Patent Grant
11446129
The invention relates to apparatus and methods for treating urinary incontinence by use of an implant to support urethral tissue.
Men, women, and children of all ages can suffer from urinary incontinence or involuntary loss of urinary control. Their lives are perpetually interrupted by thoughts of ensuring that they have ready access to a restroom. Everyday activities such as attending a theater or sporting event can become unpleasant. Sufferers often begin to avoid social situations in an effort to reduce the stress associated with their condition.
A variety of treatment options are currently available. Some of these include external devices, behavioral therapy (such as biofeedback, electrical stimulation, or Kegel exercises), prosthetic devices, and surgery. Depending on the age, medical condition, and personal preference of a patient, surgical procedures can be used to completely restore continence.
One type of surgical procedure found to be an especially successful treatment option for incontinence in both men and women is a sling procedure. Sling procedures typically entail surgically implanting a biocompatible implant or “sling” to support the bladder neck or urethra. Sling procedures are discussed in U.S. Pat. Nos. 5,112,344; 5,611,515; 5,842,478; 5,860,425; 5,899,909; 6,039,686; 6,042,534; 6,110,101; 6,478,727; 6,638,211; and PCT Publication Nos. WO 02/39890 and WO 02/069781.
Some “pubomedial” sling procedures involve an abdominal incision and installation of a sling between the rectus fascia in the abdominal region to a position below the urethra, and back again to the rectus fascia. A conventional procedure in females is to surgically place a sling by entering the abdominal cavity through an incision in the patient's pubovaginal region.
In males, one example of a conventional method involves surgical placement of a sling by entering the abdominal cavity through an abdominal incision. Unfortunately, to access the abdominal cavity a surgeon must incise the male patient's abdominal muscles. This procedure is more time consuming and uncomfortable for the male patient
Other methods for treating pelvic conditions involve installation of a sling below the urethra through incisions made at the inner thigh (e.g., in the perineal skin facing the obturator and in the groin), and using a tissue path extending through the obturator. These procedures can be referred to as “transobturator” methods. See, e.g., U.S. Pat. No. 6,911,003 and Published U.S. Pat. Appl. No. 2003/0171644A1, the entireties of each being incorporated herein by reference.
While abdominal and transobturator methods of treating urinary incontinence can be effective, safe, and long-lasting, there is ongoing effort toward improving these methods.
The invention relates to methods of treating pelvic conditions, e.g., urinary incontinence, in males and females.
Certain embodiments of methods and implants involve placement of a tissue support portion of an implant below a urethra, preferably with placement of extension portions of the implant at tissue paths that extend from a location to support the urethra in a direction toward an obturator foramen. A tissue path may extend toward and end at pelvic fascia without reaching or passing into or through the obturator foramen. In other embodiments a tissue path may extend to the obturator foramen. In still other embodiments the tissue path may extend through an obturator foramen. The methods can involve two opposing tissue paths, as described, one on each of a left and a right side of the patient.
The implant may involve an adjustment feature that allows placement of the implant followed by or along with adjustment of the positioning or size of the implant, such as one or more adjustable extension portion. The adjustment feature may be a one-way adjusting engagement, a two-way adjusting engagement feature, a two-way adjusting feature that additionally includes a locking feature, etc. A method may involve adjusting the size of the implant by use of an adjusting feature or adjusting engagement between an extension portion and a support portion. The implant may be placed and optionally adjusted by use of a tool that can contact an implant to allow manipulation of the implant; optionally at the same time the tool may allow for or may be used to provide movement or approximation of tissue to be supported by the implant (e.g., tissue of a urethra).
In one aspect, the invention relates to a system for treating urinary incontinence, the system including a multi-piece implant comprising a support portion piece and an extension portion piece, and an adjusting tool. The support portion piece comprises a tissue support portion sized and shaped for placement to support a urethra. The extension portion piece comprises a proximal end, a distal end, and a tissue fastener, and is adjustably connected to the support portion piece at an adjusting engagement. The adjusting tool comprises a surface capable of engaging the support portion piece, and a moveable holder capable of holding the proximal end of the extension portion piece and moving the proximal end relative to the adjusting engagement.
In another aspect the invention relates to a system for treating a pelvic condition such as urinary incontinence, the system comprising an implant and a tool. The implant comprising a support portion, two extension portions, and two self-fixating tips, one self-fixating tip at an end of each extension portion, and a guide engaged with at least one of the self-fixating tips. The tool includes a shaft having a distal end capable of engaging the self-fixating tip, and a release mechanism at the distal end, the release mechanism capable of selectively engaging and releasing the self-fixating tip. The shaft is capable of engaging the guide to allow the shaft to be led along the guide to become engaged with the self-fixating tip.
In another aspect the invention relates to a system for treating a pelvic condition incontinence. The system includes an adjustable implant comprising a support portion, two extension portions, and two self-fixating tips. One self-fixating tip is located at an end of each extension portion. At least one self-fixating tip is moveably engaged with one of the two extension portions. The support portion being is movable to adjust a location of the support portion along the implant between the self-fixating tips.
In another aspect the invention relates to a system for treating urinary incontinence, the system comprising a multi-piece implant comprising a support portion piece and two extension portion pieces, and an adjusting tool. The support portion piece comprises a tissue support portion sized and shaped for placement to support a urethra. The extension portion pieces each comprise a proximal end, a distal end, and a tissue fastener. The first extension portion piece is adjustably connected to the support portion piece at a first adjusting engagement. The second extension portion piece is adjustably connected to the support portion piece at a second adjusting engagement. The adjusting tool comprises two adjusting surfaces, the two adjusting surfaces being capable of engaging the support portion piece in a manner to place tension along a length of the support portion piece
In yet another aspect the invention relates to a system for treating urinary incontinence, the system comprising an implant and a tool. The implant comprises a support portion, two extension portions, and a self-fixating tip at a distal end of each extension portion. The tool comprises a proximal end and a distal end, a surface at the distal end capable of approximating a urethra, two shafts that can be extended and retracted from the distal end, and an adjusting surface at each shaft distal end, each adjusting surface being capable of engaging a self-fixating tip.
In another aspect the invention relates to a system for treating urinary incontinence, the system comprising a multi-piece implant comprising a support portion piece and an extension portion piece, and an adjusting tool. The support portion piece comprises a tissue support portion sized and shaped for placement to support a urethra. The extension portion piece comprises a proximal end, a distal end, and a tissue fastener, and is adjustably connected to the support portion piece at an adjustable connection. The adjusting tool comprises a surface capable of engaging the support portion piece.
In another aspect the invention relates to a method of treating urinary incontinence in a male or a female patient. The method includes providing a system according as described herein, placing the implant below a urethra of the patient and placing tissue fasteners at supportive tissue. Optionally the placement of the implant can be adjusted, the size of the implant or an extension portion can be adjusted, and the method can include using a tool to approximate tissue of the urethra.
The systems, devices, tools, implants, etc., described herein are directed to surgical instruments, assemblies, implantable articles, systems and related methods for treating urinary incontinence in a male or female, including stress urinary incontinence (SUI). An implant can be implanted in a male or a female to treat a condition such as urge incontinence, mixed incontinence, overflow incontinence, functional incontinence, and the like.
An implant can include a tissue support portion (or “support portion”) that can be used to support a urethra or other pelvic tissue. Supporting a “urethra” refers to supporting tissue that includes the urethra (which can refer to the bladder neck) and that can optionally include tissue adjacent to a urethra such as bulbospongiosus muscle, corpus spongiosum, or both. According to various methods, for example, a support portion may either be placed below bulbospongiosus muscle to support both ulbospongiosus muscle and corpus spongiosum (along with the urethra), or alternately bulbospongiosus muscle may be dissected and a support portion may be placed to contact corpus spongiosum tissue (to support the urethra).
An implant can additionally include one or more extension portion (otherwise known as an “end” portion or “arm”) attached or attachable to the tissue support portion. Normally, for treating incontinence, an implant can include two opposing extension portions. Extension portions are elongate pieces of material (e.g., mesh, suture, or biologic material) that extend from the tissue support portion and either are or can be connected to the tissue support portion, and are useful to attach to anatomical features or “supportive tissue” in the pelvic region (e.g., using a self-fixating tip or another form of tissue fastener) to thereby provide support for the tissue support portion and the supported tissue. Generally for treating incontinence, two extension portions can extend from the opposite ends of a tissue support portion as elongate “ends,” “arms,” or “extensions,” and may attach to supportive tissue in the pelvic region by extending through a tissue path to an internal anchoring point (see, e.g., Applicant's co-pending United States Patent Application Publication number US 2010/256442, filed Aug. 8, 2008, by Ogdahl, entitled SURGICAL ARTICLES AND METHODS FOR TREATING PELVIC CONDITIONS, the entirety of which is incorporated herein by reference), or may extend to an external incision, such as through an obturator foramen and through an external incision at a groin or inner thigh (see, e.g., Applicant's co-pending United States Patent Publication Number US 2006/0287571, the entirety of which is incorporated herein by reference). Also see U.S. Patent Publication number US 2011/0034759 and WO 2010/093421, the entireties of which are incorporated hereby by reference.
In exemplary uses, each extension portion can extend from the location of attachment with the tissue support portion, through pelvic tissue, and optionally be attached to supportive tissue within the pelvic region. For certain procedures the supportive tissue can be tissue adjacent to the urethra such as pelvic fascia; tissue between the urethra and an obturator foramen such as pelvic fascia; or tissue of an obturator foramen such as obturator fascia, obturator internus muscle, obturator membrane, obturator externus muscle, etc. For alternate procedures an extension portion can be sized to extend from the tissue support portion, through an obturator foramen, around a pubic ramus bone, and threaded (subcutaneously) back to a medial location such as near a medial incision.
