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Laparoscopic Paravaginal Repair - The Anatomic Cystocele Repair

Prolapsed Bladder Surgery - Cystocele Repair

Paravaginal Repair Video

The anatomically correct prolapsed bladder surgery or surgery for fallen bladder is a cystocele repair called the paravaginal repair. Drs. Miklos & Moore have performing this operation for than 20 years and have performed more than 2000 of these cystocele repair surgeries.

A cystocele occurs when there is a break in the ceiling of the vagina or the anterior vaginal wall that supports the bladder and urethra. (Figure 1) When there is a break in the support of the anterior vaginal wall, the bladder and urethra fall, resulting in a cystourethrocele (Figure 2) a drop of both the urethra and the bladder. 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.

Normal Support
Figure 1 - Pictures of prolapsed bladder
Cystocele Midline Defect
Figure 2

Picture on left (Figure 1) shows normal vaginal and bladder support. Picture on right (Figure 2) shows pictures of prolapsed bladder or loss of anterior wall support resulting in a Cystocele or dropped bladder. This typically occurs secondary the anterior wall tearing away from its lateral connections to the pelvic sidewalls resulting in paravaginal defects.

Symptoms of a fallen bladder

Patients who suffer from a cystocele (prolapsed bladder) will often complain of fallen bladder symptoms including but not limited to:

  • Vaginal pressure
  • Vaginal bulge
  • Lower back pain
  • Urinary leakage
  • Difficulty emptying bladder
  • Straining with urination

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. Because it is not the anatomically correct surgery often patients will have damage from an anterior repair if the surgery is done to aggressively. Patients can suffer from a short vagina, painful intercourse, or excess vaginal scar tissue making intercourse difficult. 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.

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

Normal Vaginal Support - Aerial

Paravaginal DefectThe 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 cystoceleParavaginal (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.

Paravaginal Repair
Paravaginal Aerial Repair

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