Download Management of prolapse of the anterior compartment

BJOG: an International Journal of Obstetrics and Gynaecology
December 2004, Vol. 111, Supplement 1, pp. 67– 72
Management of prolapse of the anterior compartment
Mark Slack
HISTORICAL ASPECTS
A wide range of techniques have been attempted to
repair the prolapsing anterior vaginal wall. Geradin tried
denudation of vaginal mucosa for the management of
prolapse in 1823 on a cadaver. This was first performed
on a living patient in 1830. By 1866 J.M. Simm had
performed a series of denudation operations very similar
to a modern anterior repair.1 The majority of historical
papers describing the aetiology of, and treatment for, the
cystocoele regard the condition as analogous to a herniation
of the anterior abdominal wall. Consequently all the surgical techniques concentrate on excision of the redundant
vaginal tissue with plication of the cut ends of the fascia in
the midline.2,3 George White in 1909 wrote of his frustration with the suboptimal outcome of operations for the
repair of the cystocoele.4 He believed that the practice of
removing part of the anterior wall before suturing the cut
ends together was irrational and destined for failure. In this
paper he made the first reference to the lateral supports of
the anterior wall. He proposed that injuries at parturition
produced tears in the fibres of the white line allowing the
anterior wall to dislocate from its attachments and present
as a cystocoele. His proposed solution was a vaginal
technique allowing attachment of the lateral sulci of the
vagina to the white line using absorbable sutures (the
technique described is not dissimilar to the current abdominal paravaginal repair described by Richardson1). Nineteen
cases with no recurrence at 3 years were described. White
appreciated that the operation, in addition to correcting the
prolapse, did not compromise the capacity of the vagina.
The prevailing belief at the time was that a cystocoele
represented a central herniation of the bladder through the
anterior fascia and therefore would not be served by an
operative procedure, which only approached the lateral
supports. As a consequence the procedure was largely
ignored until its resurrection by Richardson in 1981. In
the interim surgeons concentrated their efforts on improving the outcome of the midline procedures. Attention was
given to correction of midline ‘fascial’ defects by ‘lapping’
techniques.6,7
The abdominal approach was introduced in 1939 and
underwent subsequent modifications.8 – 11 Macer concluded
that the procedure was superior to the vaginal approach.12
Various techniques originally described for the management of stress incontinence have been tried for anterior wall
defects13,14 but have failed to make any real impact; the
condition continues to be managed by vaginal plication by
most surgeons. However, with the re-introduction of the
paravaginal repair by Shull15 and Richardson5 it seems as if
the management of the problem has gone ‘full circle’.
Most surgeons are less than satisfied with the outcome of
operations for prolapse. Richard TeLinde wrote
Every surgeon of extensive and long experience will
have to admit that he is not entirely and absolutely
satisfied with the long-term results of all his operations
for prolapse and allied conditions. A more assertive patient population has expectations of effective therapy
and is more likely to return for assessment if the original operation has been unsuccessful. It is extremely
important therefore to ensure that the patient is well
counselled prior to the original surgery and has a good
understanding of the aims of the operation, its limitations and the associated success and failure rates. Failure could result from the recurrence of the original
problem or arise because of the development of new
symptoms such as urinary incontinence.
Surgical management of pelvic organ prolapse is common. In the USA the lifetime risk of having an operation for
prolapse or incontinence by age 80 was 11.1%.16 A staggering 30% of these patients required a second operation for
the same problem. MacLennan and colleagues showed that
46.2% of women aged 15 –97 had pelvic floor dysfunction
with 23% of them having had a previous repair.17
Recent estimates suggest that demand for prolapse
surgery will increase by 45% in the next 30 years.18 If
so, urgent attention will need to be given to the development of new operations for prolapse or else there could be a
major increase in cases needing repeat surgery.
