Anterior vaginal wall prolapse (AVP) is defined as the herniation of bladder through the anterior vagina wall. It is the most common site of pelvic organ prolapse and also has the highest rate of recurrence after surgical repair.¹,²

The pathophysiology and etiology of anterior wall support defects is reviewed in detail in Chapters 41 and 43 and is only briefly reviewed here. Normal anterior vaginal wall anatomy is best understood by the three levels of support described by Delancey. All three levels are interconnected and crucial to maintaining normal pelvic anatomy. Level 1 includes the cardinal and uterosacral ligaments and supports the cervix and upper vagina, providing vaginal length. Level 2 includes the lateral vaginal attachments of the midvagina, including the arcus tendineus fasciae pelvis (ATFP) and the arcus tendineus fasciae rectovaginalis (ATFR). Both levels 1 and 2 serve to stabilize the proximal two-thirds of the vagina while maintaining the vaginal axis in a horizontal plane that rests on the levator plate. Level 3 is the perineum and includes the perineal body, perineal membrane, superficial and deep perineal muscles, and the surrounding connective tissue. Level 3 and the distal ATFR serve to create the vertical axis of the distal vagina. Interruption in support at levels 1 and 2 plays a large role in the development of AVP. Level 3 also contributes to anterior support but is much more important to the anatomy of the posterior compartment.

The layer of connective tissue between the vagina and bladder that is damaged and attenuated in anterior vaginal prolapse has historically been referred to as pubocervical or endocervical “fascia.” However, anatomical and histologic studies have confirmed the tissue between bladder and vagina is not a true fascial layer but a layer of vaginal epithelium, muscularis, and adventitia overlying the bladder muscularis (Fig. 44.1).³ Rather than using the term fascia, we instead refer to the fibromuscular layer of the vagina, composed of vaginal muscularis and adventitia, to more accurately describe the tissue overlying the bladder.

Injury can occur from distension and attenuation of the overlying fibromuscular layer or by lateral detachment from the ATFP, or level 2. Apical defects can occur from detachment at the level of the cervix, or level 1.

It is important to note the relationship between apical and anterior prolapse when considering anterior prolapse repair because it is estimated that approximately 50% of anterior wall support originates from the apex.⁴ Furthermore, apical suspension will address AVP in up to 63% of cases.⁵,⁶ Thus, the approach to AVP repair requires consideration of the origin of the defect. Apical suspension alone may be adequate for combined anterior and apical prolapse and may ultimately result in better long-term outcomes than anterior colporrhaphy or paravaginal repair alone.⁶,⁷,⁸,⁹,¹⁰ However, if apical prolapse is not present or significant AVP is present after apical suspension, a midline plication-based repair with anterior colporrhaphy or repair of a paravaginal defect is necessary. This chapter focuses on technique for anterior colporrhaphy and paravaginal repair. Nonsurgical treatment of AVP is covered in Chapters 15 and 16.

During physical exam, the surgeon may attempt to identify midline versus lateral defects in order to determine the optimal surgical approach. Absence of rugal folds may indicate a midline defect and distention, whereas presence of rugal folds and loss of the lateral sulcus may indicate a paravaginal defect. It is important to note, however, that data on the accuracy of these exams are limited, and exams appear to be poorly reproducible between providers.¹¹,¹²,¹³ Imaging with ultrasound or magnetic resonance imaging prior to anterior vaginal prolapse repair is not routinely recommended unless there is concern for abnormal pathology that requires further evaluation.

The objective of anterior colporrhaphy is to plicate and reinforce the attenuated muscularis and adventitial layers overlying the bladder at the midline. This serves to reduce the vaginal defect and restore the bladder to its anterior position.

All patients undergoing colporrhaphy should have a catheter placed after surgical preparation is complete, typically with a 16 French Foley catheter. Patients should receive antibiotics within 60 minutes of the surgical incision. With the patient in dorsal lithotomy position, a weighted speculum is then placed in the vagina. Suture of 0-Silk or Nylon can be placed through the medial groin and labia majora to retract the labia and optimize visualization, taking care to not strangulate the tissue. A hook retractor (i.e., Lonestar) can be used for better exposure. Exam under anesthesia with the patient relaxed can help identify specific defects and confirm surgical approach.

Hydrodissection of the vaginal epithelium from the underlying muscularis layer is then performed with normal saline, plain analgesic, or a hemostatic agent. Plain anesthetic agents include 1% lidocaine and 0.25% bupivacaine and are often used in a combined solution of 1:200,000 epinephrine for hemostasis. Alternatively, vasopressin 10 units in 50 mL of normal saline can be used.

