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Anterior vaginal wall prolapse: The challenge of cystocele repair

OBG Manag. 2004 May;16(5):16-32

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.

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References

1. DeLancey JOL. Fascial and muscular abnormalities in women with urethral hypermobility and anterior vaginal wall prolapse. Am J Obstet Gynecol. 2002;187:93-98.

2. White GR. Cystocele: a radical cure by suturing lateral sulci of vagina to white line of pelvic fascia. JAMA. 1909;21:1707-1710.

3. Richardson AC, Lyon JB, Williams NL. A new look at pelvic relaxation. Am J Obstet Gynecol. 1976;126:568-571.

4. Weber AM, Walters MD. Anterior vaginal prolapse: review of anatomy and techniques of surgical repair. Obstet Gynecol. 1997;89:311-318.

5. Romanzi LJ, Chaikin DC, Blaivas JG. The effect of genital prolapse on voiding. J Urol. 1999;161:581-586.

6. FitzGerald MP, Kulkarni N, Fenner D. Postoperative resolution of urinary retention in patients with advanced pelvic organ prolapse. Am J Obstet Gynecol. 2000;183:1361-1364.

7. Barber MD, Cundiff GW, Weidner AC, Cotes KW, Bump RC, Addison WA. Accuracy of clinical assessment of paravaginal defects in women with anterior vaginal wall proloapse. Am J Obstet Gynecol. 1999;181:1-7.

8. Bump RC, Hurt WG, Theofrastous JP, et al. Randomized prospective comparison of needle colposuspension versus endopelvic fascia plication for potential stress incontinence prophylaxis in women undergoing vaginal reconstruction for stage III or IV pelvic organ prolapse. The Continence Program for Women Research Group. Am J Obstet Gynecol. 1996;175:326-333.

9. Borstad E, Rud T. The risk of developing urinary stress incontinence after vaginal repair in continent women. Acta Obstet Gynecol Scand. 1989;68:545-549.

10. Chaikin DC, Groutz A, Blaivas JG. Predicting the need for anti-incontinence surgery in continent women undergoing repair of severe urogenital prolapse. J Urol. 2000;163:531-534.

11. Beck RP, McCormick S, Nordstrom L. A 25-year experience with 519 anterior colporrhaphy procedures. Obstet Gynecol. 1991;78:1011-1018.

12. Kohli N, Sze EHM, Roat TW, Karram M. Incidence of recurrent cystocele after anterior colporrhaphy with and without concomitant transvaginal needle suspension. Am J Obstet Gynecol. 1996;175:1476-1482.

13. Stanton SL, Hilton P, Norton C, Cardozo L. Clinical and urodynamics effect of anterior colporrhaphy and vaginal hysterectomy for prolapse with and without incontinence. Br J Obstet Gynecol. 1982;89:459-463.

14. Colombo M, Vitobello D, Proiette F, Milani R. Randomized comparison of Burch colposuspension versus anterior colporrhaphy in women with stress urinary incontinence and anterior vaginal wall prolapse. BJOG. 2000;107:544-551.

15. Shull BL, Baden WF. A six-year experience with paravaginal defect repair for stress urinary incontinence. Am J Obstet Gynecol. 1989;160:1432-1440.

16. Shull BL, Benn SJ, Kuehl TJ. Surgical management of prolapse of the anterior vaginal segment: an analysis of support defects, operative morbidity, and anatomic outcome. Am J Obstet Gynecol. 1994;171:1429-1439.

17. Mallipeddi PK, Steele AC, Kohli N, Karram MM. Anatomic and functional outcome of vaginal paravaginal repair in the correction of anterior wall prolapse. Int Urogynecol J. 2001;12:83-88.

18. Young SB, Daman JJ, Bony LG. Vaginal paravaginal repair: one-year outcomes. Am J Obstet Gynecol. 2001;185:1360-1367.

19. Brubaker L. Sacrocolpopexy and the anterior compartment: support and function. Am J Obstet Gynecol. 1995;173:1690-1694.

20. Shull BL, Bachofen C, Coates KW, Kuehl TJ. A transvaginal approach to repair of apical and other associated sites of pelvic organ prolapse with uterosacral ligaments. Am J Obstet Gynecol. 2000;183:1365-1374.

21. Morley GW, DeLancey JOL. Sacrospinous ligament fixation for eversion of the vagina. Am J Obstet Gynecol. 1988;158:872-881.

22. Shull BL, Capen CV, Riggs MW, Kuehl TJ. Preoperative and postoperative analysis of site-specific pelvic support defects in 81 women treated with sacrospinous ligament suspension and pelvic reconstruction. Am J Obstet Gynecol. 1992;166:1764-1771.

23. Paraiso MFR, Ballard LA, Walter MD, et al. Pelvic support defects and visceral and sexual function in women treated with sacrospinous ligament suspension and pelvic reconstruction. Am J Obstet Gynecol. 1996;175:1423-1431.