ANATOMY OF THE ANTERIOR VAGINAL WALL
Hinchingbrooke and Addenbrooke’s Hospitals, Cambridge,
UK
Correspondence: Dr M. Slack, Hinchingbrooke and Addenbrooke’s
Hospitals, Cambridge, UK.
D RCOG 2004 BJOG: an International Journal of Obstetrics and Gynaecology
In order to understand the various operations that have
been proposed to correct cystocoele, it is necessary to have a
three-dimensional understanding of the anatomy of the
anterior vaginal wall. The mechanisms by which the uterus
and vagina are supported have been investigated in cadaveric
www.blackwellpublishing.com/bjog
68
M. SLACK
dissections and our knowledge in this area is mainly due to the
work of John Delancey, which has brought a mechanical
framework to the landmarks described in anatomy textbooks.
These concepts, which had been suggested by Victor Bonney
in 1934,19 have received fresh attention as a result of his
work20 and have altered surgical approaches in prolapse as a
result. The following paragraphs attempt to summarise
Delancey’s ideas about supporting structures in the pelvis.
The concept of three levels or forms of support that can
be analysed for any organ in the pelvis has been proposed.
Support is provided mainly by the endo-pelvic fascia that
invests each organ and that forms condensations or (named)
ligaments. In addition to endo-pelvic fascia, the muscles of
levator ani provide indirect support by closing the genital
hiatus and providing a platform against which rises in
abdominal pressure compress the pelvic organs. Delancey
described level I support as vertical suspension of the
uterus, cervix and vagina, level II support as lateral attachment to the side-walls of the pelvis and level III support as
the fusion of the lower end of the organ to the cloacal area.
Failure of any of these supports can lead to organ prolapse
and/or incontinence.
In the case of the uterus and vagina, the suspensory
supports (level I) are provided by the cardinal and uterosacral ligaments, while level II support of the vagina is
provided by connective tissue (called paracolpium by
Delancey) which connects the vagina to the arcus tendineus
fascia pelvis or ‘white line’. This is a fibrous condensation
running along the pelvic side-wall from about 1 cm lateral
to the pubic symphysis to the ischial spine, which forms part
of the origin of the levator ani muscles. As well as fixing the
vagina laterally, the paracolpium forms a supportive layer
under the bladder anteriorly, which is called the pubocervical fascia. The posterior aspect of the paracolpium is
similarly attached to the superior fascia of the levator ani
muscles, forming the rectovaginal septum or Denonvilliers
fascia. Level III support of the lower third of the vagina is
provided by fusion of the vaginal connective tissue posteriorly to the perineal body and anteriorly to the urethra.
The main support of the bladder and bladder neck is the
‘hammock-like’ anterior vaginal wall and the condensation
of pubocervical fascia around the vagina, which extends
laterally to the arcus tendineus fascia pelvis and fuses to the
levator ani muscles beneath. As the distal urethra passes
through the perineal membrane the fascia surrounding it
fuses densely with the pubic bone. The indirect lateral
attachments to the levator ani muscles (specifically the
pubococcygeus portion) provide a base against which the
urethra is compressed during rises in intra-abdominal pressure, closing the urethral lumen. When the levator ani
muscles are voluntarily contracted, they are able to provide
compression that can interrupt the urinary stream.
Cystocoeles can arise in a number of different ways.
Defects in the endo-pelvic fascia in the midline lead to a
central cystocoele while detachment of the pubocervical
fascia from the white line gives rise to lateral prolapse of
the anterior vaginal wall. In addition, superior transverse
defects have been described in the endo-pelvic fascia where
the pub-cervical fascia attaches to the cervix, merging with
the uterosacral and cardinal ligament complex, leading to a
high central cystocoele.21 At the bladder neck, failure of the
supporting structures can give rise to stress incontinence.
