Abstract:
Described are pelvic implants and methods of surgically placing pelvic implants that provide treatment for pelvic floor disorders by support of the levator by creating an incision that allows access to a region of tissue of the pelvic floor and inserting a pelvic implant comprising a tissue support portion delivered by a delivery tool. A pelvic implant for supporting levator tissue comprising: a tissue support portion having a first end and a second; a tissue fastener disposed on the first end of the tissue support portion for fastening it to levator tissue; a guide extension portion disposed on the second end of the tissue support portion; and a support backer member attachable to the guide extension portion to adjust a tension of the tissue support portion and concomitantly the levator tissue.

Description:
PRIORITY CLAIM 
       [0001]    This application claims the benefit of U.S. Provisional Application Ser. No. 61/057,027, filed May 29, 2008, which is incorporated herein by reference in its entirety. 
     
    
     FIELD OF THE INVENTION 
       [0002]    The invention relates to apparatus and methods for treating pelvic conditions by use of a pelvic implant to support pelvic tissue. The pelvic conditions include conditions of the female or male anatomy, and specifically include treatments that involve supporting pelvic muscles and organs, such as to levator defects, female or male urinary and fecal incontinence, among other conditions. 
       BACKGROUND OF THE INVENTION 
       [0003]    Pelvic health for men and women is a medical area of increasing importance, at least in part due to an aging population. Examples of common pelvic ailments include incontinence (fecal and urinary) and pelvic tissue prolapse (e.g., female levator bulging and vaginal prolapses). Urinary incontinence can further be classified as including different types, such as stress urinary incontinence (SUI), urge urinary incontinence, mixed urinary incontinence, among others. Other pelvic floor disorders include cystocele, rectocele, enterocele, and prolapse such as anal, uterine and vaginal vault prolapse. A cystocele is a hernia of the bladder, usually into the vagina and introitus. Pelvic disorders such as these can result from weakness or damage to normal pelvic support systems, including the levator muscles. 
         [0004]    Pelvic implants, sometimes referred to as slings, hammocks, have been introduced for implantation in the body to treat pelvic conditions such as prolapse and incontinence conditions. See, for example, commonly assigned U.S. Pat. Nos. 6,382,214, 6,641,524, 6,652,450, and 6,911,003, and publications and patents cited therein, each of which are incorporated herein in their entirety by reference. The implantation of these implants involves the use of implantation tools that create transvaginal, transobturator, supra-pubic, or retro-pubic exposures or pathways. A delivery system for coupling the sling ends to ends of elongate insertion tools, to draw sling extension portions through tissue pathways, is also included. 
         [0005]    One specific area of pelvic health is trauma of the pelvic floor, e.g., of the levator (“levator ani”) or coccygeus muscle (collectively the pelvic floor). The pelvic floor is made up of the levator and coccygeus muscles, and the levator is made up of components that include the puborectalis muscle, the pubococcygeus muscle, and the iliococcygeous muscle. For various reasons, the levator may suffer weakness or injury that can result in various symptoms such as prolapse, incontinence, and other conditions of the pelvis. 
       SUMMARY OF THE INVENTION 
       [0006]    The invention relates to methods of treating pelvic conditions, especially by supporting levator tissue. Levator defects (weakness or injury) can affect any portion of the levator, and can be especially common in the pubic portion of the levator ani, including the pubococcygeus and puborectalis muscles. Such defects are relatively common, for instance, in women with vaginal prolapse. Defects can also be present at the iliococcygeus muscle. Still other defects are in the form of a paravaginal defect, such as avulsion of the inferiomedial aspects of the levator ani from the pelvic sidewall; avulsion can refer to tissue being detached from the pubic bone, and may precede prolapse conditions. Another levator defect is levator ballooning, which refers to distension of levator muscles. 
         [0007]    A different levator defect is a defect of the levator hiatus, which can reduce the stability of the pelvic floor and may result in sexual dysfunction, defecatory dysfunction, rectal prolapse, and fecal incontinence and possibly urinary incontinence. Levator hiatus is also believed to play a significant role in the progression of prolapse. Embodiments of methods of the invention can address any of the conditions, as well as related conditions and symptoms. 
