Anterior Vaginal Wall Suspension Procedure for Stress Urinary Incontinence Associated with Variable Degrees of Anterior Compartment Prolapse




Image 3.1




  • Bladder neck level on the anterior vaginal wall is marked with a marking pen after placing a Foley catheter with 10 cc into the balloon to identify the location of the bladder neck (Image 3.2.) This anterior vaginal wall marking indicates the distal limits of the anterior vaginal wall plate. No suture should be placed distal to that point in order to avoid any urethral distortion or obstruction during this procedure

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    Image 3.2


  • Marking absorbable sutures are placed laterally at the right and left sides of the apex of the vagina/cervix to delineate the proximal or upper limit of the anterior vaginal plate. These sutures are placed at the level of the dimples left by a prior hysterectomy or in case of a uterus, just cephalad to the cervix and at the junction between the anterior vaginal wall transverse ridges and the shiny lateral vaginal wall area of detachment (vaginal sulcus). Pulling on these marking sutures may help in determining the degree of support of the vaginal apex or cervix (Images 3.2 and 3.3 sutures coming over the speculum).





    • STEP 1: Vaginal incisions



      • A longitudinal (vertical) vaginal incision is marked (Image 3.3) starting 1.5–2 cm lateral to the bladder neck on the anterior vaginal wall and that incision is extended proximally to just lateral to the anchoring marking suture at the vaginal apex on the same side (Image 3.4). This incision is located about 1 cm medial to the vaginal sulcus to allow upward elevation of the anterior vaginal plate later on (Image 3.4).

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        Image 3.3


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        Image 3.4


      • Another vaginal incision is made on the contralateral side in a similar fashion (Image 3.5). Sometimes, when there is vaginal wall redundancy, the incision is helped by placing a retracting hook on the medial edge of the incision to help expose the lateral sulcus (Images 3.5 and 3.6). The incision can be made with a blade or with a long tip bovie cautery (See Chap. 2) using the cutting element (Images 3.5 and 3.6).


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      Image 3.5


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      Image 3.6


    • STEP 2: Suture placement (for a right handed surgeon)



      • After the vaginal incisions have been made bilaterally, a marking pen is used to mark the mid-portion of the anterior vaginal plate (Image 3.7). The plate is typically trapezoidal in shape, ie larger at the apex and narrower distally at the bladder neck level. When the anterior vaginal plate is longer than in this case, a transverse line can be drawn marking the separation between the mid and upper third sections of the anterior vaginal plate, thus delineating 4 quadrants for the placement of four individual anterior vaginal wall suspension sutures.

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        Image 3.7


      • In this case, only one set of suspension suture will be used on each side because the anterior vaginal plate is rather short. So, next, one set of non-absorbable sutures (No. 1 polypropylene sutures, CT-2 needle) are placed on each side to serve as support of the anterior vaginal wall, analogous to a needle suspension procedure. The important point here is that the suture should not be passed over and over in one location as it will likely pull-through as it was done in the original four corner suspension procedure described by Raz. Instead, as shown as the most reliable technique for permanent suture anchor in an animal model [7], the suture should be passed underneath a broad area of vaginal wall to provide for a strong durable anchor. Therefore, each suture is passed in an overlapping/helical fashion on each side. The start of the needle passage is to secure the cardinal ligament complex (Images 3.8 and 3.9); each pass is placed full thickness into the anterior vaginal wall sparing the vaginal epithelium, and is positioned so that each needle passage overlaps with the preceding pass. Now the suture is advanced for a second pass halfway between the entry and exit site of the prior pass, to allow a helical advancing progression (Images 3.10, 3.11, and 3.16 beginning and end of second pass). Third pass is ending up at the bladder neck level (Image 3.12). Typically 2–3 passes are needed on each side to secure a broad segment of anterior vaginal wall (Image 3.13 for securement on the left side and Images 3.14 and 3.15 for securement on the contralateral side).

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        Image 3.8


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        Image 3.9


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        Image 3.10


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        Image 3.11


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        Image 3.12


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        Image 3.13


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        Image 3.14


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        Image 3.15


      • In case of two sets of suspension sutures on each side (Image 3.16), the first bite starts at the cardinal/uterosacral ligament complex or apical scar to provide apical support, and then extends to the middle marking by adding a few additional passes of the needle which is seen passing beneath the vaginal wall from the edge of the incision to the midline marking to secure enough supporting tissue. The 2nd suture on the same side is started at the mid vagina, overlapping the end of the first suture, and ends just lateral to the bladder neck after 2–3 passes of the needle in a helical fashion. Then the same procedure is repeated on the opposite side starting from the bladder neck going down to the cardinal ligament at the vaginal apex.


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      Image 3.16


    • STEP 3: Suprapubic incision



      • A short (2 cm) midline horizontal incision is made approximately one finger-breadth above the symphysis pubis (Images 3.17 and 3.18), away from the trajectory of the ilio-inguinal and genito-femoral nerve branches going to the mons pubis. This incision is deepened to expose the tendinous portion of the rectus fascia at the back of the pubic bone. This incision will allow direct passage of the ligature carrier under fingertip guidance later on.


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      Image 3.17


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      Image 3.18


    • STEP 4: Retropubic dissection

    • Jul 13, 2017 | Posted by in GASTROENTEROLOGY | Comments Off on Anterior Vaginal Wall Suspension Procedure for Stress Urinary Incontinence Associated with Variable Degrees of Anterior Compartment Prolapse

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