This article discusses a systematic approach to the repair of cystoceles using interposition grafting. Surgeons’ opinions vary regarding which graft is most appropriate as there are several varieties for mesh interposition. High-grade cystocele repair using the porcine dermis interposition graft is successful and associated with few complications. Cystocele repair is typically low grade and does not require additional surgery.
Anterior compartment vaginal prolapse, also known as cystocele, is one of numerous types of pelvic floor relaxation that arise from weakening of the endopelvic fascia and herniation of pelvic viscera through the potential space of the vagina. Weakness of the levator fascia results in loss of pelvic floor support and subsequent formation of anterior compartment defects (the preferable term, according to International Continence Society terminology) or cystoceles.
The fascia of the levator floor serves primarily as a supportive role for the anterior vaginal wall and the bladder and urethra in composite. The abdominal aspect of this fascia is referred to as the endopelvic fascia. The vaginal side is referred to as the perivesical fascia at the level of the bladder base and the periurethral fascia at the level of the bladder neck. The pubocervical fascia is the combined periurethral and perivesical fascia complex. The vaginal and abdominal components of these fascial sheets fuse laterally at their insertion into the tendinous arch of the obturator internus (arcus tendineus fasciae pelvis), which forms the pelvic side wall anchor for these structures.
When viewing vaginal support from cephalad to caudad, the cardinal ligaments support the upper vagina and cervix and anchor them to the pelvic sidewall. In the midvagina, the vesicopelvic ligament extends from the pelvic sidewall to the bladder base and supports it and the anterior vaginal wall. The urethropelvic ligaments support the urethra from the meatus to the bladder neck. The arcuate line (arcus tendineus) of the pelvis, which is the condensation of the obturator internus fascia and endopelvic fascia, provides the lateral support insertion for all of these structures. This strong insertion provides a stabilization point for the entire pelvic floor hammock.
Cystocele defects commonly are associated with other forms of pelvic relaxation, including loss of support of the uterus (uterine descensus), vaginal apex (vault prolapse), and posterior compartment (rectocele). After hysterectomy, enteroceles can occur at the apex of the vaginal vault.
Defects of the anterior compartment may result in isolated defects in urethral support, bladder support, or both. Loss of urethral support may result in urethral hypermobility without a concomitant cystocele defect. Cystoceles are more complex and may involve central defects, lateral defects, or both. Lateral defect cystoceles result from disruption or separation of the condensation of the vesicopelvic ligament to the arcus tendineous on either side of the vagina. Central defect cystoceles result from attenuation of the perivesical (pubocervical) fascia without compromise of the urethropelvic and vesicopelvic ligaments. Central defect cystoceles often are associated with attenuation of upper vaginal support, including loss of cardinal ligament support (with a concomitant enterocele). The most common form of cystocele is a combination cystocele. Isolated central defects comprise less than 10% of diagnosed cystoceles. Isolated lateral defects are more common and often are associated with urethral hypermobility. When central and lateral defects are present, more severe degrees of prolapse often result.
Diagnosis
Diagnosis of anterior compartment defects is made using a complete history and physical examination. A variety of symptoms, such as the sensation of a vaginal mass or bulge, urinary incontinence (stress or urge), urgency, obstruction, dyspareunia, vaginal irritation, and defecatory symptoms, especially with concomitant posterior compartment defects (ie, rectocele), may be present. Physical examination of the vagina demonstrates a mass occupying the anterior vaginal wall from the vaginal apex (or the cervix if a hysterectomy has not been performed) to the bladder neck or urethra. Multichannel videourodynamics is often useful in preoperative evaluation and counseling.
Indications for surgery
Symptoms arising from the cystocele and the presence of urinary incontinence form the cornerstone indications for repair. The appropriate operation is based on the degree and severity of the patient’s incontinence, magnitude of the cystocele (grade), underlying nature of the fascial defect (central/lateral), and patient’s ability to empty the bladder. Comprehensive surgical planning also includes identification of associated prolapse elements (and their symptoms), including enterocele, rectocele, and apical prolapse defects.
The type of anterior compartment repair is indicated by the preoperatively defined fascial defect. Central fascial defects may be managed with a placation type of repair or an interposition graft repair with or without concomitant sling, and the choice depends on the presence of incontinence. Isolated central defect repair is rare in the absence of a concomitant stress incontinence procedure.
Lateral defect repairs may be performed with a variety of techniques, including multiple-point repairs (four- or six-corner bladder suspensions) and vaginal–paravaginal or abdominal–paravaginal repairs with combined incontinence intervention. Severe cystoceles with combined central and lateral defects require concomitant stress procedures and interpositional graft placement to compensate for complete disruption of the supportive pelvic floor structures.
Surgical Technique
The patient is placed in the dorsal lithotomy position with the aid of hydraulic stirrups. No extremity is flexed greater than 90°. After prepping the abdomen, perineum, and vagina, the posterior compartment is draped away from the surgical field. Access under an adherent drape is still possible, if necessary. A weighted speculum and a ring retractor are used for vaginal exposure.
A Foley catheter is placed, and hydrodissection of the anterior vaginal wall is performed with normal saline or dilute vasoconstrictor. Dissection begins with a midline incision from the midurethra to vaginal apex ( Fig. 1 ). The anterior vaginal wall, overlying the cystocele, is dissected away from the underlying attenuated pubocervical fascia ( Fig. 2 ). The dissection plane is identified by the glistening white pubocervical fascia, and the vaginal wall is thin in this plane. Dissection in the wrong plane usually is associated with significant bleeding and inability to identify the underlying fascia.
Once dissection of the vaginal wall has been completed to the fornix on either side of the bladder neck, sharp dissection is used to penetrate the endopelvic fascia and enter the retropubic space immediately under the arch of the pubis ( Fig. 3 ). This plane is generally avascular and should separate easily from the underlying fascial components. In cases that previously underwent surgery, this space may be difficult to identify, and sharp, shallow dissection (immediate proximity to the arch of the symphysis pubis) should be used to avoid inadvertent entry into the pelvic viscera, including the bladder and urethra.
After entry into the retropubic space, lateral dissection of the endopelvic fascia from the urethra to the bladder base is performed to mobilize these structures ( Fig. 4 ). Subsequently, dissection is performed to the vaginal cuff in a line parallel to the orientation of the vaginal vault. In women who have undergone a hysterectomy, the stump of the uterine arterial complex commonly is encountered during this dissection, and bleeding may occur as a result of disruption of this structure. Suture ligature of these vessels with 4-0 polydioxanone should be contemplated to avoid persistent blood loss during the reconstructive segment of the operation. Cautery should be minimized to avoid devascularization of the underlying tissues.
Apical dissection should be meticulous to aid in identifying any enterocele component; if found, the defect should be excised and closed. Apical enteroceles may be small and somewhat obscured by the bladder base descensus. The cardinal ligaments often can be identified at this level of the dissection; and when they are found, plication with a 0 or 2-0 synthetic absorbable suture (SAS) can be performed. If there is significant apical descensus, posterior placement of sutures in the coccygeus region provides further support and stability to the anterior compartment repair. Number one polydiaxonone suture (PDS) sutures are placed 1 cm inferior and medial to the ischial spines through the iliococcygeus muscle ( Fig. 5 ). Great care must be taken to place these sutures as described to avoid injury to the pudendal neurovasculature and ureter, which are in close proximity. These vault suspension sutures are brought through the vaginal apex to be tied at the completion of the procedure, after the vaginal wall has been closed.