         [0008]    The present patent application describes pelvic implants and methods for treating pelvic conditions by treating defects of the pelvic floor (coccygeus or levator), such as weakness or injury, or by otherwise supporting levator muscle. Useful methods can involve methods and implants that can restore natural pelvic floor anatomy using an implant (e.g., graft) in the form of a hammock, sling, and the like, to augment injured, weakened, or attenuated levator musculature. The levator musculature or “levator ani” can include the puborectalis, pubococcygeus, iliococcygeus, among others. 
         [0009]    Embodiments of implants useful according to the invention can be of a size and shape to address a desired pelvic floor condition, generally of a size and shape to conform to levator tissue, optionally to additionally contact or support other tissue of the pelvic region such as the anal sphincter, rectum, perineal body, etc. The implant can be of a single or multiple pieces that is or are shaped overall to match a portion of the levator, e.g., that is circular, oblong trapezoidal, rectangular, that contains a combination of straight, angled, and arcuate edges, etc. The implant may include attached or separate segments that fit together to extend beside or around pelvic features such as the rectum, anus, vagina, and the like, optionally to attach to the feature. 
         [0010]    In one embodiment, the implant can include a tissue support portion, which may contact levator tissue upon implantation. The implant can additionally include one or more guide extension portions that extends beyond the tissue support portion and extend out of an incision to guide a support backer member that may be used to tension the tissue support portion of the implant. 
         [0011]    Optionally, the tissue support portion can include one or more tissue fasteners (e.g., self-fixating tip, soft tissue anchor, etc.), connected to a portion of the tissue support portion in order to fix the tissue support portion to tissue. A sheath may also be provided that extends over at least a portion of the tissue support portion to aid in easing implantation. 
         [0012]    In an example embodiment, the tissue support portion and optionally the guide extension portion, tissue fastener, etc., may optionally be coated with antimicrobial coatings to prevent infection or coatings to encourage ingrowth or inhibit rejection. For tissue support portions and extension portions, biocompatible materials are contemplated such as porcine dermis or meshes with growth factors. 
         [0013]    A method as described herein may improve or treat a condition of the pelvic region, such as any of the pelvic conditions described. The method may support levator tissue, for treatment of prolapse; fecal incontinence; a torn, weakened, or damaged levator muscle (meaning any portion of the levator muscle); levator avulsion, levator ballooning, treatment to support a perineal body; a method of perineal body repair; a method of treating the levator hiatus by tightening or reducing the size of the levator hiatus; and combinations of one or more of these. The method may also be more general, as a treatment of more general conditions such as urinary continence that is believed to be caused by or contributed to by a weakened levator. 
         [0014]    The method may be prophylactic or medically necessary. A prophylactic treatment may be a preventative treatment for potential disease or condition that does not yet exist but that may be likely to exist. For example preventative treatment may be useful upon a grade one or two prolapse, for reinforcement of current prolapse repair, or post-partum. A medically necessary procedure may take place when a disease is present and in need of immediate treatment, such as in the case of perineal descent, fecal incontinence, urinary incontinence, reinforcement of current prolapse repair, and rectal prolapse. 
         [0015]    An implant can be placed to contact pelvic tissue as desired, to support the tissue, such as levator tissue, and can optionally be secured to the tissue to be supported, e.g., by suturing or anchoring. The implant can additionally be secured to tissue of the pelvic region for additional support, such as to tissue such as: sacrotuberous ligament; sacrospinous ligament; anococcygeal ligament (“anococcygeal body ligament”); periostium of the pubic bone (e.g., in a region of the ischial tuberosity); pubourethral ligament; ischial spine (e.g., at a region of the ischial spine); ischial tuberosity; arcus tendineus (used synonymously herein with the term “white line”), e.g., through a tissue path between levator ani muscle and obturator internus muscle and attached at the arcus tendineus; obturator internus muscle. Alternately, an extension guide portion of an implant can be extended through a tissue path that leads to an external incision such as: by passing through tissue of the obturator foramen. 
         [0016]    According to exemplary methods, an implant can be introduced through an incision that allows access to levator tissue, optionally with or without some amount of dissection. The incision can be any of a variety of incisions that provide such access, such as a small external perirectal incision that can allow a tissue path to extend from the external perirectal incision to levator tissue; an external suprapubic incision; an external incision that can be used to pass a portion of an implant through an obturator foramen, a Kraske incision under the rectum; an incision at the perineum; and a vaginal incision. An implant or a portion of the implant can be accessed or placed into position using the incision, to support tissue of the levator. Preferably the implant can be placed by dissecting a plane or region of dissection that includes the ischorectal fossa. Anatomical landmarks included with this region of dissection can include the ischial spine, the obturator internus, the arcus tendineus. 
