Anterior repair, or anterior colporrhaphy, is utilized to surgically correct a cystocele caused by a central defect in the endopelvic fascia. This can be accompanied by urethral hypermobility, overt or occult stress urinary incontinence, or voiding difficulties.

The patient is examined via split or Sims speculum while in dorsolithotomy in a 45° upright or erect position and asked to strain to determine the extent of prolapse. Use of a single side of a bivalved speculum or a Sims speculum can facilitate reduction of any prolapse from the posterior compartment that might obstruct descent of the prolapse from the anterior compartment. The severity of the prolapse can be documented utilizing the pelvic organ prolapse quantification (POP-Q) scoring system.¹ A sponge stick or ring forceps can distinguish central from paravaginal defects. Urinalysis should be performed preoperatively to exclude any active urinary tract infection. The patient should also be evaluated for stress incontinence either with a cough stress test, while reducing the prolapse, or with multichannel urodynamic testing to rule out occult incontinence.²

Consent

Anterior repair is minimally invasive since it is performed through the vaginal route, a natural orifice. The greatest risks posed during an anterior repair are cystocele recurrence, injury to the bladder and ureters, bleeding, and vaginal stenosis that could lead to dyspareunia. The success rate of anterior repair varies widely between 37% and 80%.³ There is potential risk of bladder and ureteral injury during repair due to the proximity of the bladder lumen to the vaginal surface as well as the location of the trigone on the bladder base. The blood supply of the anterior vaginal wall arises from branches of the uterine, vaginal, and pudendal arteries that run from the lateral borders of the vagina, coalescing in the midline.⁴ Meticulous hemostasis helps to minimize the risk of postoperative hematoma formation. This can be accomplished in part by dissection within the avascular plane between the vaginal epithelium and endopelvic fascial layers. Excessive trimming of the incised vaginal edges can lead to vaginal narrowing and stenosis that can subsequently cause dyspareunia. While isolated anterior vaginal wall defects/cystoceles can occur, apical support loss is very commonly associated with anterior support loss and concomitant apical repairs should also be performed when necessary (see Chapter 34).

Instruments

A deep weighted speculum is placed into the vagina to visualize the anterior vaginal wall. Allis clamps can be utilized to grasp the anterior vaginal wall near the apex. Metzenbaum scissors are used for sharp dissection of the vaginal epithelium. Raytec sponges and cautery assist with hemostatic dissection of the vaginal epithelium from the underlying bladder and endopelvic fascia. The Lone Star Retractor System^® (CooperSurgical, Inc, Stafford, TX) can be a useful tool to assist with retraction of the vaginal epithelium during the repair.

Surgical Steps

Patient Positioning, Vaginal Wall Incision, Dissection

The patient is positioned in dorsolithotomy. The anterior vaginal wall is grasped near the apex with Allis clamps. A transverse incision can be made in the vaginal epithelium. Metzenbaum scissors are then utilized to undermine and incise the anterior vaginal wall vertically from the apex to within 1 to 2 cm of the urethral meatus, sequentially grasping the incised edges of the vaginal wall with Allis clamps to retract the vaginal epithelium away from the underlying bladder and urethra (Figure 32-1). If a concomitant midurethral sling is to be placed, then the anterior colporrhaphy incision is further down, approximately 4 cm from the external urethral meatus so that a separate incision can be made for the sling dissection. Using blunt dissection with a moistened sponge or sharp dissection with Metzenbaum scissors, the vaginal epithelium is freed from the endopelvic fascia, thus splitting the vaginal muscularis (Figure 32-2). The dissection is carried out bilaterally to the ischiopubic rami.

Plication of the Endopelvic Fascia

The fascia is then plicated over the urethra and bladder utilizing multiple interrupted delayed absorbable mattress sutures such as a 2-0 Polysorb™ glycolide/lactide copolymer (Covidien, Mansfield, MA), until the cystocele is reduced (Figure 32-3). Occasionally, a second layer of delayed absorbable suture is needed imbricating the first sutured layer for complete cystocele reduction. Care is taken with depth of suture placement to avoid entry into the bladder muscularis or lumen.

Trimming and Closure of the Vaginal Epithelium

The vaginal epithelium is trimmed minimally to avoid excessive narrowing of the vaginal canal (Figure 32-4). The vaginal epithelial edges are reapproximated with a running absorbable 2-0 suture (Figure 32-5).

Free Graft-Augmented Anterior Repair

Placement of an interposing graft material such as polyglactin suture mesh or porcine dermis during anterior repair has been proposed as a means for improving the long-term success of the procedure. A Cochrane systematic review of the surgical management of pelvic organ prolapse found that standard anterior repair was associated with a higher risk of recurrent cystocele when compared with repair using polyglactin mesh inlay (RR 1.39) or porcine dermis mesh inlay (RR 2.72). However, the review found little data regarding morbidity or other clinical outcomes.⁵

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