The type of fascial defects present need to be carefully
assessed in the individual patient in order to repair and
support the affected structures. In addition at least 35% of
women will have new onset (occult) stress incontinence
postoperatively which needs to be assessed by urodynamic
investigations preoperatively with and without reduction of
the prolapse.22
SURGICAL APPROACHES TO ANTERIOR
VAGINAL WALL PROLAPSE
In this review, only operations designed to correct
anterior vaginal prolapse will be described. In the case of
bladder neck descent leading to stress incontinence, or
combined prolapse and stress incontinence, the various
operations may be combined with procedures to support
the bladder neck, such as a Burch colposuspension or the
sling procedure, which are outside the scope of this review.
Anterior colporraphy
A large number of variations have been described: in the
main, the operation involves a midline incision of the
vaginal mucosa with dissection of mucosal flaps to expose
the bladder and proximal urethra. Absorbable mattress
sutures are placed into paravesical fascia laterally in order
to support the bladder in the midline. The excess vaginal
mucosa is excised and closed in the midline with further
absorbable sutures.
As a result of the anatomical concepts described above,
it is now thought that only a central fascial defect will
respond to anterior colporrhaphy: any evidence of displacement of the vaginal wall from the white line laterally
(lateral defect) will require reattachment of the vaginal
wall back onto the white line (i.e. a paravaginal repair).
However, this hypothesis has yet to be tested.
Results of anterior colporrhaphy
The numerous retrospective studies of anterior colporrhaphy as a treatment for prolapse have been reviewed by
Weber and Walters.23 A randomised trial of different
variations in repair method has been performed. This failed
to demonstrate a difference in outcome.24 The majority of
studies had recurrent cystocoele rates of between 3% and
20% after 2 – 8 years’ follow-up, but as these were all
retrospective studies it is unclear what assessment of lateral
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MANAGEMENT OF PROLAPSE OF THE ANTERIOR COMPARTMENT
defects was carried out prior to surgery. Porges and Smilen
carried out a retrospective analysis of their case load of 486
prolapse procedures over 23 years.25 For primary anterior
repairs they had a recurrence rate of 1.4% for mild prolapse
and 3.8% for severe prolapse; in the recurrent surgery
group, recurrences of 2.9% –4.5% are quoted. No complications of the surgery are reported but there were two
deaths, one due to medical problems and one due to pelvic
sepsis in a diabetic. Stanton et al.26 noted a recurrence rate
of 15% after 2 years for anterior colporrhaphy performed
for prolapse, although the study concentrated on the preand postoperative urodynamic findings. Weber’s group
demonstrated a recurrence rate of 40% at 1 year.24
Abdominal cystocoele repair
Several techniques of abdominal repair of cystocoele
have been described at the time of hysterectomy, although
these have fallen out of favour.8 – 12 The basis of the
technique is to dissect the bladder at abdominal hysterectomy much more fully than usual, exposing vaginal mucosa
at the level of the urethra and removing a diamond-shaped
portion of vaginal mucosa in the midline. The repair is
oversewn using absorbable sutures.
In 1978, Macer published his 20 years’ experience of the
technique: subjective assessment of 76 patients showed an
overall recurrence of cystocoele occurred in 7.9% of cases,
which he compared with a recurrence rate of 22% in his
anterior colporrhaphy cases over the same period.10 Unfortunately, there was no indication in these papers of any
independent assessment of the patients nor of any indication of any complications resulting from the surgery.
Abdominal paravaginal repair
Paravaginal repair of lateral wall defects aims to reapproximate the vaginal wall to the arcus tendineus fascia
pelvis/white line. The most widely used surgical approach
has been an abdominal one, via the retropubic space, although the same structures can also be approached vaginally.
The procedure is similar to that employed in a Burch
colposuspension. After exposure of the lateral vagina by
medial dissection of the bladder base, between four and six
permanent sutures are placed through the vagina along its
length, and then via the arcus tendineus fascia pelvis rather
than the ilio-pectineal ligament, in order to restore lateral
vaginal support.