An implant may include portions, pieces, or sections that are synthetic or of biologic material (e.g., porcine, cadaveric, etc.). Extension portions may be, e.g., a synthetic mesh such as a polypropylene mesh, a suture, a biodegradable suture, etc. The tissue support portion may be synthetic (e.g., a polypropylene mesh) or biologic. Examples of implant products that may be similar to those useful according to the present description, include those sold commercially by American Medical Systems, Inc., of Minnetonka Minn., under the trade names Apogee®, Perigee®, and Elevate® for use in treating pelvic prolapse (including vaginal vault prolapse, cystocele, enterocele, etc.), and Spare®, Bioarc®, Monarc®, and MiniArc® for treating urinary incontinence.
An example of a particular type of pelvic implant is the type that includes supportive portions including or consisting of a tissue support portion and two opposing extension portions extending from the tissue support portion. An implant that has exactly two extension portions can be of the type useful for treating urinary incontinence. The term “supportive portions” refers to portions of an implant that function to support tissue after the implant has been implanted, and specifically includes extension portions and tissue support portions, and does not include optional or appurtenant features of an implant such as a sheath, tensioning suture, tissue fastener, or self-fixating tip or other type of connector for attaching the implant to an insertion tool.
A preferred implant (e.g., sling) for placement against a corpus spongiosum for treatment of urinary incontinence in a male patient may optionally and preferably include a widened central support to provide increased contact and frictional engagement with the corpus spongiosum. See, for example, Assignee's co-pending United States Patent Publication Number US 2006/0287571 and U.S. Pat. No. 7,422,557, the entireties of these applications being incorporated herein by reference.
Dimensions of a tissue support portion can be any dimensions useful to support urethra tissue for treating incontinence. A tissue support portion can be of sufficient length to support and optionally partially surround a urethra or urethra-supporting tissue. A width of a tissue support portion may optionally and preferably be greater than a width of extension portions and can be sufficiently wide to increase contact area and frictional forces between a tissue support portion and a tissue in contact with the tissue support portion. Exemplary lengths of a tissue support portion can be in the range from 0.5 to 2 inches, such as from 0.75 to 1.5 inches. Exemplary widths of a tissue support portion can be in the range from 0.4 or 0.5 to 4 centimeters, such as from 1 to 2.5 or 3 centimeters. (A tissue support portion may be part of a support portion piece that includes the tissue support portion and optionally some amount of opposing extension portions extending from ends of the tissue support portion.
Dimensions of extension portions according to the invention can allow the extension portion to reach between a tissue support portion placed to support a urethra (at an end of the extension portion connected to the tissue support portion) and a location at which the distal end of the extension portion attaches to supportive tissue at or about the pelvic region. Exemplary lengths of an extension portion for these embodiments, measured for example between a connection or boundary between the extension portion and the tissue support portion, and a distal end of the extension portion, can be, e.g., from 0.5 to 2.75 inches, preferably from LO to 2.25 inches, and the length can optionally and preferably be adjustable. As described elsewhere herein, a length of an extension portion may be fixed (i.e., the extension portion does not include any form of length-adjusting mechanism). Alternate embodiments of implants may include an adjusting engagement that allows a physician to alter the length of an extension portion before, during, or after implantation.
Implants as described can include a tissue fastener at a distal end or a distal portion of an extension portion, which is the end or portion not attached to a tissue support portion. (The term «distal” as used herein (unless noted otherwise) generally refers to a direction toward a patient and away from a surgeon installing a device.) A tissue fastener at a distal end or portion of an extension portion can be any of various types, including: a self-fixating tip that is inserted into soft tissue and frictionally retained; soft tissue anchors; biologic adhesive; a soft tissue clamp that can generally include opposing, optionally biased, jaws that close to grab tissue; and opposing male and female connector elements that engage to secure an end of an extension portion to tissue. (See International Patent Application No. PCT/US2007/014120, entitled “Surgical Implants, Tools, and Methods for Treating Pelvic Conditions, filed Jun. 15, 2007; U.S. patent application Ser. No. 12/223,846, filed Aug. 8, 2008, entitled SURGICAL ARTICLES AND METHODS FOR TREATING PELVIC CONDITIONS, now U.S. Publication No. 2010/0256442; U.S. patent application Ser. No. 12/669,099, filed Jan. 14, 2010, entitled PELVIC FLOOR TREATMENTS AND RELATED TOOLS AND IMPLANTS, now U.S. Publication No. 2010/0261955; and WO 2009/075800, the entireties of which are incorporated herein by reference.) An implant may also have one or more extension portion that does not include a tissue fastener, for example if the distal end is designed to be secured to tissue by other methods (e.g., suturing), or is intended to pass through an obturator foramen and a tissue path around a pubic ramus bone, in which case the extension portion may optionally include a connector, dilator, or dilating connector, which connects to an elongate tool that can be used to either push or pull the connector, dilator, or dilating connector through a tissue path (e.g., to a medial incision).
One embodiment of a tissue fastener is a self-fixating tip. A “self-fixating tip” in general can be a structure (sometimes referred to as a soft tissue anchor) connected at a distal end of an extension portion (or extension portion piece) that can be implanted into soft tissue (e.g., muscle, fascia, ligament, etc.) in a manner that will maintain the position of the self-fixating tip and support the attached implant. Exemplary self-fixating tips can also be designed to engage an end of an insertion tool (e.g., elongate needle, elongate tube, etc.) so the insertion tool can be used to push the self-fixating tip through and into tissue for implantation, preferably also through a medial incision to reach the interior of the pelvic region, e.g., at a location of an obturator foramen. The insertion tool may engage the self-fixating tip at an internal channel of the self-fixating tip, at an external location such as at an external surface of the base, at a lateral extension, or otherwise as desired, optionally in a manner to allow the insertion tool to push the self-fixating tip through an incision in a patient and through and into supportive tissue.
Exemplary self-fixating tips can include one or more lateral extensions that allow the self-fixating tip to be inserted into soft tissue and to become effectively anchored in the tissue. A lateral extension may be moveable or fixed. The size of the self-fixating tip and optional lateral extensions can be useful to penetrate and become anchored into the tissue. Exemplary self-fixating tips are described in Assignee's co-pending international patent application PCTUS2007/004015, filed Feb. 16, 2007, titled Surgical Articles and Methods for Treating Pelvic Conditions, the entirety of which is incorporated herein by reference. Other structures may also be useful.
According to exemplary embodiments, a self-fixating tip can have structure that includes a base having a proximal base end and a distal base end. The proximal base end can be connected (directly or indirectly, such as by a connective suture) to a distal end of an extension portion. The base extends from the proximal base end to the distal base end and can optionally include an internal channel extending from the proximal base end at least partially along a length of the base toward the distal base end. The optional internal channel can be designed to interact with (i.e.; engage, optionally by means of a release mechanism that can be selectively engaged and released) a distal end of an insertion tool to allow the insertion tool to be used to place the self-fixating tip at a location within pelvic tissue of the patient. A self-fixating tip can be made out of any useful material, generally including materials that can be molded or formed to a desired structure and connected to or attached to a distal end of an extension portion of an implant. Useful materials can include plastics such as polyethylene, polypropylene, and other thermoplastic or thermoformable materials, as well as metals, ceramics, and other types of biocompatible and optionally bioabsorbable or bioresorbable materials. Exemplary bioabsorbable materials include, e.g., polyglycolic acid (PGA), polylactide (PLA), copolymers of PGA and PLA.
According to various systems as described, one or more instrument, insertion tool, adjusting tool, or the like, may be incorporated or used with the described implants and methods. Examples of useful tools include those that generally include one or more (stationary or moveable) thin elongate, relatively rigid shaft or needle that extends from a handle. The shaft can be a single elongate shaft or multiple separate elongate shafts extending from the handle, or one or more primary shaft that extends from the handle and that contains multiple branch or “tine” shafts that separate at the end of the primary shaft. The handle is located at a proximal end of the device and attaches to one end (a proximal end) of a shaft. According to some embodiments, a distal end of one or more shaft can be adapted to engage a portion of an implant, such as a tissue fastener (e.g., a self-fixating tip), in a manner that allows the insertion tool to engage and push the tissue fastener through a tissue passage and connect the tissue fastener to supportive tissue of the pelvic region. Examples of this type of tool can be use<1 with a self-fixating tip that includes an internal channel designed to be engaged by a distal end of an insertion tool to allow the self-fixating tip to be pushed into tissue. Other general types of insertion tools will also be useful but may engage a self-fixating tip or other tissue fastener in an alternate manner, e.g., that does not involve an internal channel.
According to other embodiments, a distal end of a tool (e.g., at one more shaft) can be adapted to engage one or more other portion of an implant, such as support portion, a proximal end of an extension portion, or both. The insertion tool may manipulate a tissue support portion and an extension portion of a multi-piece implant in a manner to allow the tool to adjust the size or positioning of the implant.
Exemplary insertion tools for treatment of incontinence and vaginal prolapse are described, e.g., in U.S. patent application Ser. No. 10/834,943, now U.S. Pat. No. 7,500,945, Ser. No. 10/306,179, now U.S. Pat. No. 7,070,556; Ser. No. 11/347,553, now U.S. Pat. No. 7,422,557; Ser. No. 11/398,368, now U.S. Pat. No. 7,740,576; Ser. No. 10/840,646. now U.S. Pat. No. 7,351,197; PCT application number 2006/028828, published as WO 2007/016083; PCT application number 2006/0260618; WO 2010/093421, and US Patent Publication No. 2010-0256442 the entirety of these documents being incorporated herein by reference.
