Master Class

Treating Anterior Vaginal Wall Prolapse


 

One must also understand which symptoms are bothering the patient, if they are related to the physical findings, and if surgical correction of the anatomy will improve her symptoms. Each woman should then be appropriately counseled about the possible impact of prolapse surgery on both bladder and sexual function.

It is a common misperception that most patients with cystoceles also have stress urinary incontinence. Descent of the midvagina under the bladder base may actually reduce the chance of stress urinary incontinence occurring. Instead, voiding dysfunction is more common, as straining and increased abdominal pressure can cause the cystocele to be pushed to the point that it creates an outlet obstruction by kinking or compressing the urethra.

In a review we conducted of 35 women with stage 3 or 4 anterior wall prolapse and elevated postvoid residuals greater than 100 mL on two separate occasions, 31 women (89%) had normal postvoid residuals following reconstructive surgery and correction of their anterior wall prolapse (Am. J. Obstet. Gynecol. 2000;183:1361-4).

Paradoxically, correction of the cystocele can unmask “occult” stress urinary incontinence. Prior to surgery, a full bladder stress test with the prolapse reduced may indicate that the patient is at risk for stress incontinence symptoms after her prolapsed repair. If a sacrocolpopexy is planned, the CARE (Colpopexy and Urinary Reduction Efforts) trial recommends the placement of a Burch colposuspension at the time of surgery, regardless of preoperative urodynamics. Whether this recommendation is true for vaginal repairs is currently unknown.

Preoperative discussions with the patient concerning her risks of incontinence after cystocele repair, the benefits and risks of prophylactic anti-incontinence surgery, and the need for future surgical correction should be had as part of the surgical decision-making process.

Technique for Anterior Colporrhaphy

Traditional anterior colporrhaphy involves plication of the “endopelvic fascia” or fibromuscular layer of the vaginal wall after the vaginal wall is split. Buttressing of the bladder neck with a Kelly plication stitch was originally described by Howard Kelly in 1913.

The anterior vaginal wall is grasped on each side of the midline with Allis clamps. The cuff is grasped if a vaginal hysterectomy has been performed. If the uterus is in situ, the Allis clamps are used to grasp the vagina approximately 1 cm from the cervicovaginal junction, and an initial transverse incision is made.

The anterior wall, between the mucosa and bladder, is injected with 10 cc of vasopressin solution, 20 U in 50 cc of normal saline. This improves hemostasis and hydrodissects the space. A midline incision to within 1-2 cm of the urethrovesical neck is made.

The use of “three-point” traction can help with the dissection of the muscularis. The vagina is then grasped with several Allis clamps. The surgeon's index finger distends the vaginal wall and allows the surgeon to determine the thickness of the dissection with the Metzenbaum scissors. The assistant can provide countertraction with a tonsil clamp or DeBakey forceps. The fibromuscular layer is split to the level of the inferior pubic ramus. The procedure is repeated on the opposite side of the vagina.

One modification I prefer is to begin the plication at the apex instead of the bladder neck. This way, I avoid the pitfall of stopping short of the apex and leaving a “gap” or weakness in the repair. It is the apical portion of the repair that is most important. I use permanent sutures, preferably 2-0 Ethibond.

If the vaginal wall is the length needed to reach the apical supports, I use a transverse mattress stitch to plicate the fascia. If the vaginal wall needs to be shortened, I use a vertical mattress stitch. This will generally shorten the anterior wall 2-3 cm. For a large cystocele, two layers of plication can be used. The excess vaginal tissue is excised and closed with interrupted or running fine absorbable sutures.

When an apical repair procedure such as uterosacral ligament suspension or sacrospinous ligament suspension is performed in conjunction with anterior colporrhaphy—which is more often than not—the sutures for the apical repair should be placed and held prior to initiating the anterior colporrhaphy.

At the end of the anterior repair, the apical sutures are then incorporated into the vaginal cuff. Regardless of the type of transvaginal suspension, it is beneficial to bring one arm of the suspension suture through the anterior wall of the cuff and the other arm through the posterior cuff. This way, the anterior and posterior walls are brought together and suspended when the suture is tied.

Graft Use

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