Cystocele

A cystocele represents herniation of the urinary bladder through the weakened supportive fascia of the anterior vaginal compartment. Cystoceles range from involvement of only a small portion of the bladder base with a well-supported urethra to involving virtually the entire bladder and urethra. Cystocele is one of the manifestations of pelvic floor relaxation and prolapse. Within the context of pelvic floor relaxation, cystocele is commonly associated with other defects in the support of the superior and posterior compartments of the vagina as well. Loss of superior support (uterine prolapse, vault prolapse, and enterocele) and loss of posterior support (rectocele and perineal laxity) may coexist with defects of anterior compartment prolapse (cystocele and urethral hypermobility) and will require a coordinated approach and simultaneous repair.

Anatomically, a cystocele is the result of loss of pelvic floor support because of weakness of the levator fascia. The levator fascia has the principal role in the support of the anterior vaginal wall, urethra, and bladder. This fascial sheet covering the levator musculature of the pelvic floor inserts on the tendinous arch of the obturator muscle laterally and has a vaginal side and an abdominal side. The abdominal side is referred to as the endopelvic fascia. The vaginal side is called the periurethral fascia at the level of the urethra and the perivesical fascia at the level of the bladder. Together, the periurethral and perivesical fascia comprise the pubocervical fascia. The abdominal and vaginal sides fuse laterally as they insert onto the tendinous arch of the obturator. This fascia has several important condensations that provide lateral support to the bladder and urethra. The pubourethral ligaments support the midurethra to the inferior margin of the pubic bone. The urethropelvic ligaments suspend the urethra to the lateral pelvic sidewall from the bladder neck to the external meatus. The vesicopelvic ligament extends laterally to the pelvic sidewall, supporting the bladder, and finally, the cardinal ligaments extend from the cervix and upper vagina supporting these structures to the pelvic sidewall.

Anterior compartment weakness may involve the supporting structures of the urethra, the bladder, or both. Isolated defects in support of the urethra alone result in urethral hypermobility without cystocele. This may result in stress urinary incontinence and is discussed elsewhere in this text. Defects in the anatomic support of the bladder with or without coexisting involvement of the urethra result in cystocele. The cystocele defect may involve either the central or lateral support of the bladder and urethra, or it may be a result of weakening of both. Isolated central cystoceles are found when the fascia spanning the levator hiatus on the vaginal side (perivesical fascia) becomes attenuated without compromise of the lateral support (urethropelvic and vesicopelvic ligaments). Separation or attenuation of the cardinal ligaments in the midline usually contributes to the anatomic defect in central cystoceles, and reapproximation of these structures is critical to effect repair and prevent the onset of enterocele postoperatively. Isolated central cystoceles are a rare condition and comprise fewer than 10% of cystoceles. Isolated lateral cystoceles are more common and result from weakness or disruption of the lateral attachments of the vesicopelvic or anterior cardinal ligaments to the pelvic sidewall without significant weakness of the central support. Urethral hypermobility is commonly associated with lateral fascial defects. Combinations of central and lateral fascial defects are the most common presentation of cystocele and may result in severe degrees of prolapse.

DIAGNOSIS

Patients with cystoceles may be asymptomatic, may have associated stress urinary incontinence, or may complain of an introital bulge or a sensation of a mass in the vagina. Large cystoceles may cause kinking of the bladder neck and urethra, resulting in obstructive urinary symptoms, incomplete emptying, and, less commonly, frank urinary retention. Severe cystoceles may result in obstructive hydronephrosis and renal failure from urethral and ureteral obstruction. Rarely a cystocele may present as dyspareunia or incontinence during sexual intercourse. On physical examination, cystoceles appear as a midline mass in the vagina anterior to the cervix or vaginal cuff (if a hysterectomy has been performed). If significant pelvic relaxation is present, a cystocele may be present outside the vaginal introitus at rest or may bulge outside the introitus with Valsalva maneuver. It is important to differentiate cystocele from the other manifestations of pelvic prolapse that also may present with masses protruding from the vagina, including enterocele and rectocele. Examination with a half speculum will locate the vaginal cuff. Significant enteroceles and rectoceles will usually present posterior to the vaginal cuff or cervix. If there is doubt, cystography can be of assistance.