A tool according to the invention can optionally include a mechanism by which a tissue fastener (e.g., a self-fixating tip) can be securely and releasable engaged with a distal end of an insertion tool such that the tissue fastener can be selectively secured to the distal end mechanically, then selectively released. With a releasable engagement, a tissue fastener (e.g., self-fixating tip) can be released from the distal end by releasing the engagement (e.g., mechanical engagement) by movement of an actuator at the proximal end of the insertion tool, such as at the handle. For example, an internal channel (or external surface) of a self-fixating tip can include an engaging surface designed to engage a mechanism at a distal end of an insertion tool while the self-fixating tip is placed at, on, or over the distal end. As an example, an internal or external surface of a self-fixating tip can include a depression, ring, edge, or ledge, that can be rounded, angular, etc. A mechanical detent such as a pin, ball, spring, deflector, or other surface or extension located at the distal end of the insertion tool can be moved, deflected, or extended relative to the distal end of the insertion tool to contact the surface of the self-fixating tip to securely and releasably hold the self-fixating tip at the distal end of the insertion tool and prevent removal of the tip from the distal end until removal is desired. The detent (or other surface or mechanism) can be cause to extend (or retract) from the distal end of the insertion tool by actuating a trigger or other mechanism located at the proximal end (e.g., handle or a proximal location of a shaft) of the insertion tool, to secure (or release) the self-fixating tip. Upon placement of the self-fixating tip at a desired location during a surgical implantation procedure, the insertion tool operator can release the self-fixating tip by use of the trigger or other mechanism at the handle to disengage the detent and cause the tip to become loose. The insertion tool can then be removed from the tissue path, and the self-fixating tip can remain in a desired implanted location.
Optionally, an implant can include a tissue fastener at a location of a tissue support portion, or at a location along a length of an extension portion. This form of tissue fastener can be in the form of reinforced (e.g., by coating, heat treating, or a reinforcing weave or strip) edge extensions, multiple layers of mesh and edge extensions in an extension portion, etc., as described, for example, at Applicant's co-pending U.S. Pat. No. 7,422,557, and Applicant's co-pending United States Patent Publication Numbers US 2006/0195011, US 2006/0195007, and US 2006/0195010, all of which are incorporated herein by reference. Other examples include relatively rigid structures such as metal, plastic, or other polymeric or non-polymeric structure that may be shaped to frictionally engage soft tissue, for example to include a tine, hook, chevron, barb, arrow, etc., combinations thereof, or any structure added to an edge or surface of an extension portion to improve fixation within tissue. The structure can have any shape or form that will increase frictional force between the. implant and adjacent tissue, such as one or multiple pointed surface directed along a length of an extension portion, toward the tissue support portion, and extending away from a surface or edge of the implant (e.g., extension portion). The tissue fastener can be located at a position of an implant that will result in the tissue fastener being located at supportive tissue such as muscle or fascia when the implant is placed with a midline of the tissue support portion being located below a urethra. For example, a tissue fastener may be located on a tissue support portion or an extension portion of an implant, e.g., as close as 2 or 3 centimeters from a midline of a tissue support portion, and up to a distance that reaches tissue of an obturator foramen when the midline is located below a urethra, e.g., up to 7 centimeters from the midline.
According to various embodiments of implants described herein, an implant can include multiple pieces that are adjustably connected together by an adjusting engagement. A “multi-piece” implant refers to an implant that includes a “support portion piece” and one or multiple “extension portion piece” as separate pieces of the implant. An extension portion piece can be separate from a support portion piece, and the two pieces can be connected through an adjustable engagement. The support portion piece includes a tissue support portion.
An adjusting engagement may be for example a one-way adjusting engagement, a two-way adjusting engagement, or a locking two-way engagement, that allows a portion, piece, or a segment of an implant to be moved relative to another portion, piece, or segment if the implant and adjusted as to length, tension, or positioning. Examples of adjusting engagements are described, for example, in Applicant's co-pending U.S. patent application Ser. No. 12/308,436, filed Dec. 15, 2008, entitled SURGICAL IMPLANTS AND TOOLS FOR TREATING PELVIC CONDITIONS, now U.S. Publication No. 2011/0112357, and U.S. patent application Ser. No. 12/669,099, filed Jan. 14, 2010, entitled PELVIC FLOOR TREATMENTS AND RELATED TOOLS AND IMPLANTS, now U.S. Publication No. 2010/0261955, the entireties of which are incorporated herein by reference.
Some adjusting engagements can allow two-way movement of one piece relative to another piece (e.g., a “two-way” adjusting engagement). This type of adjusting engagement allows movement of a segment of implant (e.g., of a segment or portion of an extension portion piece) in two directions through an adjusting engagement. The force needed to move the segment of implant in one direction is substantially equal to the force needed to move the segment in the opposite direction, and, optionally, the two-way adjusting engagement does not substantially hinder the movement of a segment of implant through the adjusting engagement with frictional surfaces such as extensions (e.g., “teeth”) extending into an aperture through which the segment of implant is moved. As an example, a two-way adjusting engagement may include an open (smooth) aperture that may be circular, oval, square, elongate, or rectangular, such as in the form of a circle, slit, or slot, etc. The aperture may optionally be reinforced by a reinforced perimeter of a shape that is similar to the aperture, such as by a fabric or a polymeric material such as a grommet (e.g., a “loose grommet” or “eyelet”), which may be circular, square, rectangular, or of any desired shape. The reinforced perimeter (e.g., grommet) defines a reinforced aperture through which a segment of implant can pass relatively freely and with the same resistance two different directions
A two-way adjusting engagement may optionally be capable of an open and a closed (e.g., locked) configuration, the open configuration allowing two-way movement between the pieces, and the closed (or locked) configuration preventing any movement between the pieces. Such an adjusting engagement may be referred to as a locking two-way adjusting engagement and may include any form of mechanical securement device that can be configured in an open configuration (to allow two-way movement between pieces) and a closed configuration (to prevent movement between pieces). The locking two-way adjusting engagement may be selectively and reversibly moveable between the open configuration and the closed configuration or may instead initially be an open configuration that, once placed in a closed configuration, cannot be re-configured to the open configuration. Examples of structures that may be part of a locking two-way adjusting engagement include a mechanical clip, staple, stitch, detent, or rivet; any form of spring-loaded or moveable frictional engagement; a non-moveable frictional engagement such as a slot, slit, cleat, or other non-moveable aperture or opening through which a portion of implant can be selectively engaged, released, and re-engaged; a deformable opening, ring, clip, staple, etc., which may be generally open and then permanently closed by mechanical deformation; and the like. One form of exemplary structure may be forceably closed (e.g. by bending a part until permanent deformation or closing a part until some latch or similar feature snaps shut), while others may be biased to close (e.g. a spring-loaded clip is held open until released so it can clamp shut). Changing from an open to a closed orientation could be performed by an independent tool or may be an additional feature built into the adjustment tool. The clip or alternate opening-closing structure could be attached to larger structure of an adjusting engagement (potentially integrated into its design), or separate (so it could be loaded into the tool).
Other adjusting engagements may allow for one-way adjustment such as shortening of a length of an extension portion. These adjusting engagements can be referred to as “one-way” adjusting engagements and allow adjustment of a length of an implant portion (e.g., extension portion) in one direction and not (or not easily) in an opposite direction. An exemplary one-way adjusting engagement can include an aperture through which a segment of implant (e.g., a portion of an extension portion piece) can extend, and one or multiple surfaces (e.g., extensions or teeth) that frictionally engage the segment of implant passing therethrough, e.g., by extending into or toward the aperture or otherwise contacting the segment of implant to inhibit movement of the segment of implant relative to the adjusting engagement. The one-way engagement can preferentially allow movement of the segment of implant through the aperture in one direction while inhibiting or preventing movement of the segment of implant in an opposing direction.
In use of a tissue support portion that includes a one-way adjusting engagement such as a round or rectangular grommet, a tissue fastener (e.g., a self-fixating tip) at one end of an extension portion is placed at tissue as desired, and the second (loose) end of the extension portion piece is passed through the one-way adjusting engagement. The engagement is adjusted to place the support portion piece at a desired position (length) of the extension portion piece to provide desired support to a urethra. The one-way adjusting engagement moves easily along the extension portion piece in a direction that tightens the implant against urethra tissue and does not move easily in the opposite direction. Once placed in position below the urethra and tightened as desired, the support portion piece is prevented from moving along the extension portion piece in the direction to reduce support of the urethra. The extension portion piece may optionally be considered to be “smooth,” without any visible:frictional surface, or may alternately include bumps, detents, teeth, a jagged surface, or other frictional or mechanical structure to engage opposing structure at a surface of an aperture of the one-way adjusting engagement.
During use, a distal end of an insertion tool (e.g., distal end 14) can be inserted into a proximal end of a guide tube and guided through the guide tube to engage self-fixating tip 28. The guide allows the distal end to engage the self-fixating tip while the self-fixating tip is engaged with the guide. This allows the distal end to engage the self-fixating tip outside of the patient so a surgeon can use the insertion tool to initially place the self-fixating tip through a medial incision and into engagement with supportive tissue. The initial placement may first be performed, after which the shaft and distal end may be removed from the guide and the patient, and the placement and tension of the self-fixating tip and implant may be tested to determine if adjustment is necessary. If so, the distal end and shaft may be re-engaged with the self-fixating tip previously placed at the tissue by re-inserting the distal end into the guide (which is accessible, e.g., a proximal end can remain outside of the patient) and passing the distal end through the guide to re-engage the distal end with the self-fixating tip. The guide leads the distal end to the self-fixating tip, and the distal end can re-engage the self-fixating tip. The insertion tool can then be used to push the self-fixating tip to a location of deeper penetration into the tissue.
