Anterior vaginal wall prolapse: The challenge of cystocele repair

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May 2004 · Vol. 16, No. 5

SURGICAL TECHNIQUES

Anterior vaginal wall prolapse: The challenge of cystocele repair

What’s the best strategy? Repairs often fail and the literature is inconclusive. Three experts analyze what we can learn from the limited studies to date, and offer tips on technique.

DEE E. FENNER, MD; YVONNE HSU, MD; DANIEL M. MORGAN, MD

Dr. Fenner is Harold A. Furlong Professor of obstetrics and gynecology, director of gynecology, and associate chair for surgical services, department of obstetrics and gynecology, University of Michigan, Ann Arbor, Mich. Dr. Hsu and Dr. Morgan are fellows in urogynecology and reconstructive surgery, departments of obstetrics and gynecology and urology, University of Michigan, Ann Arbor, Mich.

KEY POINTS

At this time, the traditional anterior colporrhaphy with attention to apical suspension remains the gold standard.
If only some defects of the anterior wall are addressed at the time of reconstructive surgery, failure may be more likely.
Women with grade 3 or 4 cystoceles often have evidence of bladder outlet obstruction on urodynamic testing.
In 52% of cases, cystoceles coexist with detrusor instability and evidence of impaired detrusor contractility.
A thorough preoperative evaluation includes assessing the apex, having the patient strain to maximize the defect, looking for paravaginal detachments, and making every effort to “unmask” occult stress urinary incontinence.

Ask a pelvic reconstructive surgeon to name the most difficult challenge, and the answer is likely to be anterior vaginal wall prolapse. The reason: The anterior wall usually is the leading edge of prolapse and the most common site of relaxation or failure following reconstructive surgery. This appears to hold true regardless of surgical route or technique.

Short-term success rates of anterior wall repairs appear promising, but long-term outcomes are not as encouraging. Success usually is claimed as long as the anterior wall is kept above the hymen, since the patient rarely reports symptoms in these cases.

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