Lateral fascial defects causing cystoceles are identified in those patients with significant urethral and anterior vaginal wall hypermobility on stress maneuvers during physical examination. On examination with a half speculum directed posteriorly reducing any coexisting enterocele or rectocele, these patients have hypermobility of the entire anterior vaginal wall on stress with laxity of support for the anterolateral vaginal wall.

Isolated central fascial defects are rare and result from attenuation of the perivesical fascia in the midline and separation of the cardinal ligaments without evidence of lateral fascial weakness. Clinically these patients have a distinct anterior midline vaginal bulge without coexisting loss of support for the urethra and anterolateral vaginal wall. Typically there is no urethral hypermobility, as the lateral support of the urethra is unaffected.

Combined lateral and central defects are common and can result in urinary obstruction with or without incontinence when severe.

It is important to ascertain the level of sphincteric competence preoperatively in any patient undergoing cystocele repair. Clearly, if the patient is incontinent, some type of procedure to increase outlet resistance is needed in addition to cystocele repair. However, many patients presenting with cystoceles may not have associated symptoms of stress incontinence. In these patients sphincteric incompetence may be masked by the valvular effect of the cystocele. If the cystocele is repaired in isolation, the protective valvular effect of the cystocele on the urethra and outlet will be lost. In this case, despite adequate repair of the cystocele, the unsuspended urethra will remain in a low-lying unprotected position, and the patient will have a substantial risk of postoperative incontinence. Therefore, any degree of urethral hypermobility in the presence of a cystocele, with or without urinary incontinence preoperatively, should be repaired at the time of surgery by simultaneous suspension or sling.

Finally, a cystocele with a well-supported, nonmobile urethra from a previous suspension in combination with poor emptying ability may signal urethral obstruction. This may be caused by urethral obstruction (from the previous suspension or the cystocele or both) or detrusor hypocontractility. Patients with urethral obstruction from previous surgery may require urethrolysis and resuspension in addition to cystocele repair in order to avoid postoperative urinary retention. Patients with poor detrusor contractility should be alerted to the high risk of long-term intermittent catheterization postoperatively. Careful preoperative urodynamics with the cystocele reduced will help sort out these situations.

INDICATIONS FOR SURGERY

The repair of cystocele is based on several factors: the presence or absence of urinary incontinence, the grade of the cystocele, the inherent pathophysiological fascial weakness (central or lateral), emptying ability, and the associated vaginal or abdominal pathology to be repaired (uterine prolapse, enterocele, rectocele, etc.). Asymptomatic, small cystoceles with no evidence of stress urinary incontinence (SUI), urinary obstruction, and absence of other manifestations of pelvic prolapse do not require surgical repair. Small grade I and II cystoceles resulting from lateral fascial defects associated with SUI are usually adequately repaired using the Raz vaginal wall sling described in this text and elsewhere.

Cystoceles resulting from an isolated central fascial defect without concomitant SUI, urethral hypermobility, or demonstrated sphincteric incompetence with the cystocele reduced can undergo a central fascial defect repair alone. It should be noted that this is an uncommon presentation, and this procedure is rarely performed in isolation at our center.

In patients with a moderate cystocele resulting from a lateral fascial defect, we utilize a six-corner bladder suspension. This group of patients has, by definition, associated urethral hypermobility as a result of the associated anatomic fascial defect. The urethral hypermobility as well as the cystocele will be corrected by the six-corner suspension. This operation is a modification of our previously described four-corner suspension.3 This evolution came about from our improved understanding of the importance of the midurethral complex in the maintenance of continence in many women.

In patients with a severe cystocele (grade IV) and both a lateral and central fascial defect, a combined lateral and central fascial defect repair with mesh and vaginal wall sling will be performed. This is also a modification of a previously described procedure now redesigned to incorporate the midurethral complex into the repair.

ALTERNATIVE THERAPY

With rigorous physical therapy and intensive pelvic floor rehabilitation, some small cystoceles can be eliminated by strengthening the pelvic floor musculature. The addition of oral or topical estrogens may augment the response to nonsurgical therapy in those patients who are poorly estrogenized. Larger cystoceles without significant urinary obstruction but large enough to be bothersome to the patient can be reduced and treated with a pessary. This is also effective in those patients whose coexisting medical illness precludes surgery.

