Anatomic correction of an anterior defect or cystocele will generally relieve symptoms of protrusion and pressure and will usually improve micturition function when abnormal micturition is associated temporally with the defect and if there is no associated neuropathy. If a single, well-defined midline defect is recognized, excision of the weak vaginal wall and an imbricating closure of the defect may be performed. However, recent magnetic resonance imaging (MRI) and anatomic measurement studies indicate that at least one third of the descent of cystoceles is due to loss of apical support, so it is important to determine whether the apex needs to be suspended as well. Most central anterior defects require a more extensive dissection of the vesicovaginal space. In the case where the cuff is well suspended, the authors typically grasp the vaginal epithelium vertically with two Allis clamps cephalad to the urethrovesical junction and incise with the knife. With the use of a Metzenbaum or comparable scissors, the vaginal epithelial and subepithelial layers are separated from the fibromuscular layer out to a point lateral to the defect up to the cuff or cervix; this is followed by midline plication of this tissue with either a running or interrupted delayed absorbable suture such as polyglactin (Vicryl, Ethicon, Somerville, NJ) or no.1 polydioxanone (PDS, Ethicon, Somerville, NJ), excision of excess epithelium, and closure. The repair is similar at the time of concomitant vaginal hysterectomy or apical cuff suspension except that the dissection proceeds in a cephalad to caudad fashion. It appears of great importance to ensure that the continuum of repaired fibromuscular tissue to a well-supported vaginal apex be maintained.

Recurrence rates of traditional fibromuscular connective tissue plication anterior repairs vary in the literature from 5% to 90%; however, studies define recurrence in numerous ways from minimal prolapse to stage III descent. The clinical significance of recurrent asymptomatic cystoceles (stage I and some stage II) is debatable because many of these do not progress to larger defects. The authors’ interpretation of the literature is that when traditional anterior repairs are performed with patients with a pelvic organ prolapse quantitation (POP-Q) system of measurement of stage II or greater cystoceles (frequently concurrently with other procedures), a recurrence rate of stage II or greater prolapse of up to 20% to 40% is not uncommon. Many studies do not define how the subjects were evaluated postoperatively and vary in respect to patient populations, type and severity of defects, presence of concurrent defects, surgical technique, and follow-up time and length. Some studies have suggested higher recurrence rates when these repairs are performed concurrently with sacrospinous suspensions and hypothesize that this type of apical suspension may predispose the repair anterior wall to greater pressure transmission. Other possibilities of the higher failure rates in these studies are the fact that the patients having concurrent repairs may be more likely to have more complicated forms of prolapse or, possibly, more defective “pelvic floors” than other groups of patients.

The addition of adjunctive graft materials has been employed in the past decade to try to improve success rates. Two randomized trials suggest modest improvement in success after 1 year when polyglactin mesh (Vicryl, Ethicon, Somerville, NJ) was placed over the midline plication compared with standard repair. However, most
surgeons have abandoned this type of mesh because of subsequent failures. Other graft materials that are discussed later in this chapter may have more promise, but long-term outcome data are lacking. Fascial autologous grafts, allografts, xenografts, and newer synthetics are presently used by many surgeons with variable short-term success and, thus far, little data on adverse effects and success after 3 years. These have been used in several ways in the anterior compartment, including placement of smaller grafts to bolster suture lines and larger grafts for complete substitution of the entire anterior support plate from the pubis to the arcus to the vaginal apex.

The paravaginal or “lateral defect” repair described first by White and reintroduced by Richardson and Edmonds involves reattachment of the anterior lateral vaginal sulcus to the obturator internus fascia and, at times, muscle at the level of the arcus tendineus fascia pelvis (ATFP) or “white line.” The paravaginal repair reattaches the anterolateral vaginal sulcus to the pubococcygeus and obturator internus muscles and fascia at the level of the ATFP. The original transvaginal repair used bilateral incisions along the lateral vaginal sulci to expose the arcus tendineus. Three or four sutures were then placed from the ischial spine along the ATFP to suspend the vaginal muscularis and adventitia bilaterally.

Subsequently, use of a midline incision was described that facilitated the concurrent repair of central anterior defects. The typical vaginal paravaginal procedure involves the “three point closure” with incorporation of the detached edge of the pubocervical connective tissue into the ATFP and the anterior vaginal wall with a series of four to six nonabsorbable sutures (Prolene, Ethicon, Somerville, NJ) 1.5 cm apart, initiated approximately 1 cm anterior to the ischial spine. The sutures are tied sequentially, beginning with the one closest to the spine and ending periurethrally. Cystoscopy should be performed to ensure ureteral patency and inadvertent stitch placement into the bladder. This often is performed with a reinforcement of the midline pubocervical connective tissue with trimming of the vaginal epithelium (if necessary) and closure. The procedure has been described with the use of a Capio suturing device as well (Microvasive Endoscopy, Natick, MA).

