Chapter 61 CADAVERIC FASCIAL REPAIR OF CYSTOCELE
Traditional anterior colporrhaphy and paravaginal repair of cystoceles are associated with recurrence rates as high as 33% and 71%, respectively.1,2 The fascial defects responsible for anterior wall prolapse have been previously described.3 Lateral defects, which involve detachment of the endopelvic fascia from the arcus tendineous fascia, are more common. Central defects result from a break in the pubocervical fascia, the supportive layer between the bladder and the vaginal wall. These defects are not mutually exclusive; both may be present simultaneously.
Cystocele repair with nonfrozen cadaveric fascia lata offers several advantages. In the technique described here, both central and lateral defects are addressed and repaired simultaneously. The repair is performed transvaginally and secured without the tension that is often necessary in traditional repairs. Avoidance of tissue plication results in minimal vaginal narrowing, which is especially important for patients who are sexually active. We use solvent-dehydrated, nonfrozen cadaveric fascia (Tutoplast, Mentor Corp., Santa Barbara, CA) and avoid the use of the patient’s inherently weak tissue. Studies have shown that the tensile strength and tissue stiffness maintained by the five-step preparation process are comparable to those of native autologous rectus fascia.4 On the other hand, freeze-dried cadaveric fascia has been shown to have less tensile strength and more tissue inconsistencies.5
The technique described, cadaveric prolapse repair with sling (CaPS), involves prolapse repair and simultaneous placement of a transvaginal sling to support the proximal urethra and bladder neck. The procedure is performed both in patients who complain of preoperative SUI and in those with occult SUI demonstrated with prolapse reduction. Controversy has existed in the literature regarding the need for prophylactic placement of slings at the time of prolapse repair in women who do not complain of SUI. However, studies have shown that repairing a cystocele without simultaneously supporting the urethra/bladder neck results in unacceptable rates of postoperative SUI.6 In addition, clinically continent women with genitourinary prolapse and occult SUI are considered to be at high risk of developing symptomatic SUI once the prolapse is repaired.7,8 Although one may worry that the prophylactic placement of a pubovaginal sling at the time of prolapse repair in women who do not complain of SUI could result in higher rates of postoperative retention, our previous published results on the CaPS have not shown this to be the case.9–11
PREOPERATIVE EVALUATION
Before repair of prolapse, a thorough history is obtained, which should include a gynecologic history, number of vaginal deliveries, and prior anti-incontinence procedures. The severity of a patient’s symptoms is ascertained through subjective SEAPI scores (Table 61-1),12 and the effect of the incontinence and prolapse symptoms on the patient’s quality of life is measured by a validated questionnaire.13
Table 61-1 SEAPI Incontinence Score
| Stress-related leakage (“S”) | 0 = No urine loss |
| 1 = Loss with strenuous activity | |
| 2 = Loss with moderate activity | |
| 3 = Loss with minimal activity | |
| Emptying ability (“E”) | 0 = No obstructive symptoms |
| 1 = Minimal symptoms | |
| 2 = Significant symptoms | |
| 3 = Only dribbles or retention | |
| Anatomy (“A”) | 0 = No descent with strain |
| 1 = Descent, not to introitus | |
| 2 = Through introitus with strain | |
| 3 = Through introitus at rest | |
| Protection (“P”) | 0 = Never used |
| 1 = Certain occasions | |
| 2 = Daily, occasional accidents | |
| 3 = Continually, frequent accidents or constant leakage | |
| Inhibition (“I”) | 0 = No urge symptoms |
| 1 = Rare urge urinary incontinence (UUI) | |
| 2 = UUI once/week | |
| 3 = UUI at least once/day |
From Raz S, Erickson DR: SEAPI QNM Incontinence classification system. Neurourol Urodyn 11:187-199, 1992.
A careful physical examination is performed to determine the degree of prolapse.
The patient is examined in both the dorsal lithotomy and the standing position with a full bladder. The vaginal mucosa is inspected for signs of atrophy. The posterior blade of a Graves speculum is used to retract the posterior vaginal wall, and the patient is asked to cough and to perform Valsalva maneuvers. The urethra is examined for hypermobility and stress incon-tinence, and descensus of the anterior vaginal wall is graded using the Baden-Walker classification (Table 61-2).14 Incidental grade 1 cystoceles found in patients who present with other complaints are not routinely repaired. The posterior and apical compartments are examined systematically for associated prolapse. Apical prolapse may not be evident with the patient in the lithotomy position, so it is important to also examine the patient standing with two fingers in the vagina to evaluate for uterine/vaginal cuff descensus. A focused neurologic examination is performed to assess for the presence of neurologic deficits.
Table 61-2 Baden-Walker Prolapse Classification
Urodynamic evaluation is performed in all patients before surgical repair. Evaluation of SUI is performed both with and without prolapse reduction. Assessment of underlying bladder dysfunction, such as detrusor overactivity, sensory instability, poor compliance, or incomplete emptying, is important for documentation purposes. Patients with elevated postvoid residuals are counseled regarding the possible need for intermittent catheterization postoperatively.
An upper urinary tract evaluation with renal ultrasound is performed before prolapse repair. This provides a baseline study should the patient develop postoperative flank pain, and it also evaluates for preexisting hydronephrosis secondary to kinking of the distal ureters from prolapse.
PREOPERATIVE PREPARATION
Before prolapse repair is performed, the urine is confirmed to be sterile. Patients are taught self-catheterization preoperatively. In the event that a patient is unable to learn self-catheterization or has documented incomplete emptying preoperatively, con-sideration of placing a suprapubic tube intraoperatively should be made. Preferably, patients with vaginal wall atrophy should use estrogen vaginal cream for 4 to 6 weeks before surgery. Patients are instructed to use one third of an applicator of estrogen three times a week to improve the quality of vaginal tissue and postoperative healing properties. A povidone-iodine vaginal douche is performed the night before and on the morning of surgery. Perioperative antibiotics are given. We prefer to use a first-generation cephalosporin, ampicillin, or vancomycin (if the patient is allergic to penicillin) combined with an aminoglycoside.
Transvaginal repair of associated apical or posterior prolapse is performed with the CaPS procedure. A thorough discussion of the risks and complications of prolapse surgery is undertaken before the operation. Patients are counseled regarding the possibility of prolonged or permanent urinary retention, occult or recurrent SUI, recurrent anterior prolapse, and recurrent or de novo prolapse apically or posteriorly. All patients are counseled about the risk of persistent or de novo urgency symptoms and that either of these may require treatment in the future.
OPERATIVE PROCEDURE
Related posts:
DEVELOPMENTAL ANATOMY AND UROGENITAL ABNORMALITIES
USE OF CADAVERIC FASCIA FOR PUBOVAGINAL SLINGS
EPIDEMIOLOGY OF INCONTINENCE AND VOIDING DYSFUNCTION IN THE ELDERLY
SURGERY FOR REFRACTORY URINARY INCONTINENCE: SPIRAL SLING
URETHRAL INJECTABLES IN THE MANAGEMENT OF STRESS URINARY INCONTINENCE
FUNCTIONAL ANATOMY AND PATHOPHYSIOLOGY OF PELVIC ORGAN PROLAPSE
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