. No. 10/774,842, entitled “Devices for minimally invasive pelvic surgery,” U.S. patent application Ser. No. 10/774,826, entitled “Devices for minimally invasive pelvic surgery,” U.S. Ser. No. 10/015,114, entitled “Devices for minimally invasive pelvic surgery,” U.S. patent application Ser. No. 10/973,010, entitled “Systems and methods for sling delivery and placement,” U.S. patent application Ser. No. 10/957,926, entitled “Systems and methods for delivering a medical implant to an anatomical location in a patient,” U.S. patent application Ser. No. 10/939,191, entitled “Devices for minimally invasive pelvic surgery,” U.S. patent application Ser. No. 10/918,123, entitled “Surgical slings,” U.S. patent application Ser. No. 10/832,653, entitled “Systems and methods for sling delivery and placement,” U.S. patent application Ser. No. 10/642,397, entitled “Systems, methods and devices relating to delivery of medical implants,” U.S. patent application Ser. No. 10/642,395, entitled “Systems, methods and devices relating to delivery of medical implants,” U.S. patent application Ser. No. 10/642,365, entitled “Systems, methods and devices relating to delivery of medical implants,” U.S. patent application Ser. No. 10/641,487, entitled “Systems, methods and devices relating to delivery of medical implants,” U.S. patent application Ser. No. 10/094,352, entitled “System for implanting an implant and method thereof,” U.S. patent application Ser. No. 10/093,498, entitled “System for implanting an implant and method thereof,” U.S. patent application Ser. No. 10/093,450, entitled “System for implanting an implant and method thereof,” U.S. patent application Ser. No. 10/093,424, entitled “System for implanting an implant and method thereof,” U.S. patent application Ser. No. 10/093,398, entitled “System for implanting an implant and method thereof,” and U.S. patent application Ser. No. 10/093,371, entitled “System for implanting an implant and method thereof,” U.S. Pat. No. 6,197,036, entitled “Pelvic Floor Reconstruction,” U.S. Pat. No. 6,691,711, entitled “Method of Correction of Urinary and Gynecological Pathologies Including Treatment of Incontinence,” U.S. Pat. No. 6,884,212, entitled “Implantable Article and Method,” U.S. Pat. No. 6,911,003, entitled “Transobturator Surgical Articles and Methods,” U.S. patent application Ser. No. 10/840,646, entitled “Method and Apparatus for Cystocele Repair,” U.S. application Ser. No. 10/834,943, entitled “Method and Apparatus for Treating Pelvic Organ Prolapse,” U.S. patent application Ser. No. 10/804,718, entitled “Prolapse Repair,” and U.S. patent application Ser. No. 11/115,655, entitled “Surgical Implants and Related Methods.” The entire contents of all cited references are incorporated herein by reference in their entirety. Variations, modifications, and other implementations of what is described may be employed without departing from the spirit and the scope of the invention. More specifically, any of the method, system and device features described above or incorporated by reference may be combined with any other suitable method, system or device features disclosed herein or incorporated by reference, and is within the scope of the contemplated invention. All operative combinations between one disclosed embodiment and any other embodiments are also contemplated. It is intended that the scope of the invention be limited not by this detailed description but rather by the claims appended hereto.

Claims (38)

1. A surgical implant assembly for pelvic floor repair of a patient, comprising

a surgical implant having a first end adapted to extend to a first obturator membrane of the patient, a second end adapted to extend to a second obturator membrane of the patient, and a central region adapted to extend at least posterior to the bladderneck of the patient; and

first and second soft tissue anchors coupled to respective ones of the first and second ends of the surgical implant for securing the first and second ends to respective first and second obturator membranes.

2. The assembly ofclaim 1, wherein the central region is sized and shaped for supporting the base of the bladder of the patient.

3. The assembly ofclaim 1, wherein the implant has a maximum anterior-to-posterior width of greater than about 4 cm.

4. The assembly ofclaim 1, wherein the implant has a lateral width less than about three times an anterior-to-posterior width of the implant.

5. The assembly ofclaim 1, wherein the central region is circular.

6. The assembly ofclaim 1, wherein the first soft tissue anchor comprises an elongated body having an aperture in a proximal end and a passage extending axially in a distal direction at least part way to a distal end of the elongated body, and a plurality of barbs projecting from an outer surface of the elongated body.

7. The assembly ofclaim 1, wherein the first soft tissue anchor has a smooth outer surface.

8. The assembly ofclaim 7, wherein the first soft tissue anchor comprises an elongated body having an aperture in a proximal end and a passage extending axially in a distal direction at least part way to a distal end of the elongated body.

9. The assembly ofclaim 1, wherein the implant includes at least one tanged portion.

10. The assembly ofclaim 1, wherein the first soft tissue anchor is bioabsorbable.

11. The assembly ofclaim 1, wherein the first soft tissue anchor couples to the sling by a filament.

12. The assembly ofclaim 11, wherein the filament has sufficient length to space the first soft tissue anchor apart from the implant.

13. The assembly ofclaim 12, wherein the filament comprises an adjustable size loop to vary a space between the first soft tissue anchor and the implant.

14. The assembly ofclaim 1, wherein the first soft tissue anchor physically contacts the implant, and the orientation of the implant with respect to the soft tissue anchor is adjustable.