When anterior colporrhaphy is performed with an apical suspension, the anterior repair may be completed first. If a hysterectomy has been performed, two Allis clamps are placed at the anterior vaginal cuff with a third placed approximately 2 cm below the urethral meatus to mark the most distal edge of the planned dissection. If a midurethral sling is planned, the distal Allis clamp should be placed at the urethrovesical junction, or approximately 3 to 4 cm below the urethral meatus. Anterior colporrhaphy should be completed before the midurethral sling, which is performed through a separate suburethral incision.

A midline vertical incision is made from the distal Allis clamp and carried until 1 cm distal to the vaginal cuff edge if hysterectomy has been performed or 1 cm distal to the vaginal apex if hysterectomy has not been performed. The incision is preferentially made with the 15-blade scalpel through full thickness of vaginal epithelium in order to expose the underlying vaginal muscularis layer. Alternatives include a 10-blade scalpel or Metzenbaum scissors. If using Metzenbaum scissors, dissection is carried from the vaginal apex toward the urethra. The scissor tips face away from the bladder and are placed between the vaginal epithelium and muscularis layer, gently pushing upward half-opened and half-closed. Countertraction with Allis clamps or Russian forceps along the midline can be used to help prevent cystotomy.

Allis clamps are then placed along the cut epithelial edges of the incision to facilitate traction for dissection. The vaginal epithelium is dissected off of the underlying vaginal muscularis, which serves to leave a layer of vaginal muscularis and adventitia over the bladder. This is typically performed with Metzenbaum scissors but can also be completed with a scalpel. Traction is facilitated by folding the vaginal epithelium over the surgeon’s index finger of the nondominant hand where he or she is dissecting. Index finger placement also serves to communicate depth of dissection. An assistant can also hold traction of the vaginal muscularis and bladder with forceps to facilitate dissection. The technique is a combination of sharp dissection to identify the appropriate
white, hypovascular plane, as well as gentle blunt dissection with an unfolded Ray-Tec sponge over the index finger to enlarge the plane of dissection. Dissection is carried out bilaterally as far as the medial aspect of the ischiopubic rami.

Hemostasis during dissection can be achieved with pressure, gentle cautery, and interrupted or figure-ofeight suture of 3-0 polyglactin on a small needle, such as an SH.

If the midline defect is very large, a purse-string or running suture can be placed first to facilitate reduction with delayed absorbable suture such as 2-0 polyglactin or polydioxanone suture (PDS).¹⁴ Plication has been described with two different approaches by Goff and Bullard.¹⁵ The technique described by Goff includes plication of the vaginal muscularis just medial to the vaginal flaps in a series of interrupted U-stitches of 0 or 2-0 polyglactin or PDS suture starting at the most distal portion of the dissection and moving toward the apex. Sutures are placed where the fibromuscular tissue is still connected to the vaginal epithelium.

For the Bullard approach, the surgeon can first repair site-specific defects if noted with interrupted 2-0 PDS. Midline plication of the vaginal muscularis and adventitia is then performed with interrupted or running 2-0 PDS and can be performed in multiple layers as needed for larger defects. This is distinct from the Goff approach in that plication sutures are not placed as far laterally at the junction of vaginal epithelium and muscularis layer.

During plication, it is important to remember the proximity of the ureter, particularly with large anterior defects.

After plication, excess epithelium may be trimmed, taking care to not remove too much because this will place undue tension on the epithelial closure and risk causing vaginal stenosis, narrowing, or wound breakdown in postoperative healing. Closure is performed with 2-0 polyglactin. If there is concern regarding vaginal length, interrupted sutures or running-locked sutures can help preserve length. Otherwise, running closure is appropriate. If there is additional concern for hemostasis prior to closure, a hemostatic agent such as thrombin hemostatic matrix (Floseal) or fibrin sealant (Tisseel) can be placed before closing epithelium, or vaginal packing can be placed after closure.

Cystoscopy should always be performed after anterior colporrhaphy to ensure there is no intravesical suture placement, vesical injury, ureteral kinking, or injury.

A significant proportion of anterior vaginal support arises from the attachment of the vaginal wall to the ATFP. The objective of paravaginal repair is to reattach lateral vaginal defects to the ATFP.

The paravaginal approach can be performed by open, vaginal, or a minimally invasive approach. This chapter reviews the vaginal and open technique. The minimally invasive technique is similar to open, but through laparoscopic ports rather than a Pfannenstiel incision.