24. Benson JT, Lucente V, McClellan E. Vaginal versus abdominal reconstructive surgery for the treatment of pelvic support defects: a prospective randomized study with long-term outcome evaluation. Am J Obstet Gynecol. 1996;175:1418-1421.

25. Benson JT, McClellan E. The effect of vaginal dissection of the pudendal nerve. Obstet Gynecol. 1993;82:387-389.

26. Zivkovic F, Tamussino K, Ralph G, et al. Long-term effects of vaginal dissection on the innervation of the striated urethral sphincter. Obstet Gynecol. 1996;87:257-260.

27. Julian T. The efficacy of Marlex mesh in the repair of severe, recurrent vaginal prolapse of the anterior midvaginal wall. Am J Obstet Gynecol. 1996;175:1472-1475.

28. Weber AM, Walters MD, Piedmonte MR, et al. Anterior colporrhaphy: a randomized trial of three surgical techniques. Am J Obstet Gynecol. 2001;185:1299-1306.

29. Sand PK, et al. Prospective randomized trial of polyglactin 910 mesh to prevent recurrence of cystocele and rectocele. Am J Obstet Gynecol. 2001;184:1357-1364.

30. Ellerkmann RM, Cundiff GW, Melick CF, Nihira MA, Leffler K, Bent AE. Correlation of symptoms with location and severity of pelvic organ prolapse. Am J Obstet Gynecol. 2001;185:1332-1337.

31. Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A. Pelvic organ prolapse in the Women’s Health Initiative: gravity and gravidity. Am J Obstet Gynecol. 2002;186:1160-1166.

32. Handa VL, Garrett E, Hendrix S, Gold E, Robbins J. Progression and remission of pelvic organ prolapse: a longitudinal study of menopausal women. Am J Obstet Gynecol. 2004;190:27-32.

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.

Another challenge involves the use of allografts or xenografts, which have not undergone sufficient study to determine their long-term benefit or risks in comparison with traditional repairs.

This article reviews anatomy of the anterior vaginal wall and its supports, as well as surgical technique and outcomes.

Why the anterior wall is more susceptible to prolapse

One theory is that, in comparison with the posterior compartment, the anterior wall is not as well supported by the levator plate, which counters the effects of gravity and abdominal pressure. Normally, the anterior wall rests horizontally on the posterior wall, which in turn rests on the levator plate. When the levator muscles weaken, the anterior wall is the first to fall as increasing force is placed on the connective tissue supports.

Other possibilities: The anterior compartment’s attachments to the pelvic sidewall or apex may be weaker, the anterior wall may be more elastic or less dense than the posterior wall, and the anterior wall may be more susceptible to damage during childbirth or to the effects of age and loss of estrogen.

If only some defects are addressed at surgery, failure may be more likely. Some experts believe pelvic surgeons have focused too much attention on the urethrovesical junction in patients with concomitant urinary incontinence and not enough attention on suspending the anterior wall at the apex.

For most women, it is probably a combination of many of these factors that renders the anterior compartment so vulnerable.

Anatomy of the pelvic floor

The anterior vaginal wall resembles a trapezoidal plane due to ventral and more medial attachments near the pubic symphysis, and dorsal and more lateral attachments near the ischial spine (FIGURE 1).¹ This helps explain the many appearances of the cystocele. The type of cystocele is defined by the location of the break in the fascial attachments.

Paravaginal defects. The trapezoidal anterior wall is suspended on both sides from the parietal fascia overlying the levator ani muscles at the arcus tendineus fascia pelvis (ATFP). Prolapse can occur when there is loss of attachment to the pelvic sidewall at any point between the pubis and ischial spine.

First described by White² and characterized later by Richardson et al,³ this loss of lateral attachment is called a paravaginal defect or displacement cystocele (FIGURE 2). The goal of paravaginal repair is to reattach the lateral vaginal walls to the ATFP, either abdominally, laparoscopically, or vaginally.

Central defects, the rarest type of anterior wall prolapse, involve a loss of support near the pubis and tend to be smaller. The most common manifestation is urethral hypermobility.

Transverse defects occur when the top of the pubocervical fascia detaches from the cervix or vaginal apex, both of which are suspended from the uterosacral-cardinal ligament complex. A transverse cystocele is evidenced by loss of the anterior fornix. The anterior wall appears to be attenuated in the midline, and the vaginal mucosa is pale, thin, and smooth (FIGURE 3).

Goals of traditional repair. The traditional anterior colporrhaphy aims to excise or reinforce the attenuated transverse defect with plication of the “endopelvic fascia” in the midline of the anterior vaginal wall. The endopelvic fascia is not true fascia but the muscularis of the vaginal wall. It is comprised of smooth muscle and elastin along with the collagenous adventitia layer.⁴

The importance of restoring apical wall support becomes apparent when one considers the trapezoidal anatomy. The most common sites of defects or detachments of the anterior wall are near the ischial spines laterally. In an operative case series of paravaginal defects, DeLancey¹ found the site of defect to be near the ischial spine in 96% of cases. The reattachment of the apex near the level of the spine becomes the highest point of support for the anterior vaginal wall.