Commonly used surgical alternatives to the transvaginal procedures described below include various transabdominal procedures including the Richardson para-vaginal repair, the Burch colposuspension, and the Marshall–Marchetti–Krantz (MMK) repair. Transabdominal retropubic procedures such as the paravaginal repair and the colposuspension are indicated when the presence of other intra-abdominal pathology (large uterine leiomyomas requiring abdominal hysterectomy, ovarian pathology, etc.) requires concomitant surgical exploration. It should be noted that these procedures do not address central fascial defects and are useful only for repairing isolated lateral fascial defects. The use of retropubic procedures to repair cystoceles resulting from central defects may actually aggravate the condition, as the lateral tension placed on the suspending sutures may create increased midline fascial separation through additional shearing forces on the already weakened central fascia. The MMK should never be utilized for the repair of cystocele, as the sutures are placed too medially over the urethra to have a significant impact on the intrinsic fascial defect causing the cystocele. Simultaneous abdominal and vaginal approaches may be necessary in some cases with combined pathology.

Transvaginal approach to cystocele repair has several distinct advantages over the abdominal approach. Vaginal incision is associated with less postoperative pain and discomfort and a faster return to regular activities. Coexisting vaginal pathology such as rectocele, enterocele, and vault prolapse are easily repaired through the same or a slightly extended incision. Finally, both the lateral and central fascial defects resulting in the appearance of the cystocele are completely isolated and repaired under direct vision with a vaginal approach.

SURGICAL TECHNIQUE

Combined Repair of Lateral and Central Defects with Mesh and Vaginal Wall Sling

This procedure will repair the lateral and central fascial defects as well as the associated urethral hyper-mobility. The lateral fascial defect is repaired by non-absorbable sutures placed through the ligamentous supports of the bladder and urethra and then suspended to the anterior rectus fascia. The vaginal wall sling is accomplished by these same suspension sutures, thus repairing the urethral hypermobility. Finally, the central defect is repaired by reapproximating the cardinal ligaments in the midline and then placing several interrupted sutures plicating the perivesical fascia from the bladder neck to the level of the cardinal ligaments.

Preparation

Most vaginal surgery at our institution is performed on an outpatient basis. Antibiotics are administered parenterally 1 hour before incision. General anesthesia is preferentially used in all our vaginal surgery unless medically contraindicated.

The patient is brought to the operating room and placed in the dorsal lithotomy position with candy-cane stirrups. The buttocks are placed just off the end of the operating room table. All pressure points are padded, and care is taken to ensure that no lower extremity joint is flexed more than 90 degrees. The lower abdomen and perineum are shaved. A povidone/iodine vaginal scrub and painting are performed. The anus is draped out of the field with a self-adherent clear plastic drape. The remaining drapes are secured with silk suture across the perineum to ensure separation of the fecal and urinary streams. A weighted vaginal speculum is placed, and labial retraction sutures of 3-0 silk are used for maximal exposure.

A Lowsley retractor is placed per urethra and supported at the meatus. The tip of the Lowsley is directed anteriorly, and a suprapubic incision is performed approximately two fingerbreadths cephalad to the superior margin of the symphysis pubis in the midline. The incision is carried sharply down onto the tip of the Lowsley, and the Lowsley is extruded through the anterior abdominal wall. A 16-Fr Foley catheter is grasped and brought into the bladder and confirmed in good position by irrigation with a Toomey syringe. An additional 16-Fr Foley is placed per urethra. If indicated, a vaginal hysterectomy is now performed.

Goalpost Incision

A ring retractor is placed, and the hooks are used to expose the introitus. The anterior vaginal wall overlying the cystocele is grasped and everted through the introitus. Infiltration with injectable saline is performed along the anterior vaginal wall in the line of a goalpost-shaped incision. The limbs of the goalpost are slightly obliqued and are located on the anterior vaginal wall 1 cm from the reflection of the lateral walls of the vagina. The obliqued limbs of the goalpost extend from the midurethra to just beyond the bladder neck. The proximal extent of the paired oblique incisions are connected across the midline under the bladder neck, and then a single incision is carried to the level of the vaginal apex in the midline. The preserved island of tissue beneath the proximal urethra and bladder neck will be used for the placement of the sling sutures.

