Anterior compartment defects result from attenuation or separation of the pubocervical fibromuscularis. This defect results in a protrusion of anterior compartment structures, most commonly the bladder, leading to what is most commonly described as a cystocele.
The two most commonly described anatomic defects leading to anterior compartment prolapse are the midline defect and the paravaginal defect. A midline defect results from a separation of the fibromuscular supporting septum, commonly known as the “pubocervical fascia.” Not a true fascial layer, it is largely a sheet of muscular and connective tissue that originates from each pelvic sidewall, thus stabilizing the bladder. A weakness in this often attenuated tissue may lead to a “break” through which the anterior compartment structures, including the bladder, then bulge into of the vagina. This may occur while the lateral attachments to the pelvic sidewall are maintained ( Fig. 89.1 ).
The paravaginal defect is caused by the pubocervical septum separating from the arcus tendineus fascia pelvis (ATFP). The ATFP are bilateral fibrous structures that run from the pubic bone to the ischial spines. They are integral structures in stabilizing the anterior compartment as the ATFP inserts on the ischial spine. A “break” in the attachments to the ATFP can lead to prolapse of the bladder, urethra, or both.
According to the International Continence Society, the term anterior vaginal prolapse is the preferred term for anterior defects rather than the term cystocele . The physical examination does not allow specific identification of the structures underlying a defect. For practical purposes, the bladder most commonly does underlie the defect, and thus it is imperative to recognize and respect the integrity of this structure.
Anterior pelvic organ prolapses (POPs), especially those of higher stages, are rarely isolated entities. In evaluation of a patient with anterior POP, all compartments must be evaluated. Anterior repairs are often performed in conjunction with other compartmental repairs, with or without a concomitant sling procedure to address stress urinary incontinence (SUI).
Anterior Colporrhaphy
An anterior colporrhaphy is a native tissue surgical technique that uses plication sutures to repair a central defect in the pubocervical fibromuscularis.
- 1.
The patient is positioned in the dorsolithotomy position using candy cane, or Yellowfin (Allen Medical, Acton, MA). It is essential that all pressure points are appropriately padded. Preoperative antibiotics and deep vein thrombosis prophylaxis are administered. The perineum is then prepped and draped in the usual sterile fashion.
- 2.
Adequate exposure of the anterior vaginal wall is essential for the success of the procedure. A weighted speculum and a Lone Star Retractor (Cooper Surgical, Trumbull, CT) are useful tools in gaining exposure. A Foley catheter is placed to drain the bladder and help identify the bladder neck by palpation.
- 3.
The anterior vaginal wall is grasped with two Allis clamps at the proximal and distal portion of the defect. The locations of these points will vary depending on the extent of the prolapse and may be located anywhere from the mid vaginal wall up to the cervicovaginal junction ( Fig. 89.2, A ).
FIGURE 89.2
Classical anterior colporrhaphy. ( A ) The initial midline anterior vaginal wall incision. ( B ) The midline incision is extended using scissors. ( C ) Sharp dissection of the bladder off the vaginal wall should be lateral to the superior pubic ramus, and the base of the bladder should be dissected off the vaginal cuff or cervix to the level of the preperitoneal space of the anterior cul-de-sac. ( D ) The bladder has been completely mobilized off the vagina.
(From Karram MM, Maher C. Surgical management of pelvic organ prolapse . Philadelphia: Elsevier; 2013.)
- 4.
If desired, hydrodistention of the vaginal wall may be performed to aid dissection and provide additional hemostasis if epinephrine is used. Injectable saline or lidocaine with or without epinephrine is injected deep to the vaginal epithelium elevating it from the underlying muscularis.
- 5.
The initial incision is then made with a #15 blade scalpel. The authors prefer a midline incision, although a T-shaped incision has been described. The incision extends from the apex of the defect (previously demarcated in step 3) proximally to 1.5 cm proximal to the urethral meatus. If a concomitant sling procedure is going to be performed, then the distal extent of the incision should stop at least 3 cm proximal to the meatus. This allows room for a separate midurethral incision for the sling ( Fig. 89.2, B ).
- 6.
The edge of the incision is grasped with Allis clamps to aid in retraction. Dissection of the vaginal flaps is then accomplished by retracting the Allis over the nondominant finger and incising in the plane between the vaginal muscularis and epithelium with Metzenbaum scissors. Care should be taken to keep the tips of the scissors against the vaginal epithelium. Medial retraction of the fibromuscular tissue by an assistant will facilitate visualization of the correct plane of dissection. After the dissection has been initiated sharply and the correct place entered, further dissection can be performed bluntly with the finger or a four-by-four ( Fig. 89.2, C ).
- 7.
Bilateral vaginal flaps are developed until the entire anterior defect has been exposed. The more advanced the prolapse, the more extensive dissection is required. In general, the flaps are developed laterally to the vaginal sulcus ( Fig. 89.2, D ).
- 8.
Plicating sutures are then placed in the muscularis to repair the anterior defect. No. 2-0 absorbable or delayed absorbable sutures can be used. Stiches are placed through the vaginal muscularis and adventitia just medial to the vaginal flaps and plicated in the midline without tension. It is important to stay shallow with the sutures to avoid incorporating the bladder into the repair ( Fig. 89.3 ).
