4 Repair of Anterior Vaginal Prolapse
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White stated in 1909 that the only problem in plastic gynecology left unresolved was the permanent cure of cystocele. Today the surgical management of anterior compartment prolapse remains problematic and controversial. The anterior compartment is the most common site of prolapse and the site of prolapse with the highest anatomical failure rate, and a plethora of surgical options are available to the clinician. This chapter provides an overview of the current literature and describes various approaches to the surgical management of anterior compartment prolapse.
Anterior vaginal wall prolapse, commonly termed cystocele, is defined as pathological descent of the anterior vaginal wall overlying the bladder base. Cystoceles frequently coexist with a variety of micturition disorders. The current understanding of the anatomy and support of this segment of the pelvic floor stems from concepts proposed by Richardson et al., who described transverse, midline, and paravaginal defects. Transverse defects are said to occur when the pubocervical fascia separates from its insertion around the cervix, whereas midline defects represent an anterior-posterior separation of the fascia between the bladder and the vagina, and paravaginal defects are characterized by detachment of the lateral connective tissue attachments at the arcus tendineus fasciae pelvis (ATFP). A conceptual representation of these various defects is shown in Figure 4-1. All types of micturition disorders can be seen with anterior vaginal wall prolapse, and to date, there is no clear scientific explanation to help in understanding the correlation between anatomical descent of the anterior vaginal wall and functional derangements of the urinary tract. When conducting evaluation and planning for surgical treatment of patients with anterior vaginal wall descent, the surgeon must go to great lengths to determine how the surgical intervention will affect any potential functional derangements that the patient may be experiencing. This aspect of the preoperative discussion with the patient and the patient consent process is extremely important.
Figure 4-1 A, Normal support of the anterior vaginal wall viewed retropubically (bladder removed). The trapezoidal blue area depicts the fascial support that extends from the arcus tendineus fasciae pelvis on one side to the opposite side. This support continues to the level of the ischial spines laterally and the apex of the cervix transversely. B, Same view as in A but with the bladder in place. C, Three different fascial defects: central (midline), lateral (paravaginal), and transverse (apical).
Although many surgeons make a great effort to predict preoperatively what types of defects exist when patients have symptomatic anterior wall descent, the literature indicates that this is very difficult to do, and in our opinion determination of the various defects is best done intraoperatively. Thus it is critically important that the surgeon be able to customize the repair to meet the needs of a particular patient’s anatomy. Although numerous types of repairs are discussed and demonstrated here, the ultimate goal of any anterior vaginal wall support procedure is to re-create a trapezoid of support that runs from below the proximal urethra to the cervix or apex and laterally to the ATFP or fascia of the internal obturator muscle. Finally, the long-term success of the anterior vaginal wall repair is directly correlated with the ability to suspend the apex in a high, durable position without creating any significant distortion of the vaginal axis.
It is well known that pelvic organ prolapse (POP) and stress urinary incontinence (SUI) can coexist. In addition, prolapse can actually mask or protect against SUI. Anterior and apical prolapse can cause a kinking of the urethra. Similarly, apical or posterior prolapse can compress the urethra and do the same. Although it is not a perfect test, reduction of the prolapse manually, with a pessary, or with packing may uncover incontinence on physical examination or urodynamic testing. SUI demonstrated by reduction of POP in a patient without clinical SUI is known as occult or latent incontinence. Although how (and whether) to treat occult incontinence remains debatable, based on the current literature we recommend at least giving consideration to performing a simultaneous antiincontinence procedure (usually placement of a synthetic midurethral sling) in patients with occult or clinical SUI who are undergoing surgery to treat prolapse. We prefer to place the midurethural sling through a separate incision after completion of the anterior vaginal wall repair.
Historically, anterior vaginal wall prolapse has been treated surgically using suture repairs designed to correct the various defects. In the early 2000s, there was a move toward the use of implant material to augment native tissue repair in reconstructive pelvic surgery. Although theoretically it would appear that augmentation with a strong material would improve outcomes and durability, the potential benefits of synthetic mesh and biological materials must be weighed against their known complications and negative outcomes, which include extrusion, erosion, dyspareunia, and host-implant reactions. After these factors are considered, in some patients it may be advantageous to augment the repair. The literature contains minimal data supporting the use of biological materials to augment prolapse repair. Many more data are available on synthetic implant materials, which have been commonly used since early 2000. The literature suggests that for some patients mesh augmentation may produce better anatomical (although not necessarily functional) results. However, permanent synthetic mesh implants are associated with unique complications, including vaginal extrusion, urinary tract erosion, infection, dyspareunia, and pain. These risks must be carefully weighed against the potential benefits. In July 2011, the U.S. Food and Drug Administration (FDA) issued a notification regarding the transvaginal placement of synthetic mesh for the repair of POP. It is recommended that any surgeon implanting mesh transvaginally read the warning and share it with his or her patient. Specifically, the FDA made the following recommendations:
• Surgeons should undergo rigorous training covering the principles of pelvic anatomy and pelvic surgery as well as proper patient selection for POP reconstructive procedures. Such training must be completed before implantation of surgical mesh is attempted for the treatment of prolapse.
• Before implantation of mesh, surgeons should be competent in recognizing intraoperative and postoperative complications as well as comfortably and completely managing these adverse events. Such adverse events include those involving the urinary and gastrointestinal tracts.
• Before implantation of surgical mesh for the treatment of POP, the surgeon and patient must have a proper informed consent discussion regarding the risks, benefits, alternatives, and indications for the use of mesh.
This chapter describes techniques that can be performed without implants but can be adapted to tissue augmentation with a material if the surgeon so desires. The use of commercially available prolapse mesh kits is discussed in Chapter 8.
In many cases of anterior prolapse, other compartments, especially the apex, need to be corrected. The techniques described here can be used to correct an isolated anterior defect and can also be combined with procedures to restore apical support (see Chapter 6).
Anterior colporrhaphy is used to repair a central or midline defect. It is essentially a plication of the pubocervical fascia (vaginal muscularis and the vaginal side of the endopelvic fascia). This in effect repairs the central defect and reduces the prolapsed bladder. Anterior colporrhaphy can be combined with a paravaginal repair as well as an apical repair.
A 55-year-old woman complained of pelvic pressure, a vaginal bulge, and SUI. Physical examination showed Pelvic Organ Prolapse Quantification (POP-Q) stage II anterior prolapse with the leading edge of the prolapse about 0.5 cm beyond the hymen with straining (POP-Q point Ba = −0.5). The uterus and cervix were relatively well supported with the leading edge of the cervix 4 cm above the hymen with straining (point C = −4). The patient was sexually active and concerned about the consequences of implantation of permanent mesh. The defect was found to be predominantly a central defect. An anterior colporrhaphy was performed before placement of a synthetic midurethral sling (Video 4-1).