After desired placement of the self-fixating tip, followed by disengagement and optional re-engagement of an insertion tool with the initially-placed self-fixating tip, and adjustment, the insertion tool can be removed from the guide and the guide can be removed from the self-fixating tip (optionally while the distal end is engaged with the self-fixating tip).
As then shown at
Tool 50 includes handle 40, shaft 42, and distal end 44 capable of engaging an aperture of each of self-fixating tips 88. Tool 50 is not specifically illustrated to include a release mechanism like that described with respect to tool 10, but tool 50 could optionally include a release mechanism.
Upon desired adjustment, locking disk 92 can be moved distally (toward the patient and toward support portion 84 and self-fixating tips 88) along proximal portions (or loop) 76 of extension portions 86, to secure the location of support portion 84 relative to extension portions 86. Locking disk 92 can be frictionally secured to proximal portions 76 to prevent movement of support portion 84 relative to extension portions 86 after desired placement of locking disk 92 relative to proximal portions 76. Optionally an adjusting tool 90 (or “disk pusher tool” 90) can be used to push disk 92 along lengths of proximal portions 76 and toward support portion 84. Proximal portions 76 can be threaded through aperture 96 at a distal end of tool 90, and distal surface 94, which surrounds aperture 96, can contact a proximal surface of disk 92 to push disk 92 distally along proximal portions 76 and toward support portion 84.
Tool 80 includes handle 81, shaft 83, and distal end 89 capable of engaging an aperture of each of self-fixating tips 88. Tool 80 is not illustrated to include a release mechanism like that described with respect to tool 10, but tool 80 could 20 optionally include a release mechanism.
Embodiments of systems, kits, methods, and devices as described also include adjusting tools for simultaneously contacting two surfaces of an implant, especially two spaced surfaces of a support portion piece, e.g., to manipulate or stabilize the support portion piece, to allow adjustment of extension portion pieces relative to the support portion piece. Preferred tools can include two adjusting surfaces that are capable of concurrently (e.g., simultaneously) contacting two spaced surfaces of a support portion piece, each of the two surfaces of the support portion piece being part of, at, or adjacent to a component of an adjusting engagement, e.g., a one-way adjusting engagement or a two-way adjusting engagement that can be closed or locked.
An adjusting tool can include any useful structure to support the adjusting surfaces of the adjusting tool, such as a handle (optional) at a proximal end, a shaft or multiple shafts extending from the handle, or alternate forms of support for the adjusting surfaces. An adjusting surface can be any surface that can contact or otherwise engage a surface of an implant or a component of an implant. Optionally an adjusting surface can be a structure that defines an aperture, slot, opening, channel, peg, slit, extension, insert, or other surface that is sized to engage a opposing or complementary component or surface of a single piece or a multi-piece implant, e.g., an extension portion piece (e.g., a proximal end of an extension portion piece), a support portion piece, or a tissue fastener (e.g., a self-fixating tip). Adjusting surfaces of an adjusting tool can be spaced from each other by a distance that will allow simultaneous contact with two locations on opposing sides of an implant during use of the adjusting tool to position and optionally adjust the position of the implant relative to urethral tissue being supported. For example, adjusting surfaces may be located on a line that is perpendicular to an axis of a shaft of an adjusting tool, or that is perpendicular to a line parallel to an axis of a shaft of a tool, and may be spaced by a distance in the range of 0.5 to 10 centimeters, such as a distance in the range from 2 to 8 centimeters or from 2 to 6 centimeters (depending on the locations of the implant that the adjusting surfaces are intended to contact). Optionally, the adjusting surfaces can be either stationary or moveable (e.g., extendable away from another component of the adjusting tool such as a handle or a primary shaft.
In certain embodiments, each of two adjusting surfaces can be located at an end of a single or of two separate shafts extending from a handle. In particular embodiments a single (e.g., primary) shaft may extend from a handle, two separate tines or extensions can extend in different directions from the single shaft at a distal location, and one adjusting surface can be at an end of each tine (or “extension”). For example, an adjusting tool may include a handle, a single shaft, and a “yoke” fixed or movably located at a distal end of the shaft; the yoke can extend in two directions from the shaft and can include one adjusting surface at the end of each extension. A line that connects the adjusting surfaces may be located to intersect a longitudinal axis of the shaft (the shaft, shaft extensions, and adjusting surfaces are contained in a single plane), or, in alternate embodiments, a line that connects the adjusting surfaces may be located to not intersect a longitudinal axis of the shaft (the shaft, shaft extensions, and adjusting surfaces are not contained in a single plane).
The adjusting surfaces can optionally be fixed or may be moveable, e.g., relative to a shaft or a handle of the tool. The adjusting surfaces may be fixed or may be capable of being moved relative to a shaft or handle in a manner to allow the adjusting surfaces to contact and adjust an implant by contacting opposite ends of an implant (opposite self-fixating tips) or opposite ends of a piece of an implant (e.g., a support portion piece or an extension portion piece) simultaneously. For example, the adjusting tool may include a handle, a single shaft, and a “yoke” that can be stationary or that can be moved along a length of the shaft, the yoke extending in two directions from the shaft and including one adjusting surface at the end of each extension.
A distal end of a handle, shaft, or other feature of an insertion or adjusting tool may optionally be designed to contact tissue of a urethra to assist in approximating the urethra. For example, a distal end of a handle or a shaft may optionally be adapted to contact a urethra during placement or adjustment of an implant, for example by having a curved (e.g., concave) or a flat surface that approximates or matches a shape of a surface of urethral tissue (e.g., at a bulbospongiosus muscle or a corpus spongiosum) to be supported by the tissue support portion of the implant being adjusted.
Each receiver 100 is located at an end of adjustable support portion piece 106 and includes structure to receive adjusting surface 102 as well as a component, portion, or feature of extension portion piece 110. As shown, extension portion piece 110 includes a mesh portion 114, a non-mesh portion 112, and a self-fixating tip 116. Non-mesh portion 112 includes structure that frictionally engages receiver 100 to provide an adjusting engagement as described herein, e.g., a one-way or a two-way adjusting engagement. As illustrated, non-mesh portion 112 includes a slotted or apertured tab that has openings, slots, apertures, or surfaces that engage a one-way ratcheting structure of receiver 100. The distance of separation of surfaces 102 is about equal to the distance of separation of receivers 100, which is approximately the same as the length of support portion 106. To engage the two surfaces 102 of the two opposing yoke extensions 99 with each of the two receivers 100, one surface 102 can be initially inserted into one receiver 100. Yoke 99 can be squeezed together, e.g., by hand, to allow the spacing between surfaces 102 to be reduced, so the second surface 102 can be inserted into second receiver 100. Yoke 99 can be removed from the two receivers 100 in the same manner. The system also includes one or more insertion tool (e.g., 10, 50, or 80) (not shown) for engaging self-fixation tips 116 for placing self-fixating tips 116 into supportive tissue.
Non-mesh portions 112 are inserted, one each, into each of the two receivers 100, to assemble an adjusting engagement between receiver 100 and non-mesh portions 112. Adjusting surfaces 102 of tool 96 are then inserted (e.g., with squeezing together of yoke extensions 99) into receivers 100. See
A multi-piece implant includes support portion piece 126 and two extension portion pieces 170. Extension portion pieces 170 include a mesh portion 144, a non-mesh portion (or “adjustment portion”) 142, a self-fixating tip 146, and a male snapfit component 150, which can engage female snap-fit component 154. Support portion piece 126 includes a surface to support a urethra and two apertures 130; each aperture 130 can be a component of an adjusting engagement with non-mesh portion 142, e.g., a grommet or other one-way (or two-way, locking) frictional engagement.
As illustrated extension portion piece 170 and a distal end of each secondary shaft 155 include opposing snap-fit components to allow the extension portion piece and secondary shaft to be snap-fitted together; any alternative type of connection (e.g., a non-snap-fit mechanical engagement such as a thread, ratchet, etc.) would also be useful. Also as illustrated, snap fit component 154 is a female component (aperture) and snap-fit component 150 is a male snap-fit component (insertable into the aperture of snap-fit component 154). Alternate arrangements would also be useful. Non-mesh portions 142 include structure that frictionally engages aperture 130 to provide an adjusting engagement between aperture 130 and non-mesh portion 142, the adjusting engagement being, e.g., a one-way or a two-way adjusting engagement. As illustrated, non-mesh portion 112 includes a polymeric rod that has surfaces that engage a one-way frictional structure (e.g., grommet) at each aperture 130. The non-mesh portion of this or any other embodiment may alternately be a mesh material or an alternate form of a mesh or a non-mesh material, such a perforated strip, a slotted strip, a tubular mesh material, or a standard mesh (e.g., mesh strip or mesh tape). A tubular mesh material may be a mesh formed, in any manner, into a tube, such as being woven or knitted into tubular form, or treated with heat (e.g., thermoformed, melted) to form a tubular mesh.