         [0017]    One embodiment of implant can be a synthetic or biologic implant having a tissue support portion. The tissue support portion can be sized and shaped to support levator tissue. The precise form can depend on the type of condition being treated. Certain embodiments of a tissue support portion may optionally include a segment or support for addressing levator hiatus opening, perineal descent, rectal prolapse, fecal incontinence, etc. 
         [0018]    The invention contemplates various methods of supporting levator tissue. Exemplary methods include steps that involve creating a single medial incision (a transvaginal incision or a perineal incision) or an incision near the rectum, anus, or perineum; and dissecting within a plane or region of dissection including the ischorectal fossa. An implant can be inserted to contact tissue of the levator, over a desired area. Optionally, the implant can be a single piece or multiple pieces or portions, and may include one or more tissue fasteners that can be secured to tissue in the pelvic region. An implant may include materials or components such as those used in the Elevate, MiniArc, SPARC and Monarc systems (from American Medical Systems), include connectors for engagement between a needle of an insertion tool and an distal end of an extension portion, as well as helical, straight, and curved needles. 
         [0019]    In one aspect, the invention relates to pelvic implant for supporting tissue of the pelvic floor (e.g., levator tissue, coccygeus tissue, or combinations of these), and related surgical systems and kits. In another aspect, the invention provides a system and method of repairing levator avulsion. Namely, a small incision can be made to deploy a relatively small implant, with anchoring device, unilaterally or bilaterally. The implant is delivered and deployed via a needle or introducer device that can be anatomically (curved, helical, etc.) shaped and configured for traversal along the vaginal sidewall to advance through the obturator membrane such that a first anchor of the implant is securable to or proximate the tissue defect or avulsion. The needle and implant are then retrieved or withdrawn, with the anchored tissue being pulled back to or proximate the tissue tear site or damaged area. At this point, adjustment can be made to the anchor devices, implant length, or by employing other known adjustment systems or methods to remove slack in the implant or facilitate tautness in the repaired tissue. 
         [0020]    Various implant and anchoring devices can be implemented for the present invention. For instance, various mesh supports and fixating anchoring end portions can be employed. 
     
    
     
       BRIEF DESCRIPTION OF DRAWINGS 
         [0021]    Other features and advantages of the present invention will be seen as the following description of particular embodiments progresses in conjunction with the drawings. Drawings are schematic and not to scale. 
           [0022]      FIG. 1A  illustrates example of health anatomy of a pelvic region. 
           [0023]      FIG. 1B  illustrates example of a pelvic region having a defect. 
           [0024]      FIG. 2  illustrates exemplary features or components of the invention for repairing defects in pelvic anatomy. 
           [0025]      FIG. 3A  illustrates an exemplary implant of the invention. 
           [0026]      FIG. 3B  illustrates an exemplary implant of the invention. 
           [0027]      FIG. 3C  illustrates a carrier for carrying support backer members of the invention. 
           [0028]      FIG. 3D  illustrates a carrier for carrying support backer members of the invention coupled to a portion of the implant. 
           [0029]      FIG. 4A  illustrates an implant disposed upon a delivery tool. 
           [0030]      FIGS. 4B-4G  illustrates example embodiments of delivery tools. 
           [0031]      FIG. 5A  illustrates an example of process for repairing a pelvic defect. 
           [0032]      FIG. 5B  illustrates another step in a process for repairing a pelvic defect. 
           [0033]      FIG. 5C  illustrates another step in a process for repairing a pelvic defect. 
           [0034]      FIG. 5D  illustrates another step in a process for repairing a pelvic defect. 
           [0035]      FIG. 6  illustrates an example of a support backer member. 
           [0036]      FIG. 7  illustrates a cross section of  FIG. 6  above. 
           [0037]      FIGS. 8A-9B  illustrates example embodiments of delivery tools used to deliver the support backer member. 
           [0038]      FIG. 10A  illustrates an example of delivering the support backer member. 
           [0039]      FIG. 11A  illustrates an example of the implant prior to adjusting to repair a defect. 