15. A surgical implant assembly for pelvic floor repair of a patient, comprising

an implant for extending at least partially between a first obturator membrane and a second obturator membrane of a patient, and having a first strap end for aligning with the first obturator membrane and a second strap end for aligning with the second obturator membrane; and

a first plurality of soft tissue anchors coupled to the first strap end of the implant for securing the first strap end to a first soft tissue region, and

a second plurality of soft tissue anchors coupled to the second strap end of the implant for securing the second strap end to a second soft tissue region.

16. The assembly ofclaim 15, wherein the first plurality of soft tissue anchors secure the first strap end to the first obturator membrane, and the second plurality of soft tissue anchors secure the second strap end to the second obturator membrane.

17. The assembly ofclaim 16, wherein the first plurality of soft tissue anchors comprises at least three soft tissue anchors, and the second plurality of soft tissue anchors comprises at least three soft tissue anchors.

18. A method for implanting a surgical implant in the pelvic floor region of a patient comprising

creating an incision in the vaginal wall of the patient,

coupling the implant to a delivery device,

inserting the delivery device through the vaginal incision via the external vaginal opening of the patient to extend a portion of the implant to an anatomical location posterior to the bladder neck of the patient, and

guiding the device to a location beneath the patient's epidermis to secure the implant in the patient's soft tissue.

19. The method ofclaim 18, comprising securing a first end of the implant to a first obturator membrane, and securing a second end of the implant to a second obturator membrane.

20. The method ofclaim 18, comprising

coupling a first soft tissue anchor to a first end of the implant,

coupling a second soft tissue anchor to a second end of the implant, and

anchoring the first and second soft tissue anchors to respective obturator membranes.

21. The method ofclaim 20, comprising adjusting the tension of the implant by extending or retracting a portion of at least one of the first end and the second end of the implant through the respective obturator membranes.

22. The method ofclaim 20, comprising

coupling the first soft tissue anchor to the first end of the implant by threading a filament through the first soft tissue anchor and the implant,

cinching the filament into a loop with a first slidable filament locking element,

coupling the second soft tissue anchor to the second end of the implant by threading a filament through the second soft tissue anchor and the implant, and

cinching the filament into a loop with a second slidable filament locking element.

23. The method ofclaim 22, further comprising tensioning the implant by sliding at least one of the first filament locking element and the second filament locking element towards a respective one of the first soft tissue anchor and the second soft tissue anchor, thereby drawing a respective one of the first end and the second end of the implant towards the respective one of the first soft tissue anchor and the second soft tissue anchor.

24. The method ofclaim 18, wherein inserting the delivery device through the vaginal incision via the external vaginal opening of the patient comprises

coupling the implant to a delivery device having a shaft and a slidable cannula disposed about the shaft,

inserting the delivery device through the external vaginal opening,

guiding the delivery device through the vaginal incision subsequent to inserting the delivery device through the external vaginal opening,

aligning the shaft with a first obturator membrane,

sliding the cannula distally along the shaft, and

securing the implant to the first obturator membrane.

25. The method ofclaim 18, wherein coupling the implant to the delivery device includes coupling the implant to at least soft tissue anchor, and coupling the soft tissue anchor to a shaft of the delivery device.

26. The method ofclaim 25, further comprising

creating an aperture in an obturator membrane, and

driving the soft tissue anchor through the aperture.

27. The method ofclaim 18, wherein securing the implant comprises

coupling a first plurality of soft tissue anchors to a first end of the implant,

coupling a second plurality of soft tissue anchors to a second end of the implant,

anchoring the first plurality of soft tissue anchors to a first obturator membrane, and

anchoring the second plurality of soft tissue anchors to a second obturator membrane.

28. The method ofclaim 18, wherein the implant has at least one tanged portion.

29. The method ofclaim 18, wherein the implant has a plurality of soft tissue anchors on a first end of the implant.

30. The method ofclaim 18, comprising securing the mesh to one or both of the sacrospinous ligament and levator ani muscle.

31. A surgical implant assembly for pelvic floor repair of a patient, comprising

a surgical implant having a first end, a second end, and a central region adapted to extend to a position posterior to the bladderneck of the patient; and

at least one soft tissue anchor coupled to an end of the surgical implant and adapted to secure the implant within the patient's pelvic floor.

32. The assembly ofclaim 31, wherein the central region is sized and shaped for supporting the base of the bladder of the patient.

33. The assembly ofclaim 31, wherein the implant has a lateral width less than about three times an anterior-to-posterior width of the implant.

34. The assembly ofclaim 31, wherein the first end is adapted to extend to a first obturator membrane of the patient, and the second end is adapted to extend to a second obturator membrane of the patient.

35. The assembly ofclaim 31, wherein the at least one soft tissue anchor comprises an elongated body having an aperture in a proximal end and a passage extending axially in a distal direction at least part way to a distal end of the elongated body, and a plurality of barbs projecting from an outer surface of the elongated body.

36. The assembly ofclaim 31, wherein the implant includes at least one tanged portion.

37. The assembly ofclaim 31, wherein the at least one soft tissue anchor is bioabsorbable.

38. The assembly ofclaim 31, wherein the at least one soft tissue anchor couples to the sling by a filament.

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