Development of the Vesicovaginal Space

The cut edges of the vaginal wall in the midline are grasped with Allis clamps to provide countertraction for the ensuing initial dissection. Sharp, shallow dissection is then carried out laterally, using Metzenbaum scissors, to develop the vesicovaginal space. This plane is avascular, and the vaginal wall should easily separate from the underlying periurethral and perivesical fascia. In reoperative cases, the vesicovaginal space may be difficult to define, and very shallow sharp dissection on the vaginal wall is imperative to avoid inadvertent entry into the bladder.

Lateral and anterior dissection toward the limbs of the goalpost incision is carried out first. Posterior dissection toward the vaginal cuff in patients who have had previous hysterectomy can be difficult, and extreme care should be taken to avoid inadvertent bladder injury. Initial mobilization of the anterior and lateral vaginal walls will make the difficult posterior dissection toward the vaginal cuff considerably less dangerous because the tissues can be reflected over the surgeon’s finger in order to facilitate dissection in the correct plane. Careful attention should be paid to the possible presence of a coexisting enterocele in the region of the vaginal cuff.

All dissection should be done under direct vision. The hooks of the ring retractor can be replaced onto the developing vaginal flaps to assist in exposure. Excessive bleeding during the early portion of the dissection indicates entry into an incorrect plane and may signal imminent bladder perforation. Sudden brisk bleeding in the posterior dissection toward the vaginal cuff may indicate severing of a branch of the uterine artery. This can be readily controlled under direct vision with forceps and cautery. However, cautery should be kept to a minimum to avoid tissue devitalization and subsequent development of vesicovaginal fistula.

The entire bladder base with attached fascia should be dissected free of the vaginal wall. Anteriorly, the periurethral fascia should be exposed toward the inferior pubic ramus and its attachment to the tendinous arc of the obturator muscle. Posteriorly, the dissection is carried to the level of the vaginal apex in the region of the cardinal ligaments.

Once the entire cystocele has been dissected from the anterior vaginal wall, a 2-0 synthetic absorbable suture (SAS) is placed through the area of the cardinal ligaments so that it will reapproximate both cardinal ligaments to the midline when tied. This stitch is not tied at this time, as it marks the proximal extent of the central defect repair.

Repair of the Lateral Fascial Defect

Attention is now turned to the suspension. The retropubic space is entered with Mayo scissors pointed at the ipsilateral shoulder, perforating the urethropelvic ligament at its insertion onto the tendinous arc of the obturator muscle. The urethropelvic ligament is released from its attachment to the tendinous arc. The adhesions in the retropubic space are lysed bilaterally, leaving the urethra freely mobile.

The four suspending sutures (two proximal and two distal sutures) of #1 polypropylene (Prolene) are now placed. The proximal suture individually incorporates three structures: the proximal edge of the released urethropelvic ligament at the bladder neck, the perivesical fascia at the reflection of the dissected vaginal wall midway between the bladder neck and the cardinal ligaments, and, finally, the area of the cardinal ligaments at the level of the vaginal cuff. Exposure of the proximal portion of the urethropelvic ligament is aided by placing blunt forceps into the retropubic space and retracting the urethra medially. The suture is then passed through all these structures again.

The distal polypropylene suture is passed with helical bites through the midurethral complex, urethropelvic ligament, and the periurethral fascia (anterior vaginal wall excluding epithelium). Exposure of the midurethral complex is facilitated by opening a forceps horizontally within the retropubic space and placing downward traction with the open forceps. This suture incorporates the midurethral complex, including the pubourethral ligament and levator entrance into the urethra, and the distal aspect of the freed urethropelvic ligament and finally is passed parallel to the anterior vaginal wall to include the periurethral fascia but exclude the vaginal epithelium. The identical two sutures are placed on the opposite side.

Transfer of Sutures

A 1-cm skin incision is performed at the upper margin of the symphysis pubis on the lower abdominal wall. Blunt dissection is carried down to the anterior abdominal wall fascia. A double-pronged ligature carrier is now passed from the suprapubic incision to the vaginal incision under fingertip guidance. The ligature carrier should scrape the posterior surface of the symphysis as it is passed to avoid inadvertent bladder or urethral injury. Piercing the abdominal wall fascia too cephalad off the superior margin of the pubis will result in mobility of the sutures and considerable postoperative pain and discomfort.