           [0040]      FIG. 11B  illustrates an example of the implant after adjustment with a defect repaired. 
       
    
    
       [0041]    The preceding description of the drawings is provided for example purposes only and should not be considered limiting. The following detailed description is provided for more detailed examples of the invention. Other embodiments not disclosed or directly discussed are also considered to be within the scope and spirit of the invention. It is not the intention of the inventor to limit the scope of the invention by describing one or more example embodiments. 
       DETAILED DESCRIPTION 
       [0042]    The following description is meant to be illustrative only and not limiting. Other embodiments of this invention will be apparent to those of ordinary skill in the art in view of this description. 
         [0043]    The invention relates to surgical implants, insertion tools, kits, and assemblies, and related methods for treating pelvic defect and disorders related to levator avulsion, ballooning, etc. As a secondary effect the methods of treating levator avulsion or ballooning may treat, improve, or prevent a condition such as prolapse, incontinence (urinary or fecal incontinence), conditions of the perineal body, conditions of the levator hiatus, levator ballooning, and combinations of two or more of these. 
         [0044]    According to various embodiments, a surgical implant can be used to support levator tissue in a region of a levator avulsion. The implant may be placed to contact or support levator tissue at a location in a region of a levator avulsion. A “region of a levator avulsion” refers to a location of levator tissue that can be contacted by a support portion of an implant to allow the implant to be manipulated or tensioned in a manner that will cause approximation of tissue of the levator muscle, to at least in part remedy the avulsion; the region may be at a surface of the levator tissue or at a location at an interior of the tissue, and may be at a location that is considered to be either “inferior” to (“caudal” to) the avulsed tissue or “superior” to the avulsed tissue; optionally the region can be proximal to the avulsion, such as within 3 centimeters, within 2 centimeters, or within 1 centimeter from tissue of an avulsion. 
         [0045]    As an example, a portion of implant (e.g., a portion of support portion, such as a short length of the support portion) can be placed within the tissue of the levator muscle (“embedded” in the muscle or “tunneled” through a length of the muscle). According to such an example, a portion of implant may enter (or exit) levator tissue inferior to the avulsed tissue, be embedded in the belly of the levator muscle and extend through an obturator foramen. Alternately, the implant may extend through the levator muscle tissue inferior to the avulsed tissue, traverse the avulsion, and continue on a superior side of the avulsion, then exit at a location superior to the avulsed tissue, such as at a location near the obturator internus muscle. Generally, the implant can exit the levator muscle tissue on the obturator internus side of the levator muscle, extend through tissue of the obturator internus muscle, through the obturator foramen, toward the anterior external incision, and exit the patient at the anterior incision. 
         [0046]    The implant can be used to support the levator tissue to remedy a levator avulsion such as by approximating levator tissue, supporting levator tissue, or both, to cause levator tissue to move to close the avulsion. In the event that an avulsion involves a detachment of levator tissue from tissue or bone at a superior region of levator tissue—e.g., a detachment at or near tissue of an arcus tendineus, tissue of an obturator internus muscle, a pubic bone, an ischial spine, or any combination of these˜the levator tissue can be approximated in a direction to allow the detached tissue to be moved closer to the location of the detachment. After this tissue approximation, the implant can be maintained in the implanted position to continue to support the levator tissue to prevent subsequent return of the levator muscle to the avulsed condition, and to potentially prevent future conditions of avulsion or related prolapse, incontinence, levator ballooning, or other pelvic condition. 
         [0047]    Turning now to the figures,  FIG. 1  shows anatomy relevant to methods and devices of embodiments of the invention. In particular,  FIG. 1 , illustrates a superior view of tissue at different levels of the pelvic region, including ischiococcygeous muscle  20 , iliococcygeus muscle  22 , puborectalis and pubococcygeous muscles  24 , ischial spine  26 , pubic symphasis  228 , coccyx  30 , arcus tendineus  32 , and obturator foramen  34 . Vagina  36 , urethra  37 , rectum  38 , and pelvic bone  39  are also shown. Continuing with  FIG. 1 , a levator avulsion (not illustrated) may typically be located along the superior portion of the levator muscle extending between the ischial spine, along the arcus tendineus, and to the obturator internus muscle, for example at a superior portion of any one or more of the puborectalis muscle, pubococcygeus muscle, or iliococcygeous muscle. According to embodiments of the invention, an implant can be placed to approximate, support, or approximate and support, one or more of these muscles to treat the avulsion. 
