Providing optimal care for a cystocele, or prolapse of the anterior vaginal wall, begins with recognition of the heterogeneous nature of pelvic organ prolapse, and a focus on the primary goal of intervention, which is relief of symptoms. Cystoceles frequently occur with concurrent prolapse of the posterior vaginal wall and/or the vaginal apex, and a durable repair requires attention to these support defects as well.

While prolapse is ubiquitous in parous women, it does not warrant treatment unless it is symptomatic. The symptoms commonly attributed to anterior prolapse include pelvic pressure, a sensation or visualization of protrusion, urinary dysfunction, and sexual dysfunction. While symptoms of protrusion are almost always due to prolapse, predicting which patients will have relief from urinary dysfunction and sexual dysfunction depends on a thorough understanding of the anatomy of support of the anterior wall as well as the differential diagnosis of these symptoms. Studies show that resolution of urinary symptoms is the most commonly stated goal for patients, regardless of stage of prolapse. The ability to perform daily activities, and sexual function goals are at least as important as resolution of prolapse symptoms and may be the reason for seeking care.

There are a variety of surgical techniques available to the surgeon treating cystocele, including the anterior colporrhaphy and defect-directed cystocele repair (Chapter 33). Each of these approaches has strengths and limitations. The defect-directed repair, also known as the site-specific fascial repair, aims to maximize relief of symptoms without creating new functional symptoms, through recreating normal anatomy. This approach appears to improve the relief of protrusion symptoms due to prolapse; however, its reliance on native tissues that may be compromised in women with pelvic organ prolapse, may have a negative impact on its durability. The anterior fascial reinforced repair attempts to overcome the shortcomings of the defect-directed approach by adding a graft to reinforce the native tissue and thereby provide added durability.

The use of grafts in transvaginal prolapse repairs is a controversial topic in reconstructive pelvic surgery. The concept of a graft-reinforced repair was adopted from the management of hernias, where there is ample evidence that the addition of a graft significantly improves the durability of hernia repairs. The concept became popular during the late decade of the 20th century, and enthusiasm led to multiple approaches and the development of new technologies, including different grafts and different kits for placement of the grafts. However, this surge in interest was not initially accompanied by data on either safety or efficacy. As that data began to emerge, it became clear that placing grafts through a vaginal incision was associated with complications that might overcome any benefit from added durability. This culminated in two FDA warnings about the use of transvaginally placed grafts for prolapse repairs, the first in 2008 and the most recent in 2011. Based on several systematic reviews, the 2011 warning noted that the only use of transvaginal
grafts in prolapse repairs that had evidence to support added durability was in the repair of cystoceles. Importantly, the added graft did not provide better results in terms of symptom relief, but only in anatomical outcomes. Moreover, there remain added complications related to graft use, including graft erosion, injury to surrounding organs related to instruments developed for placement, and postoperative pain and dyspareunia. Consequently, we reserve the anterior fascial reinforced cystocele repair for patients with recurrent anterior wall prolapse, so that the potential benefits outweigh the added risks. There remain many unanswered questions about the use of grafts for cystocele repairs in spite of the evidence of improved anatomical outcomes. These include the relative merits of surgical mesh versus biological grafts, the use of surgical kits that replace sutures for anchoring the graft, and whether the graft should reinforce a native tissue repair, or be placed without efforts to repair the native tissue. Prudence dictates an in-depth discussion of these issues for any patient that is considering an anterior fascial reinforced repair.

Some surgeons advocate preoperative estrogen cream to promote a healthier mucosal epithelium in atrophic postmenopausal patients although histological studies do not support this hypothesis. A bowel prep is not generally indicated preoperatively. Antibiotic prophylaxis with a second generation cephalosporin or metronidazole is recommended, although there is minimal data to show its efficacy. A risk assessment for deep venous thromboembolism prophylaxis is also recommended. Given the lithotomy position and the average length of surgery, most patients have at least a moderate risk of venous thromboembolism, and consequently, we routinely use prophylaxis. Either pharmacologic or mechanical prophylaxis is appropriate.

The patient should be positioned in lithotomy or modified lithotomy position. Either regional anesthesia or general anesthesia is appropriate. Submucosal infiltration with injectable lidocaine with epinephrine simplifies postoperative pain and assists dissection and hemostasis. A Foley catheter should be placed during the surgery to drain the bladder. Following is a brief description of the surgical procedure used (see also video: Cystocele Repair Using Anterior Fascial Reinforcement).

Begin by defining the scope of the cystocele. Placement of a vaginal retractor provides access to the anterior vaginal wall (Figure 34.1). The surgical approach begins with a longitudinal incision in the midline of the anterior vaginal wall (Figure 34.2). This incision begins just proximal to the external urethral meatus and is carried approximately two-thirds of the vaginal length. The vaginal epithelium is then dissected off the underlying tissue in the plane between the mucosa and the vaginal muscularis or pubocervical fascia (Figure 34.3A). Finding this plane is essential to identifying the location of the rent in the pubocervical fascia. This dissection is facilitated by using sharp dissection combined with counter traction provided by Allis clamps, a self-retaining retractor, or by using a finger behind the vaginal mucosa. This dissection should be carried laterally to the white line and superiorly to the cervix or vaginal cuff (Figure 34.3B). Once the left side of the dissection is complete, the right side should be developed in the same fashion (Figure 34.3C).

Once the dissection is complete, the surgeon must identify the location of the rent in the pubocervical fascia. The defect in the pubocervical fascia can occur in the midline, or through a separation of the pubocervical fascia from the white line on either side. Less commonly, the pubocervical fascia separates from the cervix. We begin by assessing the lateral attachment to the white line. Recognizing its end points, the ischial spine and the symphysis pubis, helps to identify the course of the white line. Place the tip of contralateral index finger on the ischial spine and the proximal phalangeal joint against the lower margin of the symphysis pubis, and the white line will course between the two, along the outer aspect of the index finger. Once the location of the white line is confirmed, an attempt to sweep the finger anteriorly should be blocked by the pubocervical fascia. If the finger easily moves anteriorly into the space of Retzius, then the lateral attachment of the pubocervical fascia is compromised. This is often referred to as a paravaginal defect, and can be confirmed by visualizing Retropubic space fat. If the pubocervical fascia’s lateral attachment to the white line is intact, then this maneuver should be repeated on the other side to assess both lateral attachments. If both lateral attachments are intact, then the break is most likely in the midline.

Identifying the midline defect requires the ability to discriminate between the pubocervical fascia and the

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