In use, after placing each extension portion piece 170 at a desired patient location, e.g., with self-fixating tips 146 at supportive tissue, support portion piece 126 can be placed over distal surface 158 of tool 117 with apertures 130 seated against apertures 133. Proximal ends of extension portion pieces 170 can be passed through aperture 130 and aperture 133 and engaged with aperture 154 of secondary shaft 155. A user can grasp handle 160 with fingers in finger rings 162 and a thumb at thumb ring 164. Movement of finger rings 162 toward thumb ring 164 causes finger rings 162 to move in a proximal direction relative to (and toward) thumb ring 164. Simultaneously, secondary shafts 154 move proximally relative to primary shaft 118, distal surface 158, and support portion piece 126. In turn, extension portion pieces 170 (engaged with secondary shafts 154) are pulled in a proximal direction relative to support portion piece 126. Surface 158, in contact with support portion piece 126, can be inserted through the medial incision to contact tissue of a region of a urethra, to push or otherwise contact or place pressure on the urethra, to assist in approximating the urethra. The extension portion pieces can then be drawn through apertures 130 (using the tool as described) to adjust the length of the extension portions and the location of the tissue support portion.
Non-mesh portions 142 are inserted, one each, through apertures 130 and 133, and snap-fit component 150 is engaged with aperture 154. See
Implant 200 as illustrated is a single-piece, e.g., integral mesh implant comprising a central tissue support portion, extension portions extending in opposite directions from the tissue support portion, and self-fixating tips 202.
In use, with primary shaft 176 extended proximally away from handle 174, and shafts 198 retracted into handle 174, implant 200 can be placed at the distal end of tool 188 with self-fixating tips 202 placed at each of two distal end adjusting surfaces 204. A user can grasp handle 174 and adjust the angle of the shafts 198 (relative to a longitudinal axis of the tool) by movement of angle adjustment 182. This may be referred to as a “non-extended” configuration (shafts 198 are non-extended). The distal end of tool 188, engaged with implant 200, can be inserted through the medial incision, whereupon surface 186 (also in contact with implant 200) can contact tissue of a region of a urethra to push or otherwise contact or place pressure on the urethra, to assist in approximating the urethra. Shafts 198 can then be extended (simultaneously) from handle 174 by movement of primary shaft 176 in a distal (toward the patient) direction while maintaining the position of handle 174 and surface 186. Self-fixating tips 202 become extended at distal ends of shafts 198 to contact and become secured to supportive tissue (e:g., in a region of an obturator foramen) in the pelvic region of the patient.
In use, after placement of self-fixating tips at a left and a right side of a patient, tool 290 can be used to moved supports 285 distally along support portions 286, toward self-fixating tips 288, to shorten the length of implant between self-fixating tips 288. Movement of supports 285 can be assisted by use of tool 290, which includes distal surface 294 at an end of stationary shaft 296. Surface 294 is capable of contacting and approximating support portion 284, placed in contact with tissue of a urethra (e.g., corpus spongiosum, bulbospongiosus muscle). Puller 292 is located behind surface 294 and at a distal end of moveable shaft 293. To adjust lengths of extension portions 286, proximal loop 276 is placed on a proximal side of puller 292, as surface 294 is placed against support portion 284, in contact with tissue of a urethra, and after self-fixating tips are placed in supportive tissue. Moveable shaft 293 is advanced in a proximal direction (see arrows), causing support portion 284 to move distally along lengths of extension portions 286 and toward self-fixating tips 288; i.e., proximal portions of extension portions 286 are pulled in a proximal direction through supports 285. The result is to shorten the length of implant between self-fixating tips 288, while approximating the urethra, and thereafter supporting the urethra with implant 281.
A multi-piece implant includes support portion piece 362 and two extension portion pieces 370. Extension portion pieces 370 include a mesh portion 344, a non-mesh portion 342, and self-fixating tip 346. Support portion piece 326 includes a surface to support a urethra having two apertures 330; each aperture 330 can be a component of an adjusting engagement with non-mesh portion 342 or mesh portion 344. Non-mesh portions 342 include a surface or structure that can frictionally engage an aperture 330 to provide an adjusting engagement between aperture 330 and non-mesh portion 342, the adjusting engagement being, e.g., a one-way or a two-way adjusting engagement. As illustrated, non-mesh portion 312 includes a polymeric rod that has surfaces that engage a one-way frictional structure (e.g., grommet) at each aperture 330.
In use, after placing each extension portion piece at a desired patient location, e.g., as described herein with self-fixating tips at supportive tissue, support portion piece 326 can be placed at distal surface 364 of tool 317 with apertures 330 seated to be accessed through aperture 333. Proximal ends of extension portion pieces 370 can be passed through aperture 330 and aperture 333. A user can grasp (by hand or by use of a tool) a proximal end of each support portion piece 370 to pull the proximal end in a proximal direction. Simultaneously, surface 364 can be used to approximate tissue of a urethra by inserting the distal end of tool 317 through a medial incision to contact tissue of a region of a urethra, to push or otherwise contact or place pressure on the urethra, to assist in approximating the urethra. The extension portion pieces can be drawn through apertures 330 to adjust the length of the extension portions and the location of the tissue support portion.
According to certain preferred methods of treating incontinence in a male, using implants as described, an implant can be placed below a urethra to contact tissue of a corpus spongiosum (by dissecting bulbospongiosus muscle), and the urethra can be approximated to improve continence without requiring the urethra to be compressed.
As described more specifically in US 2006-0287571-A1, according to exemplary embodiments of treating incontinence using any of the implants or tools described herein, a tissue support portion of an implant can be placed in a position to approximate and support a urethra, optionally without placing compressive forces on the urethra, to effect improved continence (e.g., in a male patient). Preferably, for treatment of a male patient, a tissue support portion can be placed to contact tissue of a corpus spongiosum and then tensioned to cause approximation of the corpus spongiosum and urethra in a direction toward a bladder, optionally with use of a tool as described herein for placing pressure on or moving the urethra. Accordingly, embodiments of the invention generally, in a male patient, can relate to placement of a tissue support portion at a location that supports and is tensioned to re-position a urethra toward a bladder. The implant can be tensioned to cause the urethra—especially the posterior portion of urethra above a perineal membrane—to be moved from an abnormal (e.g., prolapsed or descended) position to a position of normal healthy urethral tissue capable of being fully coapted upon contraction of the rhabdosphincter. Alternate methods can cause compression of the urethra, but compression is not required in methods that result in approximation of the urethra to improve continence.
According to these embodiments, a method of surgically installing a urethral implant can include providing a medial incision at the perineum of a male patient to expose bulbospongiosus muscle, optionally and preferably dissecting through bulbospongiosus muscle to expose corpus pongiosum, and placing a tissue support portion of the implant to contact the corpus spongiosum tissue. Optionally the tissue support portion can be fixed to the corpus spongiosum, such as by use of a medical attachment in the form of a suture, staple, adhesive, or the like. The implant can be adjusted, tensioned, etc., e.g. based on the use of an adjusting engagement, an adjustment tool, or another means, to approximate the urethra to improve continence, and tension can optionally and preferably maintained chronically.
According to exemplary methods, the implant can be inserted through a single medial (perineal or vaginal) incision (no external incision is required) and an extension portion of the implant can be attached to supportive tissue within the pelvic region, such as tissue at a region of an obturator foramen, or to tissue (e.g., fascia) that lies between a urethra and tissue of an obturator foramen, or other supportive tissue. According to such methods, a tissue fastener such as a self-fixating tip at a distal end or distal portion of an extension portion can be engaged at a distal end of an insertion tool (e.g. a curved elongate needle). The insertion tool can be used to place the tissue fastener and extension portion through a medial incision (of a male or female patient) and extend the tissue fastener and extension portion in a direction of an obturator foramen, e.g., to tissue of the obturator foramen or to other supportive tissue. Features of the inventive methods, implants, and tools that are described herein can be incorporated into such a technique, such as placement of the urethral sling below a urethra at a tissue of a bulbospongiosus muscle or a corpus spongiosum, approximation of the urethra to improve continence (without the need for compression of the urethra), etc., use of an implant that includes adjustable engagements (and steps of adjusting the implant), use of an adjustment tool. This method avoids the need for lateral incisions at the inner thigh and adjacent to each opposing obturator foramen.