         [0048]      FIG. 1B  illustrates relevant anatomy (on a patient&#39;s right side), as described, and includes an exemplary depiction of avulsion  40 . Although the avulsion is demonstrated as being located in the iliococcygeus muscle it should be understood that the avulsion could be located in any of the pelvic muscles and the implant of the present invention may be used to repair such defect. 
         [0049]    Generally,  FIG. 2  illustrates various parts or components of the pelvic defect repair system  42 .  FIG. 2  shows an implant  44  with one-way frictional adjusting engagement members or support backer members  46 . The system  42  may also include an implant delivery device  48  to deliver the implant  44  to a tissue approximate a defect and a backer delivery device  50  to deliver one or more support backer members  46  to a tissue used to support the tissue via the implant  44 . 
         [0050]    As particularly illustrated in  FIGS. 3A and 3B , the implant  44  may include a tissue support portion  51  made from any material capable of permitting tissue ingrowth such as synthetic or biological mesh materials. The tissue support portion  51  may have first  52  and second  54  opposed ends. Attached or connected to the first end  52  of the tissue support portion  51  may be a tissue anchor or self fixating tip  56  that is designed to engage tissue proximate a defect such that the tissue support portion  51  may support and/or contact the tissue proximate the defect. By contacting or connecting with the tissue proximate the defect the tissue support portion  51  may permit tissue ingrowth, thereby providing additional support to the musculature. 
         [0051]    As particularly illustrated in  FIG. 3B , the implant  44  may also have an extension guide portion  58  disposed on or connected to the second end  54  of the tissue support portion  51  to guide the support backer member(s)  46  toward a portion of the tissue support portion  51 . In one embodiment, the extension guide  58  may comprise a generally rigid, generally flexible or bendable rod or shaft. In other embodiments, as illustrated in  FIG. 3A  the extension guide  58  may comprise one or more sutures  60  that are connected or sewn to a portion of the tissue support portion  51 . In yet other embodiments, the extension guide  58  may comprise mesh, wire or any other material or structure capable of guiding the support backer member(s)  46  toward the tissue support portion  51 . 
         [0052]    As illustrated in  FIGS. 3C and 3D , the system  42  may also include a carrier  62  to carry and transfer one or more of the support backer members  46  to the extension guide portion  58 . In one embodiment, the carrier  62  may comprise a rod or shaft having a mating feature such as a shaft having a reduced outer diameter or axially extending bore that can fit into or onto a free end  64  of the extension guide portion  58 . The carrier  62  ensures that the support backer members  46  are properly transferred to the extension guide portion  58  of the implant  44 . 
         [0053]    Turning to  FIG. 4A , the implant delivery device  48  of the system  42  may include a handle  66  having a needle  68  extending away from a portion of the handle  66 . As particularly illustrated in  FIG. 4A , the self fixating tip  56  is designed to engaged, connect or couple to a tip or free end  70  of the needle  68 . In one embodiment, the self fixating tip  56  may have a channel or bore that may be keyed to ensure proper connection between it and the free end  70  of the needle  68 . The self fixating tip  56  may also be connected to the free end  70  of the needle  60  by a mechanism that permits controlled release into a tissue mass such as a levator muscle. 
         [0054]    Referring to  FIGS. 4B-4G , the needle  68  may have any of a variety of shapes to facilitate placement of the implant  44  in a therapeutic location designed to repair pelvic defects. As particularly illustrated in  FIGS. 4B-4E , the needle  68  may have a portion between the handle  66  and its free end  70  that is generally helical. The system  42  may include multiple delivery tools  48  designed for insertion of the implant  44  in different anatomical locations such as the left and right obturator foramen. As particularly illustrated in  FIGS. 4D and 4E , the needle  68  may be bent or have a slight bend located between the handle  66  and the free end  70  of the needle  68 . The delivery tools  48  may be sterilized or disposable. The needle  68  may also have a number of notches or measurements  72  disposed along its length to permit a physician to determine a length of the needle  68  disposed in a patient. 