Observational outcome studies have reported good success (80% to 95%); however, long-term data on durability and function is lacking. Previous work has shown that most subjects with anterolateral detachments almost always have separation of the upper vaginal fornices from the arcus tendineus immediately adjacent to the ischial spine. Thus, it is important to resuspend those specific areas.

It is the authors’ opinion that it is difficult to achieve optimal results when vaginal paravaginal repair is used in combination with traditional central repairs because of the creation of tension on opposing suture lines. A repair that removes a weakened central vaginal wall may decrease the side-to-side dimensions of the anterior vaginal wall, making it difficult to suspend its lateral points more laterally. When large central defects are coexistent with lateral defects, one option is an extensive central repair accompanied by a good apical support procedure. This changes the shape of the vagina to a more cylindrical structure. Another choice is placement of a graft material to span the entire anterior rhomboid-shaped plate, thus augmenting anterior paravaginal tissue strength. The graft with tension adjusted may be anchored to the arcus tendineus along with the adjacent vaginal wall from the level of the pubic rami to the ischial spine. The new synthetic graft kits utilize this principle, as described later.

Although most reports indicate that repair of anterior defects with all of these procedures relieves symptoms that are directly related to prolapse, there is very little data on patient satisfaction and quality-of-life improvement over time. Such studies are much needed. There are no randomized trials that compare outcomes after anterior colporrhaphy versus vaginal paravaginal repair.

The first description of the posterior colporrhaphy was by Jeffcoate in 1959 and involved plication of the pubococcygeus muscles across the anterior rectum as well as perineal body reconstruction. Since that time, the technique has been modified in attempts to preserve sexual function. Typically, a midline incision is extended from the perineal body to the vaginal apex or to the cephalad border of a small or distal rectocele. The Denonvilliers fascia is mobilized from the vaginal epithelium, leaving as much of this tissue attached laterally to the levator fascia as possible.
After obvious defects in the rectal muscularis are repaired, the fascia is then plicated in the midline with interrupted or continuous sutures (Fig. 49.2). The authors prefer delayed absorbable suture, no. 1–0 or no. 0 polydioxanone, for this plication. Permanent nonbraided suture material may be used as well. In our experience, braided permanent suture material is subject to a greater incidence of stitch infection and formation of granulation tissue. The vaginal epithelium is trimmed and closed with absorbable sutures.

When there is a defective perineal body or perineal membrane, reconstruction is performed after accompanying posterior colporrhaphy. The superficial muscles of the perineum and bulbocavernous fascia are plicated in the midline by using delayed absorbable suture, and the skin closed as in an episiotomy repair. Detachments of the inferior portion of the Denonvilliers fibromuscular connective tissue from the perineal body are also corrected. Plication of the puborectalis muscles concurrently with these procedures is performed by some surgeons in all or selected cases, but because this has been associated with a high incidence of sexual dysfunction, the authors do not recommend that it be performed routinely. However, puborectalis plication will be performed in selected patients with severe prolapse accompanied by a large genital hiatus with palpable levator weakness or inability to contract pelvic floor muscles. Sutures are carefully placed through the puborectalis muscles at least 3 cm or greater posterior to their insertion on the pubic rami, thereby decreasing the tension of the plication. For those women who desire sexual function with findings of an enlarged hiatus and weakened puborectalis muscles, there is an attempt to plicate the muscles far enough posteriorly to easily allow two fingers through the vaginal introitus and reconstruct the distal posterior vagina and perineum so that there will not be a ledge or ridge at the site of the puborectalis plication. Outcome data on such procedures is inadequate to make conclusions regarding its efficacy; however, it is the authors’ opinion that pelvic floor defects producing an enlarged genital hiatus are common reasons for failure of support procedures and that puborectalis plication may decrease the incidence of such failures.

Reported anatomic cure rates for traditional posterior colporrhaphy have ranged from 76% to 90% with variable follow-up. Most studies show a benefit to ease of defecation if patients are using preoperative splinting; however, overall defecatory dysfunction (defined as constipation) is usually not relieved in the majority of the subjects. These repairs, per se, also appear to be of little to no benefit to fecal incontinence. It is not surprising that the repairs are not particularly effective for defecatory dysfunction related to disorders of constipation or for fecal incontinence since the etiology of these problems are multifactorial. De novo dyspareunia is reported to occur in up to 25% of sexually active patients who have traditional posterior colporrhaphy and is not always associated with levator plication
procedures. Potential causes for dyspareunia other than vaginal strictures or introital tightness include scarring with immobility of the vaginal wall, levator spasm, and neuralgias associated with sutures and/or dissection. Dyspareunia may also occur when a Burch colposuspension procedure (or other procedures that cause anterior displacement of the vaginal canal) is combined with a posterior repair. Careful surgical technique and appropriate choice of procedure should decrease the incidence of postoperative dyspareunia.

