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Transobturator Approach For Cystocele Repair
With Anterior Wall Mesh
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Perigee Figure: 1
Introduction/Background
Anterior vaginal wall relaxation (cystocele) is one of the most commonly diagnosed forms of pelvic organ prolapse in women. More than 200,000 cystocele repairs are completed yearly, however to date the procedures that are completed do not provide very high cure rates and/or poor anatomic outcomes. Successful treatment of anterior vaginal wall prolapse remains one of the most challenging aspects of pelvic reconstructive surgery we face. We have developed very good procedures that provide excellent support for the posterior wall (ie rectoceles) and the apex of the vagina (ie vaginal vault prolapse) and reproduce normal anatomy. We were one of the first centers in the country to utilize grafts in rectocele repairs and have seen improved cure rates to over 90% with minimal complications. It has been known for many years that abdominal sacralcolpopexy with placement of a mesh graft at the top of the vagina for vaginal vault prolapse is the most successful procedure in the literature. We have made advancements with this procedure as well in being able to offer our patients a laparoscopic minimally invasive approach for sacralcolpopexy, with the same excellent cure rates (>92%) and with hospital stays typically less than 24 hours and reduced complications. However the anterior wall has been one of the most difficult compartments in the vagina to get good anatomic results and high cure rates with traditional repairs and at the same time not cause sexual dysfunction, pain with intercourse, voiding dysfunction (ie incontinence or urgency/frequency Syndrome), or a shortened or scarred down vagina.
Perigee Figure: 2
Figure 2 Normal anatomic support of the pelvis and the bladder. Note the layer of pubocervical fascia that supports under the bladder and keeps it in proper position.
Anterior vaginal wall reconstruction concentrates on the surgical repair of cystocele, which in essence is a hernia that occurs when the bladder bulges down into the vagina due to attenuation or site-specific defect of the pubocervical fascia. This fascia is the layer under the vaginal skin that provides support to the bladder and keeps it in its normal anatomic position in the pelvis. It stretches from one side of the pelvis to the other (from what is called the white line or the arcus) and provides a floor of support that the bladder sits on. If this fascia has a tear in the middle of it (midline defect), is torn away from the pelvic sidewalls (paravaginal defects) or is just generally stretched out or attenuated beyond its capacity to recover, the result is that the bladder sags down or bulges out of the vagina with a resultant cystocele (Fig 3).
Perigee Figure: 3
Figure 3 Cystocele. Defect (hernia) in the supportive layer (pubocervical fascia) causing the bladder to drop into the vagina and creating a bulge (cystocele) that may eventually protrude outside the vaginal opening.
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