         [0055]    As illustrated in  FIG. 5A , an incision  72  can be made in a patient&#39;s dermis proximate their obturator foramen. A physician can attach the self fixating tip  56  to the free end  70  of the needle  68 . The free end  70  of the needle  68  and the self fixating tip  56  can then be inserted into the incision  72 . As illustrated in  FIG. 5B , the needle  68  and self fixating tip  56  may be passed through the obturator foramen  34  (not shown) and into the levator tissue as shown in  FIG. 10A . As particularly illustrated in  FIG. 11A , the self fixating tip  56  may be inserted into levator muscle inferior the defect or any other tissue such as tissue surrounding the urethra or rectum. 
         [0056]    As illustrated in  FIG. 5B , the extension guide portion  58  of the implant  44  may extend out of the incision  72 . At this particular point a physician may remove the delivery tool  48  or maintain it in contact with the implant  44 . The carrier  62  can be coupled to the extension guide  58  and one or more support backer members  46  moved down onto the extension guide portion  58 . The backer delivery device  50 , which may comprise a shaft  74  having an engagement end  76  and an engagement configuration attached to or formed on the shaft  74  for engaging a support backer member  46 , may be moved along the extension guide  58  to engage the support backer member  46  and move it through the incision  72 . 
         [0057]    As the support backer member  46  is moved toward the obturator foramen by the backer delivery device  50  it engages the tissue support portion  51  of the implant  44 . The support backer member  46 , which may comprise a ring  78  having an aperture and a plurality of inwardly radiating engagement portions or flanges, flaps or teeth  79  (as illustrated in  FIGS. 6 and 7 ) extending into the aperture engage the tissue support portion  51  of the implant  44 . The support backer member  46  may be designed to permit movement along the extension guide portion  58  and onto the tissue support portion  51  but resist movement in a reverse direction. As the support backer member  46  is disposed proximate the obturator foramen the physician may pull on the extension guide portion  58  to place the tissue support portion  51  in tension. In another embodiment, the physician may permit a predetermined amount of slack in the tissue support portion  51  between the obturator foramen and the self fixating tip  56  in the tissue to create a backstop for organs and/or tissue. 
         [0058]    In one embodiment, the engagement end  76  of the backer member delivery device  50  may include one or more solid rings and aperture  80  or arms  81  and  82  defining an opening for receiving the extension guide portion  58 . In one embodiment of the invention, as illustrated in  FIGS. 9A and 9B , the engagement end  76  may include multiple apertures  80 ,  80 ′ and/or arms  81 ,  81 ′ and  82 ,  82 ′. In this particular embodiment, a backer member  46  can be disposed between the pairs of arms  81 ,  81 ′ and  82 ,  82 ′. The aperture  80  or apertures  80  and  80 ′ may have a central axis that is generally parallel to or generally angled to a longitudinal axis of the shaft  74  of the backer member delivery tool  50 . The shaft  74  of the backer delivery tool  50  may have spaced apart notches, markings and the like to permit a physician to determine a length or depth of the backer member delivery tool  50  disposed in a patient. 
         [0059]    The following patent documents are incorporated herein by reference to permit one skilled in the art to better understand the invention and its various embodiments: US Patent Publication No. US 2004/0039453 A1; US Patent Publication No. US 2005/0250977 A1; US Patent Publication No. US 2005/0245787 A1; U.S. Pat. No. 6,652,450; U.S. Pat. No. 6,612,977; U.S. Pat. No. 6,802,807; U.S. Pat. No. 7,048,682; U.S. Pat. No. 6,641,525; U.S. Pat. No. 6,911,003; U.S. Pat. No. 7,070,556; U.S. Pat. No. 6,354,991; U.S. Pat. No. 6,896,651; U.S. Pat. No. 6,652,449; U.S. Pat. No. 6,862,480; U.S. Pat. No. 6,712,772; and PCT Application Serial No. Unknown, filed Jun. 15, 2007, titled “Surgical Implants, Tools and Methods for Treating Pelvic Conditions” (Attorney Docket No. AMS-3419-PCT). (See International Patent Application No. PCT/US2007/014120, entitled “Surgical Implants, Tools, and Methods for Treating Pelvic Conditions, filed Jun. 15, 2007, the entirety of which is incorporated herein by reference.) PCTUS2007/004015, filed Feb. 16, 2007, titled Surgical Articles and Methods for Treating Pelvic Conditions, the entirety of which is incorporated herein by reference. WO 2007/016083, published Feb. 8, 2007, and entitled “Methods and Symptoms for Treatment of Prolapse,” the entirety of which is incorporated herein by reference); including tissue at or near an ischial spine, e.g., at a region of an ischial spine. 