Vaginal paravaginal repair
Initially described by White in 1909,4 this operation can
be performed through a midline vaginal incision or through
bilateral vaginal incisions. The bladder is dissected medially
69
from the vagina and the pelvic side-walls, exposing the
ischial spines. Permanent sutures are placed from the
iliococcygeus fascia anterior to the ischial spine and then
through the vagina (leaving the epithelium intact), suspending the vagina bilaterally using the same technique as for
sacrospinous fixation. Further sutures are then placed
through the arcus tendineus fascia and through the lateral
vaginal wall to reattach the vagina on both sides to the white
line. Any central defects can be repaired by an anterior
colporrhaphy: the lateral wall sutures are only tied to elevate
the anterior wall after the vaginal mucosa has been closed.
A modification of the technique described by Scotti
et al.26 is the use of ischial periosteum anterior to the ischial
spine or the obturator membrane as an anchoring tissue
rather than the arcus tendineus fascia. In a prospective study
of 40 patients, 75% of whom also had urodynamic stress
incontinence, only one patient had a recurrent paravaginal
defect during the follow up period (mean 39 months, range
7 – 52 months). However, a high proportion of patients had
other procedures performed concomitantly, which ranged
from abdominal sacrocolpopexy to suburethral sling procedures, so the results are difficult to interpret.
RESULTS OF PARAVAGINAL REPAIR
(ABDOMINAL AND VAGINAL)
Shull et al.15 reported on 62 women with bilateral paravaginal defects, leading to severe cystocoele (87% beyond
hymen) operated on vaginally and followed up for a mean
of 1.6 years; 69% had had previous pelvic surgery, including anterior or posterior repair in 34 patients. As well as
bilateral paravaginal repairs, additional procedures were
carried out in a proportion of patients, with 73% having a
form of culdoplasty and all patients also having a perineorraphy and posterior repair. Thirty-three per cent developed
recurrent anterior vault prolapse, none of which was as severe as the preoperative state and none of which had required further surgery, although the follow up data and its
method of assessment was unclear.
Benson et al.27 carried out a randomised study of
patients with primarily uterine or vault prolapse associated
with relaxation of the anterior vaginal wall, up to or
beyond the hymen, with a paravaginal defect present.
Women with central cystocoeles were excluded. Eightyeight women were operated on after careful assessment,
including subtracted dual channel cystometry and 48
women were randomised to a vaginal approach which
included bilateral sacrospinous fixation and vaginal paravaginal repair, using permanent monofilament sutures. In
addition, however, vaginal hysterectomy, Pereya urethropexy or sling, McCall culdoplasty or anterior colporrhaphy
were also undertaken at the surgeon’s discretion. The other
40 women underwent an abdominal surgical approach,
with the main part of the procedure being sacrocolpopexy
and abdominal paravaginal repair, also with permanent
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70
M. SLACK
monofilament sutures. In addition, in this arm of the study
patients underwent abdominal hysterectomy, Burch or
sling procedures, culdoplasty or a Macer abdominal anterior wedge repair as well. Of the abdominal group 30%
required a vaginal anterior colporrhaphy, and in 50% of the
abdominal group and 67% of the vaginal group, posterior
repairs were also performed. Patients were followed up at
6 months and annually for 5 years by an independent coauthor (not the surgeon). Patients operated on vaginally had
significantly shorter operating times and operative costs,
but longer duration of catheter use (greater than 5 days
in 75% compared with 48% of the abdominal group) and
twice the rate of postoperative urinary incontinence. Mean
time to recurrence of prolapse was 11.2 months (F11.5)
in the vaginal group and 22.2 (F16.2) in the abdominal
group, which was significant. Re-operation for cystocoele
was required in 29% of the vaginal group and only 10.5%
of the abdominal group. Despite the confounding differences in the other surgical procedures performed, this
study does indicate some possible advantages for the abdominal route, especially in terms of the longevity of the
repair.
Monga28 described the results of paravaginal repair for
cystourethrocoele as ‘cure’ in between 76% and 97% of
patients; however, he noted that the patient groups were
often mixed, and definitions of ‘cure’ varied.