This application is a continuation of, and claims priority to, U.S. patent application Ser. No. 15/200,236, filed on Jul. 1, 2016, entitled “SURGICAL ARTICLES AND METHODS”, which claims priority to U.S. patent application Ser. No. 13/579,811, filed on Aug. 17, 2012, entitled “SURGICAL ARTICLES AND METHODS”, now U.S. Pat. No. 9,381,076, which claims the benefit from International Patent Application No. PCT/US2011/025917, filed on Feb. 23, 2011, entitled “SURGICAL ARTICLES AND METHODS”, which claims priority under 35 USC § 119(e) from U.S. Provisional Patent Application No. 61/307,264, filed on Feb. 23, 2010, entitled “SINGLE INCISION SLING AND METHOD THEREFOR”, the disclosures of which are incorporated herein by reference in their entirety.
| Number | Name | Date | Kind |
|---|---|---|---|
| 2738790 | Todt et al. | Mar 1956 | A |
| 3384073 | Van Winkle, Jr. | May 1968 | A |
| 3472232 | Earl | Oct 1969 | A |
| 3580313 | McKnight | May 1971 | A |
| 3763860 | Clarke | Oct 1973 | A |
| 3858783 | Kapitanov et al. | Jan 1975 | A |
| 3995619 | Glatzer et al. | Dec 1976 | A |
| 4172458 | Pereyra | Oct 1979 | A |
| 4235238 | Ogiu et al. | Nov 1980 | A |
| 4441497 | Paudler | Apr 1984 | A |
| 4509516 | Richmond | Apr 1985 | A |
| 4548202 | Duncan | Oct 1985 | A |
| 4632100 | Goble et al. | Dec 1986 | A |
| 4873976 | Schreiber et al. | Oct 1989 | A |
| 4932962 | Yoon et al. | Jun 1990 | A |
| 4938760 | Burton et al. | Jul 1990 | A |
| 4969892 | Burton et al. | Nov 1990 | A |
| 4979956 | Silvestrini | Dec 1990 | A |
| 5013292 | Lemay | May 1991 | A |
| 5013316 | Goble et al. | May 1991 | A |
| 5053043 | Gottesman et al. | Oct 1991 | A |
| 5085661 | Moss | Feb 1992 | A |
| 5112344 | Petros | May 1992 | A |
| 5141520 | Goble et al. | Aug 1992 | A |
| 5149329 | Richardson | Sep 1992 | A |
| 5188636 | Fedotov | Feb 1993 | A |
| 5203864 | Phillips et al. | Apr 1993 | A |
| 5209756 | Seedhom et al. | May 1993 | A |
| 5234438 | Semrad | Aug 1993 | A |
| 5256133 | Spitz | Oct 1993 | A |
| 5268001 | Nicholson et al. | Dec 1993 | A |
| 5269783 | Sander et al. | Dec 1993 | A |
| 5281237 | Gimpelson | Jan 1994 | A |
| 5328077 | Lou | Jul 1994 | A |
| 5337736 | Reddy | Aug 1994 | A |
| 5354292 | Braeuer et al. | Oct 1994 | A |
| 5368595 | Lewis | Nov 1994 | A |
| 5370650 | Tovey et al. | Dec 1994 | A |
| 5370662 | Stone et al. | Dec 1994 | A |
| 5376097 | Phillips et al. | Dec 1994 | A |
| 5383904 | Totakura et al. | Jan 1995 | A |
| 5403328 | Shallman | Apr 1995 | A |
| 5439467 | Benderev et al. | Aug 1995 | A |
| 5474518 | Velazquez | Dec 1995 | A |
| 5474543 | McKay | Dec 1995 | A |
| 5520700 | Beyar et al. | May 1996 | A |
| 5520703 | Essig et al. | May 1996 | A |
| 5527342 | Pietrzak et al. | Jun 1996 | A |
| 5544664 | Benderev et al. | Aug 1996 | A |
| 5562689 | Green et al. | Oct 1996 | A |
| 5571139 | Jenkins et al. | Nov 1996 | A |
| 5582188 | Benderev et al. | Dec 1996 | A |
| 5584860 | Goble et al. | Dec 1996 | A |
| 5591163 | Thompson | Jan 1997 | A |
| 5591206 | Moufarrege et al. | Jan 1997 | A |
| 5611515 | Benderev et al. | Mar 1997 | A |
| 5628756 | Barker, Jr. et al. | May 1997 | A |
| 5643320 | Lower et al. | Jul 1997 | A |
| 5647836 | Blake et al. | Jul 1997 | A |
| 5669935 | Rosenman et al. | Sep 1997 | A |
| 5674247 | Sohn | Oct 1997 | A |
| 5683349 | Makower et al. | Nov 1997 | A |
| 5690655 | Hart et al. | Nov 1997 | A |
| 5697931 | Thompson | Dec 1997 | A |
| 5709708 | Thal | Jan 1998 | A |
| 5725529 | Nicholson et al. | Mar 1998 | A |
| 5725541 | Anspach et al. | Mar 1998 | A |
| 5741282 | Anspach et al. | Apr 1998 | A |
| 5782862 | Bonutti | Jul 1998 | A |
| 5842478 | Benderev et al. | Dec 1998 | A |
| 5860425 | Benderev et al. | Jan 1999 | A |
| 5873891 | Sohn | Feb 1999 | A |
| 5899909 | Claren et al. | May 1999 | A |
| 5904692 | Steckel et al. | May 1999 | A |
| 5922026 | Chin | Jul 1999 | A |
| 5925047 | Errico et al. | Jul 1999 | A |
| 5944732 | Raulerson et al. | Aug 1999 | A |
| 5954057 | Li | Sep 1999 | A |
| 5972000 | Beyar et al. | Oct 1999 | A |
| 5980558 | Wiley | Nov 1999 | A |
| 5984927 | Wenstrom et al. | Nov 1999 | A |
| 5988171 | Sohn et al. | Nov 1999 | A |
| 5997554 | Thompson | Dec 1999 | A |
| 6007539 | Kirsch et al. | Dec 1999 | A |
| 6019768 | Wenstrom et al. | Feb 2000 | A |
| 6027523 | Schmieding | Feb 2000 | A |
| 6030393 | Corlew et al. | Feb 2000 | A |
| 6036701 | Rosenman | Mar 2000 | A |
| 6039686 | Kovac | Mar 2000 | A |
| 6042534 | Gellman et al. | Mar 2000 | A |
| 6042583 | Thompson et al. | Mar 2000 | A |
| 6048351 | Gordon et al. | Apr 2000 | A |
| 6053935 | Brenneman et al. | Apr 2000 | A |
| 6056688 | Benderev et al. | May 2000 | A |
| 6099538 | Moses et al. | Aug 2000 | A |
| 6099551 | Gabbay | Aug 2000 | A |
| 6099552 | Adams et al. | Aug 2000 | A |
| 6110101 | Tihon et al. | Aug 2000 | A |
| 6127597 | Beyar et al. | Oct 2000 | A |
| 6168611 | Rizvi et al. | Jan 2001 | B1 |
| 6200330 | Benderev et al. | Mar 2001 | B1 |
| 6241736 | Sater et al. | Jun 2001 | B1 |
| 6245082 | Gellman et al. | Jun 2001 | B1 |
| 6264676 | Gellman et al. | Jul 2001 | B1 |
| 6273852 | Lehe et al. | Aug 2001 | B1 |
| 6319272 | Brenneman et al. | Nov 2001 | B1 |
| 6322492 | Kovac | Nov 2001 | B1 |
| 6328744 | Harari et al. | Dec 2001 | B1 |
| 6334446 | Beyar | Jan 2002 | B1 |
| 6382214 | Raz et al. | May 2002 | B1 |
| 6387041 | Harari et al. | May 2002 | B1 |
| 6406423 | Scetbon | Jun 2002 | B1 |
| 6406480 | Sohn et al. | Jun 2002 | B1 |
| 6409733 | Conlon et al. | Jun 2002 | B1 |
| 6423072 | Zappala et al. | Jul 2002 | B1 |
| 6423080 | Gellman et al. | Jul 2002 | B1 |
| 6440154 | Gellman et al. | Aug 2002 | B2 |
| 6451024 | Thompson et al. | Sep 2002 | B1 |
| 6454778 | Kortenbach | Sep 2002 | B2 |
| 6475139 | Miller | Nov 2002 | B1 |
| 6478727 | Scetbon | Nov 2002 | B2 |
| 6491703 | Ulmsten | Dec 2002 | B1 |
| 6502578 | Raz et al. | Jan 2003 | B2 |
| 6506190 | Walshe | Jan 2003 | B1 |
| 6530943 | Hoepffner et al. | Mar 2003 | B1 |
| 6544273 | Harari et al. | Apr 2003 | B1 |
| 6582443 | Cabak et al. | Jun 2003 | B2 |
| 6592515 | Thierfelder et al. | Jul 2003 | B2 |
| 6592610 | Beyar | Jul 2003 | B2 |
| 6596001 | Stormby et al. | Jul 2003 | B2 |
| 6599235 | Kovac | Jul 2003 | B2 |
| 6602260 | Harari et al. | Aug 2003 | B2 |
| 6612977 | Staskin et al. | Sep 2003 | B2 |
| 6635058 | Beyar et al. | Oct 2003 | B2 |
| 6638210 | Berger | Oct 2003 | B2 |
| 6638211 | Suslian et al. | Oct 2003 | B2 |
| 6641525 | Rocheleau et al. | Nov 2003 | B2 |
| 6673010 | Skiba et al. | Jan 2004 | B2 |
| 6685629 | Therin | Feb 2004 | B2 |
| 6689047 | Gellman | Feb 2004 | B2 |
| 6730110 | Harari et al. | May 2004 | B1 |
| 6746455 | Beyar et al. | Jun 2004 | B2 |
| 6752814 | Gellman et al. | Jun 2004 | B2 |
| 6802807 | Anderson et al. | Oct 2004 | B2 |
| 6845082 | Bourget et al. | Jan 2005 | B2 |
| 6884212 | Thierfelder et al. | Apr 2005 | B2 |