         [0060]    Embodiments of exemplary implants that may be useful as discussed herein and in the incorporated references can include a tissue support portion  51  and no extension portions  58 . Other embodiments can include one, two, three, or more extension portions  58  attached to a tissue support portion  51 . An exemplary urethral sling can be an integral mesh strip or hammock with supportive portions consisting of or consisting essentially of a tissue support portion  51  and zero, one, or two extension portions  58 . 
         [0061]    An implant may include portions or sections that are synthetic or of biological material (e.g., porcine, cadaveric, etc.), and that may be resorbable or non-resorbable. Extension portions may be, e.g., a synthetic mesh such as a polypropylene mesh. The tissue support portion may be synthetic (e.g., a polypropylene mesh) or biologic. 
         [0062]    The implant  44 , either or both of the tissue support portion  51  or a guide extension portion  58 , may comprise variable weave meshes with varying elasticities such as a mesh that is highly elastic around the anus to allow stool to pass. 
         [0063]    Some example of commercially available materials may include MarleX™ (polypropylene) available from Bard of Covington, R.I., Prolene™ (polypropylene) and Mersilene (polyethylene terephthalate) Hernia Mesh available from Ethicon, of New Jersey, Gore-TeX™ (expanded polytetrafluoroethylene) available from W. L. Gore and associates, Phoenix, Ariz., and the polypropylene sling material available in the SPARC™ sling system, available from American Medical Systems, Inc. of Minnetonka, Minn. Commercial examples of absorbable materials include Dexon™ (polyglycolic acid) available from Davis and Geck of Danbury, Conn., and Vicryl™ available from Ethicon. 
         [0064]    Dimensions of an implant can be as desired and useful for any particular installation procedure, treatment, patient anatomy, to support a specific tissue or type of tissue, and to extend to a desired location of internal supportive tissue or an external incision. Exemplary dimensions can be sufficient to allow the tissue support portion to contact tissue of the levator, coccygeus, rectum, external anal sphincter, etc., or any desired portion of one or more of these. Optionally, one or more guide extension portions  58  can extend from the tissue support portion  51  to a desired internal or external anatomical location to allow the guide extension portion  58  to be secured to anatomy of the pelvic region, to support the tissue support portion  51 . 
         [0065]    Dimensions of guide extension portions  58  according to the invention can allow the guide extension portion  58  to reach between a tissue support portion  51  placed to support tissue of the pelvic floor (at an end of the extension portion connected to the tissue support portion) and a location at which the distal end of the guide extension portion  58  pass through an external incision. 
         [0066]    An implant  44  can be of a single or multiple pieces that is or are shaped overall to match a portion of the levator, e.g., that is completely or partially circular, trapezoidal (non-symmetric or symmetric), rectangular, rhomboidal, etc. The implant may be multiple pieces to fit beside or around pelvic features such as the rectum or anus. Alternately, the implant  44  may be irregular (while optionally symmetrical) to reach different areas of the levator. 
         [0067]    To contact tissue of the pelvic floor, the implant  44  or any portion thereof can be a continuous or a non-continuous sling, and of one or multiple pieces or segments. A continuous implant may be substantially continuous between edges, to be placed over a level surface area of levator tissue. A non-continuous implant may include breaks or cuts that allow much of the implant to be placed on a level surface of levator tissue, with portions being formed to extend around tissue structure extending from or to the levator tissues, such as the anus, rectum, etc. 
         [0068]    An embodiment of a non-continuous sling may be designed to cover or contact area of the levator, coccygeus, or both, and also reach around to contact a posterior side of the rectum or external anal sphincter. For example, a portion of an implant could attach to the lateral sides of the external anal sphincter and extend toward or in the direction of the obturator foramen, or any other suspensory structure (e.g., supportive tissue), but need not engage tissue of the obturator foramen directly. In this embodiment, the tissue support portion of the implant need not necessarily be directly under the anus to provide the corrective action for fecal incontinence. An advantage to of this approach is to allow the anus to expand unrestricted to facilitate normal rectal function and may give the levator plate (or plates) the support necessary to be leveraged. 
