Cystocele Repair (Laparoscopic Paravaginal Repair)
Laparoscopic and Minimally Invasive Procedures Continued
The bladder and urethra are supported by the anterior or upper vaginal wall. When there is a break in the support of the anterior vaginal wall, the bladder and urethra fall, resulting in a cystourethrocele. Review of the gynecologic literature reveals that the most common reason for so called "bladder drop" is a paravaginal defect or loss of support of the lateral attachment of the vagina. Greater than 90% of cystoceles are due to paravaginal defects. In an attempt to repair the cystocele, most physicians would perform an anterior repair (anterior colporrhaphy); however, this is rarely the correct anatomical operation. In patients with a cystocele from paravaginal defects, the most appropriate surgical procedure is the paravaginal repair, which is also called cystocele surgery or repair.
Picture on left shows normal vaginal and bladder support. Picture on right shows loss of anterior wall support resulting in a Cystocele or dropped bladder. This typically occurs secondary the the anterior wall tearing away from its lateral connections to the pelvic sidewalls resulting in paravaginal defects.
The cystocele repair is accomplished by suturing the lateral aspect of the anterior vaginal wall back to its original point of attachment, known as the arcus tendineus fascia pelvis (ATFP) or the "white line". Re-approximation of the vaginal wall to the fascia overlying the obturator internus muscle will restore the bladder and the urethra to its normal anatomical position. Important points of paravaginal cystocele repair:
- 90% of cystoceles are due to paravaginal defects
- Paravaginal repairs are traditionally performed using sutures
- Paravaginal and mid-line defects can be present simultaneously
- Paravaginal repairs can be performed laparoscopically
- Paravaginal repairs can be performed with Burch urethropexy (incontinence)
- Paravaginal repairs can be coupled with other prolapse surgeries
Normal Vaginal Support -Aerial View
Paravaginal defects – Loss of lateral vagina attachment at the arcus tendineus resulting in a cystocele (bladder drop).
Paravaginal Defects – (aerial view)
The anterior vaginal wall that supports the bladder tears away from its lateral attachment to the pelvic sidewalls (ie the Arcus Tendineus) resulting in Paravaginal Defects and dropping of the bladder (Cystocele)
Paravaginal (lateral) defect – resulting in a cystocele (aerial view)
Paravaginal Defect Repair – Repairing the vagina by utilizing sutures to reattach the fascia back out to the arcus (ie fixing the tears or defects) restores support to the bladder thus removing the cystocele or bladder drop.