The ligature carrier is used to transfer the four sutures individually from the vagina to the abdominal incision. They are not tied at this time. These four sutures represent the repair of the lateral defect of the cystocele as well as the vaginal wall sling.

Repair of the Central Fascial Defect

Absorbable mesh (Dexon or Vicryl) is used to pack and reduce the cystocele cephalad in the midline. This is left in situ but is not sutured in place. Interrupted horizontal mattress sutures of 2-0 SAS are placed in the lateral edges of the perivesical fascia sequentially from the bladder neck to the area of the cardinal ligaments. These imbricating sutures are placed just medially to the suspending polypropylene sutures into the perivesical fascia but are not tied. Usually four or five sutures are required to close the defect.

Cystoscopy

The urethral Foley is removed, and cystoscopy is performed to ensure that a polypropylene suture has not been inadvertently placed through the bladder or urethra as well as to confirm efflux from both ureteric orifices. The suprapubic tube location should be confirmed as well. Gentle upward traction on the suspending sutures should elevate the bladder neck and proximal urethra as viewed through the cystoscope.

Up to this point the operation is completely reversible, as no sutures have been tied. Thus, if a misplaced suture or incidental cystotomy is detected on cystoscopy, it is easily remedied.

Closure of the Vaginal Wall

The cardinal ligament suture is now tied, thus reapproximating these structures toward the midline at the level of the vaginal apex or cuff. The sutures repairing the central defect are now tied.

The limbs of the goalpost incision are closed with a running interlocking 2-0 SAS. The excess vaginal wall is trimmed, and the remaining vaginal wall is closed with 2-0 SAS in a running interlocking fashion incorporating the underlying central defect repair, thus closing potential dead space. The vagina is packed with an antibiotic-impregnated gauze.

Completing the Suspension

The suprapubic sutures are tied with the knot laid down onto the anterior abdominal wall fascia under no tension. A cystoscope sheath should be placed per urethra at a 30-degree incline while the suspending sutures are tied down. In our experience, if the cystoscope sheath maintains elastic mobility after all the sutures are tied, then there is no undue tension on the suspending sutures. The suprapubic incision is irrigated with antibacterial solution and closed with a subcuticular 4-0 SAS.

Postoperative Care

The SP tube is placed on slight traction and left to gravity drainage. The vaginal pack is removed in 2 to 3 hours. The patient is allowed to void immediately postoperatively. Postvoid residuals are checked every 2 to 3 hours. The patient is discharged from the same-day surgery unit when ambulatory and able to tolerate a regular diet. She is taught suprapubic tube care and how to measure her own postvoid residuals. When the residual is less than 30 to 60 cc, the suprapubic tube is removed. Alternatively, when the postvoid residuals remain high, the patient is taught clean intermittent catheterization techniques, and the tube is removed at the end of 4 weeks.

The patient may resume all regular activities immediately postoperatively except heavy lifting, running, and sexual intercourse. These limitations are removed at 4 weeks at the time of the first postoperative office visit.

Repair of Lateral Defect (Six-Corner Bladder Suspension)

This procedure is best suited for those patients with moderate cystoceles (grade II or III) and primarily lateral fascial defects.

Preparation

The positioning, preparation, and placement of suprapubic tube are identical to those for the repair described above.

Incision

The anterior vaginal wall overlying the distal urethra is grasped with an Allis clamp and stretched cephalad. Two oblique vaginal incisions are performed 1 cm medial to the reflection of the lateral vaginal wall onto the anterior vaginal wall, from the midurethra to the region of the vaginal cuff (if a hysterectomy has been performed) or to the paracervical region if the uterus is to be preserved.

Exposure of Ligamentous Supports

Sharp dissection is carried laterally from both incisions using the Metzenbaum scissors. Proximally, dissection is performed to expose the area of the cardinal ligaments. Distally, lateral dissection is carried over the glistening periurethral fascia, exposing the insertion of the urethropelvic ligament onto the tendinous arch of the obturator muscle.