Defect or site-specific posterior repairs are restorative procedures by which the posterior defects described by Richardson are corrected. These repairs begin by midline posterior vaginal incision through the epithelium and then separation of the epithelium from the fibromuscular wall (Fig. 49.3). After irrigation for better exposure, a finger is inserted in the rectum to better define defects of the rectal wall and in the fibromuscular connective tissue layer that has been dissected from the vaginal wall subepithelium. The specific defects are closed with either interrupted or running sutures (the authors prefer the delayed absorbable type). Defect closure is accomplished in such a way to minimize tension on the surrounding tissue and may involve vertical, horizontal, or oblique approximation. When there is separation of the fibromuscular tissue from the perineum, the upper anterior rectum, or a well-supported cervix or vaginal cuff, it is important to reapproximate these connections. Repairs of coexistent perineal and apical support defects are important. The goal of the surgery is to re-establish an intact plane of connective tissue that positions the rectum against the pelvic floor and obliterates any potential space between a well-supported cervix or vaginal cuff and the cephalad edge of the tissue plane and upper rectum. The technique should minimize tension and avoid potential strictures, which may be more likely to occur with traditional posterior colporrhaphy.

Just as in anterior compartment procedures, the placement of graft materials to improve the success of posterior compartment repairs has been employed. Kohli and Miklos describe the use of a dermal allograft to augment
defect-directed repairs whereby the graft is sutured to the levator fascia on both sides of the defect to cover the rectovaginal plane. One concern about this technique is that in patients with relatively thin vaginal walls, removal of the fibromuscular tissue may devascularize the epithelium and make it more subject to erosion over the graft material. To improve the quality of vaginal epithelium in women with vaginal atrophy, patients in the authors’ practice use vaginal for 4 to 8 weeks preoperatively. The initial surgical dissection is deep to the fibromuscular layer. Access to the lateral levator fascia is generally easily accomplished with a division of the Denonvilliers fascia at its incorporation into the posterior vaginal wall or, if the lateral attachment is not present, with combined sharp and blunt dissection to expose the paralevator fascia. This levator fascia on each side as well as any remaining lateral Denonvilliers fascia and occasionally muscle is incorporated into the edge of the graft with sutures. The posterior cephalad edge of the graft is attached to the anterior rectum at its sigmoid junction, and the anterior cephalad edge is attached to a well-suspended vaginal cuff. The caudad edge is incorporated in an appropriate repair of the perineal area. With short-term, mean follow-up of 12 to 30 months, overall results reveal good anatomic cure rates of 89% to 100% with cadaveric dermis, autologous dermis, polyglactin mesh, and polypropylene mesh. Improvement in obstipation has also been reported. Although the numbers of subjects assessed have been relatively low, de novo dyspareunia rates have been between 0% and 7%.

The aim of transanal rectocele repair, usually performed by colorectal surgeons rather than gynecologists, is to remove or plicate redundant rectal mucosa, to decrease the size of the rectal vault, and to plicate the rectal muscularis, rectovaginal adventitia, and septum. Since the vaginal
epithelium is not incised or excised, this probably accounts for the procedure’s reported lack of adverse affects on sexual function in contrast to the vaginal approach to posterior repair. Two randomized trials and several case series from transanal repairs with mean follow-up of 12 to 52 months report anatomic cure rates of 70% to 98%, improved constipation and fecal incontinence, and less need for vaginal digitation to expel stool. Complications included infections and rectovaginal fistulas, which were surprisingly rare in the reported series. From the gynecologic perspective, transanal posterior repair only makes sense when the procedure is performed for defecatory dysfunction and not for prolapse of the posterior vaginal wall. It is unclear whether the transanal approach with defect excision and repair improves defecatory dysfunction better than a defect-specific transperineal or transvaginal approach with imbrication of tissues to correct palpable weakness in the rectal wall and its adjacent connective tissues.

Enterocele repair usually is performed in the setting of concomitant procedures for prolapse, more often as related to posterior compartment repair and apical repair. Whether by vaginal, abdominal, or laparoscopic access, the enterocele repair is traditionally performed by sharply dissecting the peritoneal sac from the rectum and bladder. A purse-string suture can be used to close the peritoneum as high (cephalad) as possible; whether excision of the peritoneum itself is necessary has not been determined. Care must be taken to identify and avoid the ureters during peritoneal closure. More important than closing the enterocele sac is approximating the anterior to the posterior fibromuscular connective tissue of the vagina. Suspension of the vaginal apex is almost always necessary except in those rare cases when the enterocele occurs in the presence of adequate apical support.