         [0069]    Embodiments of implants can include a segment that is located anterior to the anus, such as in contact with levator tissue or tissue of the perineal body, anterior to the anus. Alternate implants may be designed to replace the perineal muscle or attach to the superior portion of the external sphincter. The various embodiments disclosed herein are also applicable to men and can be implanted via an incision in the perineal floor (see attached figures). 
         [0070]    An implant, e.g., at a tissue support portion  51  can optionally include a tissue fastener such as a soft tissue anchor, a self-fixating tip, a biologic adhesive, a tissue clamp, opposing male and female connector elements that securely engage when pushed together, or any other device to secure a distal end of an extension portion to tissue of the pelvic region. Exemplary tissue fasteners are discussed, e.g., in PCT/SU2007/014120 “Surgical Implants, Tools, and Methods for Treating Pelvic Conditions, filed Jun. 15, 2007; the entirety of which is incorporated herein by reference. The implant may also have extension portions that do not include a tissue fastener at a distal end thereof, 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 a tissue path ending in an external incision. Exemplary self-fixating tips are described, for example, in PCT/US2007/004015 “Surgical Articles and Methods for Treating Pelvic Conditions,” filed Feb. 16, 2007, the entirety of which is incorporated herein by reference. 
         [0071]    A self-fixating tip  56  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 an 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. 
         [0072]    Alternate embodiments of self-fixating tips  56  do not require and can exclude an internal channel for engaging a delivery tool  48 . These alternate embodiments may be solid, with no internal channel, and may engage a delivery tool  48 , if desired, by any alternate form of engagement, such as, for example, by use of a delivery tool  48  that contacts the self-fixating tip  56  at an external location such as by grasping the base (on a side or at the face of the proximal base end) or by contacting a lateral extension. 
         [0073]    Examples of commercial implants include those sold 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 Sparc®, Bioarc®, Monarc®, and MiniArc™ for treating urinary incontinence. Implants useful according to the present description can include one or more features of these commercial implants. 
         [0074]    Generally, transobturator tissue approaches are described at pending application Ser. No. 11/347,047 “Transobturator Methods for Installing Sling to Treat Incontinence, and Related Devices,” filed Feb. 3, 2006, and at U.S. publication 2005/0143618 (Ser. No. 11/064,875) filed Feb. 24, 2005, the entireties of these being incorporated herein by reference. 
         [0075]    Also straight, helical and curved needles, as described in U.S. Publication no. 2005/0250977; 2005/0245787 and 2004/0039453, which are herein incorporated by reference in their entirety, can also be used with their associated tunneling paths and techniques. 
         [0076]    In a related embodiment, a depth limiting feature such as a sheath design or a mechanical stop or a bend in the needle to facilitate correct depth placement. Also inside out as opposed to the outside in implantation approach is a possible variation to the described embodiments (similar to the ISCP methods and techniques). 
         [0077]    Examples of various tissue paths, relevant anatomy, implant materials, features of implants (e.g., connectors, tensioning devices), insertion tools, are described, for example, in US Publication Nos. 2002/0161382 (Ser. No. 10/106,086) filed Mar. 25, 2002; 2005/0250977 (Ser. No. 10/840,646) filed May 7, 2004; and 2005/0245787 (Ser. No. 10/834,943) filed Apr. 30, 2004; 2005/0143618 (Ser. No. 11/064,875) filed Feb. 24, 2005; and U.S. Pat. No. 6,971,986 (Ser. No. 10/280,341) filed Oct. 25, 2002; U.S. Pat. No. 6,802,807 (Ser. No. 09/917,445) filed Jul. 27, 2001; U.S. Pat. No. 6,612,977 (Ser. No. 09/917,443) filed Jul. 27, 2001; U.S. Pat. No. 6,911,003 (Ser. No. 10/377,101) filed Mar. 3, 2003; U.S. Pat. No. 7,070,556 (Ser. No. 10/306,179) filed Nov. 27, 2002, PCT/US2007/004015 “Surgical Articles and Methods for Treating Pelvic Conditions,” filed Feb. 16, 2007; PCT/US2007/014120 “Surgical Implants, Tools, and Methods for Treating Pelvic Conditions, filed Jun. 15, 2007; the entireties of each of these being incorporated herein by reference.