The retropubic space is entered with Mayo scissors pointed at the ipsilateral shoulder and perforating the urethropelvic ligament at its insertion onto the tendinous arc of the obturator muscle. The urethropelvic ligament is released from its attachment to the tendinous arch bluntly. The adhesions in the retropubic space are lysed bilaterally, leaving the urethra freely mobile.

Placement of Sutures to Repair the Lateral Fascial Defect

Three sutures of #1 polypropylene (Proline) are placed on each side. Each suture incorporates multiple passes through the tissue. The proximal suture is passed through the perivesical fascia parallel to the anterior vaginal wall, incorporating the area of the cardinal ligaments at the apex of the vagina but excluding the vaginal epithelium. If passed correctly, this suture should be anchored into very strong, supportive tissue.

The middle suture is first placed at the level of the bladder neck and is passed with helical bites through the perivesical fascia parallel to the anterior vaginal wall excluding the vaginal epithelium. The bladder neck is then held medially and the suture is placed through the freed proximal edge of the urethropelvic ligament in a helical fashion at the level of the bladder neck.

The third suture is placed at the level of the midurethral complex. Exposure of the midurethral complex is facilitated by opening a forceps horizontally within the retropubic space and placing downward traction with the open forceps. This suture incorporates the midurethral complex, including the pubourethral ligament and levator entrance into the urethra, and the distal aspect of the freed urethropelvic ligament and finally is passed parallel to the anterior vaginal wall including the periurethral fascia but excluding the vaginal epithelium.

Transfer of Sutures

A 1-cm skin incision is performed at the upper margin of the symphysis pubis on the lower abdominal wall. The ligature carrier is used to transfer the six sutures individually from the vagina to the abdominal incision in the same manner as described for the combined repair. They are not tied at this time.

Cystoscopy

The urethral Foley catheter is removed, and cystoscopy is carried out examining for intravesical or intraurethral suture as well as proper location of the suprapubic tube at the dome. Urinary efflux should be confirmed from both ureteral orifices.

Closure of the Vaginal Wall

The oblique incisions in the anterior vaginal wall are now closed with a running interlocking 2-0 SAS with care taken not to trap the polypropylene suspension sutures in the closure.

Completing the Suspension

The suprapubic sutures are tied under no tension as described previously, and the abdominal incision is irrigated and closed.

Postoperative Care

The vaginal packing is removed in 2 to 3 hours, and the patient is discharged home when ambulatory and able to tolerate a regular diet. The remaining postoperative care is identical to that previously described for the combined repair.

Repair of a Central Defect

This procedure is specifically indicated only for the repair of isolated central fascial defects with a well-supported, competent, nonobstructed sphincteric mechanism. This is an uncommonly performed procedure, as most central defects are accompanied by other manifestations of pelvic prolapse.

Preparation

The positioning, preparation, and placement of a suprapubic tube are identical to those for the repairs described above.

Incision and Dissection of the Anterior Vaginal Wall

The anterior vaginal wall is infiltrated with injectable saline in the midline from the bladder neck to the apex of the vagina. The anterior vaginal wall overlying the cystocele is then incised sharply with the knife. The cut edges of the vaginal wall are grasped with Allis clamps to provide countertraction for the ensuing initial dissection. Sharp dissection is then carried out laterally, using Metzenbaum scissors to expose the vesicovaginal space and the perivesical fascia. This plane is avascular, and the vaginal wall should easily separate from the underlying periurethral and perivesical fascia. Lateral flaps of vaginal wall are developed from the midurethra to the vaginal apex. A ring retractor can be placed to assist in the retraction of the developing flaps.

Lateral dissection is carried out until the weakened perivesical fascia found in the midline—the cause of the anatomic defect allowing for the formation of the cystocele—is no longer attenuated. This strong lateral aspect of the perivesical fascia will constitute the tissue for the subsequent central defect repair.

Proximal dissection toward the vaginal cuff in patients who have had previous hysterectomy can be difficult, and extreme care should be taken to avoid inadvertent bladder injury. Dissection should be carried proximally to the area of the cardinal ligaments.