The objective of graft augmentation is to replace the weakened fibromuscular layer between vagina and bladder with a permanent implant to prevent future herniation. Alternatively, some grafts serve as a nonpermanent scaffold for fibroblast infiltration and scarring to reinforce the attenuated fibromuscular layer.¹⁴ Implants can be allografts (human donor), autografts (self-donor), xenografts (animal donor), or synthetic.

In a large 2016 Cochrane review of 33 randomized controlled trials (RCTs) on anterior colporrhaphy using native tissue, biologic grafts, and synthetic grafts, anterior compartment repair with permanent mesh resulted in decreased rates of prolapse recurrence, awareness of prolapse, and reoperation.³ However, permanent mesh was associated with higher rates of adverse events, including increased operating time, blood loss, transfusion, cystotomy, de novo stress incontinence, and de novo dyspareunia when compared to native tissue repair. Mesh exposure rate was 11.3% with a 7% reoperation rate for mesh removal. Furthermore, in 2019, the U.S. Food and Drug Administration¹⁸ removed vaginal mesh from the market.

The same Cochrane review demonstrated that absorbable mesh and biologic grafts were not superior to native tissue repair in preventing recurrence of prolapse, and there were no advantages to employ these grafts over native tissue repair.

The authors conclude that grafts should not be considered as first-line management. Despite transvaginal mesh demonstrating improved anatomical outcomes, the disadvantages and adverse events appear to outweigh these benefits. If considering graft augmentation, the physician should have a detailed conversation of the risks and benefits with the patient before proceeding.

Given the findings of the Cochrane review as well as the removal of vaginal mesh from the market, we do not review surgical technique for graft augmentation in this chapter.

After surgery is complete, the decision to remove the indwelling catheter depends on the extent of surgery. For example, if only anterior colporrhaphy or vaginal paravaginal repair was performed, then the catheter can be removed in the operating room followed by an active or passive voiding trial in postoperative recovery prior to discharge. However, if the patient has also undergone an anti-incontinence procedure and/or hysterectomy with apical suspension and is being admitted, it is reasonable to leave the catheter in place for 6 to 24 hours depending on patient status and recovery. A postvoid residual greater than 100 to 200 mL is considered elevated. Depending on surgeon preference, the patient can be discharged home with a Foley catheter for several days or taught how to perform clean intermittent catheterization depending on preference. A voiding trial can be performed in the office several days postoperatively.

For anterior colporrhaphy alone with or without midurethral sling, hospital admission is typically unnecessary. If the patient has undergone more extensive surgery, such as hysterectomy and apical suspension, admission requirements vary across hospitals and providers; however, if meeting postoperative milestones, same-day discharge is reasonable.

Open approach to paravaginal repair often requires hospital admission for pain control due to the Pfannenstiel incision. Foley catheter is not indicated for paravaginal repair alone, but if the patient has had a Burch procedure or a more extensive surgery such as sacral colpopexy, the catheter is often left in place in postoperative recovery until the patient is able to undergo a passive or active voiding trial.

The anterior vaginal wall is not only the most common site of prolapse, but it is also the most common site to recur after repair.³ Surgical failure rates vary between 3% and 70% among clinical trials.⁶ This may, in part, be due to a lack of standardized approach to anterior colporrhaphy and paravaginal repair. In a systematic review of 40 RCT, there was no single RCT that provided a detailed description of each step of the procedure, and the steps that were described were highly variable between studies.³⁸ A separate study by the Dutch Urogynecologic Society similarly found that even within a small group of FPMRS providers, operative technique varied greatly, possibly explaining some of the discrepant outcomes among studies.³⁹

Interpretation of RCT outcomes is further confounded by the presence of multiple other concomitant prolapse procedures at the time of anterior repair such as apical suspension. Definitions of success also vary across studies and impact outcomes. The majority of RCTs define success as stage 1 pelvic organ prolapse or less using the Pelvic Organ Prolapse Quantification (POP-Q) system, but others define it as point Ba on POP-Q of -1 cm or less. Not surprisingly, trials that use the definition of Ba of -1 cm or less have better outcomes than those that use stage 1 or less (61% to 80% success vs. 30% to 80% success).²⁰,²³,²⁴,²⁶,²⁷,²⁸,²⁹,³⁰,³¹,³²,³³,³⁴,³⁵,³⁶,³⁷,⁴⁰,⁴¹,⁴²,⁴³,⁴⁴,⁴⁵ It is important to note that despite high failure rates in the majority of trials (Table 44.1), subjective outcome was often better than anatomical outcome, and most women did not elect for repeat surgery even if anatomical failure was noted. However, most trials did not follow patients past 12 months; thus, it is impossible to say if any of those women went on to undergo additional surgery in the future.