| 6908425 | Luscombe | Jun 2005 | B2 |
| 6908473 | Skiba et al. | Jun 2005 | B2 |
| 6911002 | Fierro et al. | Jun 2005 | B2 |
| 6911003 | Anderson et al. | Jun 2005 | B2 |
| 6932759 | Kammerer et al. | Aug 2005 | B2 |
| 6936052 | Gellman et al. | Aug 2005 | B2 |
| 6971986 | Staskin et al. | Dec 2005 | B2 |
| 6974462 | Sater | Dec 2005 | B2 |
| 6981983 | Rosenblatt et al. | Jan 2006 | B1 |
| 6991597 | Gellman et al. | Jan 2006 | B2 |
| 7014607 | Gellman | Mar 2006 | B2 |
| 7025772 | Gellman et al. | Apr 2006 | B2 |
| 7037255 | Inman et al. | May 2006 | B2 |
| 7048682 | Neisz et al. | May 2006 | B2 |
| 7056333 | Walshe | Jun 2006 | B2 |
| 7070556 | Anderson et al. | Jul 2006 | B2 |
| 7083637 | Tannhauser | Aug 2006 | B1 |
| 7087059 | Harari et al. | Aug 2006 | B2 |
| 7112171 | Rocheleau et al. | Sep 2006 | B2 |
| 7121997 | Kammerer et al. | Oct 2006 | B2 |
| 7131943 | Kammerer | Nov 2006 | B2 |
| 7223229 | Inman et al. | May 2007 | B2 |
| 7226407 | Kammerer et al. | Jun 2007 | B2 |
| 7226408 | Harai et al. | Jun 2007 | B2 |
| 7226409 | Peng et al. | Jun 2007 | B2 |
| 7229404 | Bouffier | Jun 2007 | B2 |
| 7229453 | Anderson et al. | Jun 2007 | B2 |
| 7235043 | Gellman et al. | Jun 2007 | B2 |
| 7261723 | Smith et al. | Aug 2007 | B2 |
| 7267645 | Anderson et al. | Sep 2007 | B2 |
| 7291104 | Neisz et al. | Nov 2007 | B2 |
| 7297102 | Smith et al. | Nov 2007 | B2 |
| 7303525 | Watschke et al. | Dec 2007 | B2 |
| 7326213 | Benderev et al. | Feb 2008 | B2 |
| 7347812 | Mellier | Mar 2008 | B2 |
| 7351196 | Goldmann et al. | Apr 2008 | B2 |
| 7351197 | Montpetit et al. | Apr 2008 | B2 |
| 7357773 | Watschke et al. | Apr 2008 | B2 |
| 7364541 | Chu et al. | Apr 2008 | B2 |
| 7371245 | Evans et al. | May 2008 | B2 |
| 7387634 | Benderev et al. | Jun 2008 | B2 |
| 7393320 | Montpetit et al. | Jul 2008 | B2 |
| 7407480 | Staskin et al. | Aug 2008 | B2 |
| 7410460 | Benderev | Aug 2008 | B2 |
| 7413540 | Gellman et al. | Aug 2008 | B2 |
| 7422557 | Rehder et al. | Sep 2008 | B2 |
| 7494495 | Delorme et al. | Feb 2009 | B2 |
| 7500945 | Cox et al. | Mar 2009 | B2 |
| 7517313 | Thierfelder et al. | Apr 2009 | B2 |
| 7527588 | Zaddem et al. | May 2009 | B2 |
| 7527633 | Rioux | May 2009 | B2 |
| 7547316 | Priewe et al. | Jun 2009 | B2 |
| 7588598 | Delorme | Sep 2009 | B2 |
| 7601118 | Smith et al. | Oct 2009 | B2 |
| 7614999 | Appell et al. | Nov 2009 | B2 |
| 7621865 | Appell et al. | Nov 2009 | B2 |
| 7637860 | MacLean et al. | Dec 2009 | B2 |
| 7686759 | Sater | Mar 2010 | B2 |
| 7686760 | Anderson et al. | Mar 2010 | B2 |
| 7691050 | Appell et al. | Apr 2010 | B2 |
| 7691052 | Appell et al. | Apr 2010 | B2 |
| 7740576 | Hodroff et al. | Jun 2010 | B2 |
| 7753839 | Arnal et al. | Jul 2010 | B2 |
| 7762942 | Neisz et al. | Jul 2010 | B2 |
| 7828715 | Haverfield et al. | Nov 2010 | B2 |
| 8727963 | Knoll et al. | May 2014 | B2 |
| 9381076 | Wirbisky et al. | Jul 2016 | B2 |
| 9445881 | Wirbisky et al. | Sep 2016 | B2 |
| 20010000533 | Kovac et al. | Apr 2001 | A1 |
| 20010018549 | Scetbon | Aug 2001 | A1 |
| 20010027321 | Gellman et al. | Oct 2001 | A1 |
| 20010041895 | Beyar et al. | Nov 2001 | A1 |
| 20010049467 | Lehe et al. | Dec 2001 | A1 |
| 20010053916 | Rioux | Dec 2001 | A1 |
| 20020007222 | Desai | Jan 2002 | A1 |
| 20020028980 | Thierfelder et al. | Mar 2002 | A1 |
| 20020035369 | Beyar et al. | Mar 2002 | A1 |
| 20020038119 | Weber et al. | Mar 2002 | A1 |
| 20020038132 | Abrams et al. | Mar 2002 | A1 |
| 20020050277 | Beyar | May 2002 | A1 |
| 20020055748 | Gellman et al. | May 2002 | A1 |
| 20020058959 | Gellman et al. | May 2002 | A1 |
| 20020068948 | Stormby et al. | Jun 2002 | A1 |
| 20020077526 | Kammerer et al. | Jun 2002 | A1 |
| 20020082619 | Cabak et al. | Jun 2002 | A1 |
| 20020091373 | Berger | Jul 2002 | A1 |
| 20020095064 | Beyar | Jul 2002 | A1 |
| 20020095163 | Beyar et al. | Jul 2002 | A1 |
| 20020095181 | Beyar | Jul 2002 | A1 |
| 20020107525 | Harari et al. | Aug 2002 | A1 |
| 20020128681 | Broome et al. | Sep 2002 | A1 |
| 20020147382 | Neisz et al. | Oct 2002 | A1 |
| 20020151909 | Gellman et al. | Oct 2002 | A1 |
| 20020156487 | Gellman et al. | Oct 2002 | A1 |
| 20020156488 | Gellman et al. | Oct 2002 | A1 |
| 20020161382 | Neisz et al. | Oct 2002 | A1 |
| 20020188169 | Kammerer et al. | Dec 2002 | A1 |
| 20030004395 | Therin | Jan 2003 | A1 |
| 20030009181 | Gellman et al. | Jan 2003 | A1 |
| 20030023136 | Raz et al. | Jan 2003 | A1 |
| 20030023138 | Luscombe | Jan 2003 | A1 |
| 20030036676 | Scetbon et al. | Feb 2003 | A1 |
| 20030045774 | Staskin et al. | Mar 2003 | A1 |
| 20030050530 | Neisz et al. | Mar 2003 | A1 |
| 20030065402 | Anderson et al. | Apr 2003 | A1 |
| 20030171644 | Anderson et al. | Sep 2003 | A1 |
| 20030176875 | Anderson et al. | Sep 2003 | A1 |
| 20030191360 | Browning | Oct 2003 | A1 |
| 20040015057 | Rocheleau et al. | Jan 2004 | A1 |
| 20040039453 | Anderson et al. | Feb 2004 | A1 |
| 20040073235 | Lund et al. | Apr 2004 | A1 |
| 20040106847 | Benderev | Jun 2004 | A1 |
| 20040193215 | Harari et al. | Sep 2004 | A1 |
| 20040225181 | Chu et al. | Nov 2004 | A1 |
| 20040267088 | Kammerer | Dec 2004 | A1 |
| 20050000523 | Beraud | Jan 2005 | A1 |
| 20050004576 | Benderev | Jan 2005 | A1 |
| 20050131391 | Chu et al. | Jun 2005 | A1 |
| 20050131393 | Chu et al. | Jun 2005 | A1 |
| 20050199249 | Karram et al. | Sep 2005 | A1 |
| 20050245787 | Cox et al. | Nov 2005 | A1 |
| 20050256530 | Petros et al. | Nov 2005 | A1 |
| 20050277806 | Cristalli et al. | Dec 2005 | A1 |
| 20050278037 | Delorme et al. | Dec 2005 | A1 |
| 20050283189 | Rosenblatt | Dec 2005 | A1 |
| 20060041185 | Browning | Feb 2006 | A1 |
| 20060058578 | Browning et al. | Mar 2006 | A1 |
| 20060089524 | Chu | Apr 2006 | A1 |
| 20060089525 | Mamo et al. | Apr 2006 | A1 |
| 20060161188 | Kennedy et al. | Jul 2006 | A1 |
| 20060195007 | Anderson et al. | Aug 2006 | A1 |
| 20060195010 | Arnal et al. | Aug 2006 | A1 |
| 20060195011 | Arnal et al. | Aug 2006 | A1 |
| 20060217589 | Wan et al. | Sep 2006 | A1 |
| 20060229493 | Weiser et al. | Oct 2006 | A1 |
| 20060229596 | Weiser et al. | Oct 2006 | A1 |
| 20060252980 | Arnal et al. | Nov 2006 | A1 |
| 20060260618 | Hodroff et al. | Nov 2006 | A1 |
| 20060287571 | Gozzi et al. | Dec 2006 | A1 |
| 20070015953 | MacLean | Jan 2007 | A1 |
| 20070043255 | O″Donnell | Feb 2007 | A1 |
| 20070078295 | Landgrebe et al. | Apr 2007 | A1 |
| 20070173864 | Chu | Jul 2007 | A1 |
| 20080039678 | Montpetit et al. | Feb 2008 | A1 |
| 20080200751 | Browning | Aug 2008 | A1 |
| 20080300607 | Meade et al. | Dec 2008 | A1 |
| 20090012353 | Beyer et al. | Jan 2009 | A1 |
| 20090182190 | Dann et al. | Jul 2009 | A1 |
| 20090221867 | Ogdahl et al. | Sep 2009 | A1 |
| 20090221868 | Evans | Sep 2009 | A1 |
| 20090259092 | Ogdahl et al. | Oct 2009 | A1 |