Repair of the Central Defect

Repair commences with the reapproximation of the area of the cardinal ligaments in the midline with a 2-0 synthetic absorbable suture. Attention is now turned to the perivesical fascia lateral to the bladder neck on either side. A horizontal mattress stitch of 2-0 synthetic absorbable suture is used to plicate this fascia toward the midline. When tied, this stitch will draw the perivesical fascia beneath the bladder neck. The cystocele is reduced manually or, as we prefer, using absorbable Vicryl or Dexon (polyglycolic acid) mesh. The cystocele is thus packed cephalad, and the mesh is left in situ. The remaining perivesical fascia is then plicated from the level of the bladder neck to the cardinal ligaments with interrupted closely approximated horizontal mattress sutures of 2-0 synthetic absorbable suture. The sutures are not tied at this time.

Cystoscopy

The urethral Foley is removed and cystoscopy is performed to ensure that a suture has not been inadvertently placed through bladder or urethra as well as ensure efflux from both ureteric orifices.

Closure

The plicating sutures are now tied. The excess vaginal wall is trimmed, and the vaginal wall is reapproximated with a running 2-0 absorbable suture. An antibiotic impregnated vaginal packing is placed. In 4 to 6 hours the vaginal packing and Foley are removed.

OUTCOMES

Complications

Complications associated with cystocele repair can be avoided by careful attention to detail during dissection of the cystocele and passage of the ligature carrier. Incidental cystotomy occurs rarely and should be repaired intraoperatively. A multiple-layer closure with nonopposing suture lines and maximal urinary drainage should be performed to prevent late-onset vesicovaginal fistula.

Careful cystoscopic evaluation intraoperatively should alert the surgeon to many other potential complications. Ureteral obstruction is diagnosed by noting the lack of urinary efflux from the ureteral orifice. Removal and replacement of the offending stitch should suffice for repair. Internal ureteral stenting is considered only if there was extensive trauma to the ureter. Inadvertent intravesical or intraurethral placement of nonabsorbable suture will result in recurrent infections and stone formation. This should be recognized intraoperatively during careful cystoscope examination. Removal and replacement of the suture is easily performed if it has not yet been tied as described above.

Postoperative bladder instability is a well-documented complication of cystocele repair. Detrusor instability may result from three sources: continuation of preoperative instability, de novo bladder instability temporally related to cystocele repair, and finally, urethral obstruction as a result of tying the suspension sutures under tension. Preoperative detrusor instability is expected to resolve in over 70% of patients postoperatively. The remaining patients may be treated pharmacologically with anticholinergic agents. De novo instability is treated pharmacologically as well. Nonresolution of de novo instability in the presence of incomplete emptying may indicate urethral obstruction. Tying the sutures with a cystoscope sheath in the urethra under no tension as described is the best way to avoid this complication. Urethral obstruction may require formal urethrolysis or complete takedown of the suspension for resolution. In this situation, resolution of instability can be expected in over 90% of cases.8

Incomplete emptying and urinary retention may also result from poor detrusor contractility unrecognized preoperatively. Long-term clean intermittent catheterization is preferable to indwelling Foley catheterization in these unfortunate cases.

Persistent pain, infection, bleeding, recurrent incontinence, vaginal stenosis and/or shortening, vesicovaginal fistula, ureterovaginal fistula, and dyspareunia are also potential complications of cystocele repair.

Finally, enterocele may result months to years later from alteration of the pelvic axis and insufficient anatomic reapproximation of the cardinal ligaments to the midline during repair. Plication of the perivesical fascia without reapproximation of the cardinal ligaments during repair of central defects leaves a considerable anatomic defect in the region of the vaginal cuff, allowing for the formation of an enterocele.

Results

Because these procedures represent relatively new modifications of previous technique, we are still compiling data on the results. Previously we had reported on the four-corner bladder suspension for moderate cystocele, which is the forerunner of the six-corner bladder suspension described above. This procedure did not incorporate the midurethral complex in the form of the vaginal wall sling as it does now. Nonetheless, with the previous technique, 105 of 107 patients with moderate cystocele were successfully treated at a mean follow-up of 2 years.

We have also reported on a previous modification of the combined repair of central and lateral defects. Likewise, this procedure did not incorporate the midurethral complex in the repair. In this preliminary study, we reported a 96% success rate for grade 4 cystocele at a follow-up of 34 months. The current modifications were designed to address the midurethral complex and improve postoperative continence in this complex group of patients.

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