| 20100010631 | Otte et al. | Jan 2010 | A1 |
| 20100030016 | Knoll | Feb 2010 | A1 |
| 20100094079 | Inman et al. | Apr 2010 | A1 |
| 20100256442 | Ogdahl et al. | Oct 2010 | A1 |
| 20100261952 | Montpetit et al. | Oct 2010 | A1 |
| 20100261955 | O″Hern et al. | Oct 2010 | A1 |
| 20110034759 | Ogdahl et al. | Feb 2011 | A1 |
| 20110112357 | Chapman et al. | May 2011 | A1 |
| 20120316386 | Wirbisky et al. | Dec 2012 | A1 |
| 20160310250 | Wirbisky et al. | Oct 2016 | A1 |
| Number | Date | Country |
|---|---|---|
| 2002241673 | Aug 2005 | AU |
| 2404459 | Aug 2005 | CA |
| 2305815 | Aug 1974 | DE |
| 4220283 | May 1994 | DE |
| 20016866 | Dec 2000 | DE |
| 10211360 | Oct 2003 | DE |
| 0632999 | Jan 1995 | EP |
| 0643945 | Mar 1995 | EP |
| 0650703 | May 1995 | EP |
| 1342450 | Jan 2007 | EP |
| 2852813 | Oct 2004 | FR |
| 2852817 | Oct 2004 | FR |
| 2268690 | Jan 1994 | GB |
| 2353220 | Feb 2001 | GB |
| 1225547 | Apr 1986 | SU |
| 1342486 | Oct 1987 | SU |
| 9310715 | Jun 1993 | WO |
| 9319678 | Oct 1993 | WO |
| 9511631 | May 1995 | WO |
| 9525469 | Sep 1995 | WO |
| 9716121 | May 1997 | WO |
| 9730638 | Aug 1997 | WO |
| 9747244 | Dec 1997 | WO |
| 9819606 | May 1998 | WO |
| 9835606 | Aug 1998 | WO |
| 9835616 | Aug 1998 | WO |
| 9842261 | Oct 1998 | WO |
| 9853746 | Dec 1998 | WO |
| 9937216 | Jul 1999 | WO |
| 9937217 | Jul 1999 | WO |
| 9952450 | Oct 1999 | WO |
| 9953844 | Oct 1999 | WO |
| 9958074 | Nov 1999 | WO |
| 9959477 | Nov 1999 | WO |
| 0013601 | Mar 2000 | WO |
| 0030556 | Jun 2000 | WO |
| 0040158 | Jul 2000 | WO |
| 0057796 | Oct 2000 | WO |
| 0074594 | Dec 2000 | WO |
| 0074613 | Dec 2000 | WO |
| 0074633 | Dec 2000 | WO |
| 0230293 | Apr 2002 | WO |
| 0232284 | Apr 2002 | WO |
| 0234124 | May 2002 | WO |
| 0239890 | May 2002 | WO |
| 02058563 | Aug 2002 | WO |
| 02062237 | Aug 2002 | WO |
| 02069781 | Sep 2002 | WO |
| 02071953 | Sep 2002 | WO |
| 03013392 | Feb 2003 | WO |
| 03017848 | Mar 2003 | WO |
| 03034939 | May 2003 | WO |
| 03047435 | Jun 2003 | WO |
| 03068107 | Aug 2003 | WO |
| 03075792 | Sep 2003 | WO |
| 03086205 | Oct 2003 | WO |
| 03092546 | Nov 2003 | WO |
| 03096928 | Nov 2003 | WO |
| 03096929 | Nov 2003 | WO |
| 2004016196 | Feb 2004 | WO |
| 2004034912 | Apr 2004 | WO |
| 2005004727 | Jan 2005 | WO |
| 2005046511 | May 2005 | WO |
| 2005048850 | Jun 2005 | WO |
| 2005079702 | Sep 2005 | WO |
| 2005122954 | Dec 2005 | WO |
| 2006007189 | Jan 2006 | WO |
| 2006007190 | Jan 2006 | WO |
| 2006031879 | Mar 2006 | WO |
| 2006069078 | Jun 2006 | WO |
| 2006108145 | Oct 2006 | WO |
| 2007002012 | Jan 2007 | WO |
| 2007002071 | Jan 2007 | WO |
| 2007014241 | Feb 2007 | WO |
| 2007016083 | Feb 2007 | WO |
| 2007027592 | Mar 2007 | WO |
| 2007059199 | May 2007 | WO |
| 2007097994 | Aug 2007 | WO |
| 2007137226 | Nov 2007 | WO |
| 2007146784 | Dec 2007 | WO |
| 2007149348 | Dec 2007 | WO |
| 2008057261 | May 2008 | WO |
| 2008124056 | Oct 2008 | WO |
| 2009005714 | Jan 2009 | WO |
| 2009017680 | Feb 2009 | WO |
| 2009038781 | Mar 2009 | WO |
| 2009075800 | Jun 2009 | WO |
| 2009145911 | Dec 2009 | WO |
| 2010093421 | Aug 2010 | WO |
| Entry |
|---|
| “Capio® CL Transvaginal Suture Capturing Device”, The Capio CL Transvaginal Suture Capturing Device allows for a transvaginal suture fixation to Cooper's Ligament for Sling Procedures, 2002, 8 pages. |
| “Gynecare TVT Tension-Free Support for Incontinence, The tension-free Solution to Female Incontinence”, Gynecare Worldwide, 2002, 6 pages. |
| “IVS Tunneller”, ICS/IUGA Symp 2002, Tyco Healthcare, 2002, 4 pages. |
| “Low Profile design for Precise Anchor Placement”, Precision Twist, Boston Scientific Microvasive, 2001, 2 pages. |
| “SABRE™ Bioabsorbable Sling”, Generation Now, Mentor, May 2002, 4 pages. |
| “SABRE™ Surgical Procedure”, Mentor, 2002, 6 pages. |
| “The Precise Approach to Transvaginal Sling Procedures”, Precision Tack, Boston Scientific, 1998, 4 pages. |
| “Vesica Sling Kit”, Microvasive Boston Scientific, 1997, 6 pages. |
| “Vesica® Percutaneous Bladder Neck Stabilization Kit, A New Approach to Bladder Neck Suspenison”, Microvasive® Boston Scientific Corporation, 1995, 4 pages. |
| “We're staying ahead of the curve”, Introducing the IVS Tunneller Device for Tension Free Procedures, Tyco Healthcare, 2002, 3 pages. |
| Benderev, “A Modified Percutaneous Outpatient Bladder Neck Suspension System”, Journal of Urology, vol. 152, Dec. 1994, pp. 2316-2320. |
| Benderev, “Anchor Fixation and Other Modifications of Endoscopic Bladder Neck Suspension”, Journal of Urology, 40, Nov. 1992, pp. 409-418. |
| Boston Scientific, “Surgical Mesh Sling Kit”, Advantage AT™, 2002, 6 pages. |
| Cook/Ob Gyn®, “Urogynecology”, Copyright Cook Urological Inc., 1996, 36 pages. |
| Dargent, et al., “Insertion of a sub urethral sling through the obturating membrane in the treatment of female urinary incontinence”, Gynécol Obstét Fertil, vol. 30, 2002, pp. 576-582. |
| IVS Tunneller, “A Universal Instrument for Anterior and Posterior Intra-Vaginal Tape Placement”, Tyco Healthcare, Aug. 2002, 4 pages. |
| IVS Tunneller, “ein universelles Instrument fur die Intra Vaginal Schlingenplastik”, Tyco Healthcare, 2001, 4 pages. |
| Karram , et al., “Chapter 19: Surgical Treatment of Vaginal Vault Prolapse”, Urogynecology and Reconstructive Pelvic Surgery, Walters & Karram eds., 1999, pp. 235-256. |
| Kovac, et al., “Pubic Bone Suburethral Stabilization Sling: A Long Term Cure for SUI?”, Contemeorary Ob/Gyn, Feb. 1998, 10 pages. |
| Pelosi, et al., “Pubic Bone Suburethral Stabilization Sling: Laparoscopic Assessment of a Transvaginal Operation for the Treatment of Stress Urinary Incontinence”, Journal of Laparoendoscopic & Advaned Surgical Techniques, vol. 9, No. 1, Feb. 1999, pp. 45-50. |
| Sanz, et al., “Modification of Abdominal Sacrocolpopexy Using a Suture Anchor System”, The Journal of Reproductive Medicine, vol. 48, No. 7, Jul. 2003, pp. 496-500. |
| Ulmsten, et al., “A Three Year Follow Up of Tension Free Vaginal Tape for Surgical Treatment of Female Stress Urinary Incontinence”, British Journal of Obstetrics and Gyanaecology, vol. 106, 1999, pp. 345-350. |
| Ulmsten, et al., “An Ambulatory Surgical Procedure Under Local Anesthesia for Treatment of Female Urinary Incontinence”, International Urogynecology Journal, vol. 7, May 1996, pp. 81-86. |
| International Search Report for PCT Application No. PCT/US2011/025917, dated Apr. 20, 2011, 2 pages. |
| Extended European Search Report for European Application No. 20178363.6, dated Sep. 2, 2020, 9 pages. |
| Number | Date | Country | |
|---|---|---|---|
| 20200046481 A1 | Feb 2020 | US |
| Number | Date | Country | |
|---|---|---|---|
| 61307264 | Feb 2010 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 15200236 | Jul 2016 | US |
| Child | 16654583 | US | |
| Parent | 13579811 | US | |
| Child | 15200236 | US |