ABDOMINOPERINEAL PROCEDURES:
FOUR CORNER REPAIR
An abdominoperineal procedure was suggested by Raz in
1989 for the correction of anterior vaginal wall laxity. The
initial description was for a group of patients with grade II
to III cystocele.29 A significant number of these patients had
coexistent stress incontinence. The procedure is based on
the same principles as the Raz long needle colpsuspension.
In addition to two paraurethral sutures another two sutures
are placed more proximally and through the entire vaginal
wall. The four sets of sutures are transferred to the abdomen
with a double pronged needle through a suprapubic incision.
The degree of elevation of the bladder neck is estimated
cystoscopically, then the prolene sutures are tied abdominally across the rectus sheath.
Both in this series and in a second series30 on patients
with grade IV cystocoele a cure rate of greater than 90% was
reported (for cystocoele). A more modest success rate was
achieved for the cure of urodynamic stress incontinence.
Using the same technique in a smaller series, Miyazaki
and Miyazaki had excellent results at 6 weeks but this had
dropped to 59% by 4 years.31
Kohli32 retrospectively compared two groups of patients,
27 undergoing anterior colporrhaphy alone and 40 who
underwent four corner repair for anterior wall prolapse and
concomitant genuine stress incontinence. The patients were
a mixed group with 28 of the 67 patients having had
previous pelvic floor surgery, including seven who had
had previous bladder neck surgery. The authors aimed to
assess the degree of anterior wall descent in the two groups
postoperatively. After mean follow up in both groups of
13 months (range 4– 38 months), 7% of the anterior repair
group had a recurrent cystocoele compared with 33% of
the four corner repair group. This was a statistically significant difference and indicated that the needle suspension did not add further support to the anterior repair.
It does not appear that this procedure has any real
advantages over anterior colporrhaphy.
SYNTHETIC PROSTHESES
Dissatisfaction with the outcome of operations for the
management of anterior wall prolapse have encouraged
surgeons to experiment with a variety of natural and
synthetic grafts. A report on the use of Tantalum mesh
was published in 1955.33 Ten patients had Tantalum mesh
grafts inserted for the repair of large symptomatic cystoceles. Follow-up was very short (6–18 months) and was
completed on nine of the patients. Five had a complete
resolution of the symptoms but in four the mesh was exposed
and required trimming.
Friedman in 1970 reported on the use of a collagen mesh
prosthesis in the management of four patients with a variety
of pelvic floor defects.34 In one patient with a uterine and
anterior wall prolapse the mesh was placed below the
epithelium of the anterior wall. No objective or long-term
(greater than 10 years) results are available. Rosing described fibrin sealant placed in the Cave of Retzius.35 In a
group of nine patients with anterior wall defects and a high
body mass index he successfully corrected the prolapse. No
details of type or length of follow up are available. A
descriptive paper on the use of a free full-thickness epithelial graft for the correction of prolapse was made by
Zacharin.36 Again no results are available. More recently
Julian used Marlex mesh in a randomised prospective
study.37 Twenty-four patients were randomised into control
and treatment groups. All patients underwent an anterior
colporrhaphy, paravaginal repair and urethral suspension.
In the treatment group a Marlex polypropylene mesh was
placed under the anterior vaginal wall before closure. There
were only four failures which all occurred in the control
group. Three patients suffered vaginal erosions but these
were successfully treated conservatively. Data on the use of
synthetic prostheses are limited but following the success
of the tension-free vaginal tape for the treatment of urinary
incontinence there will no doubt be renewed interest.38
Polypropylene is probably one of the ideal biocompatible
materials. It is strong and both chemically and physically
inert. It is not carcinogenic and is easy to produce. It is
possible that the characteristics of the weave impart specific properties to the mesh and thus not all forms of
polypropylene are identical. The behaviour of different
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MANAGEMENT OF PROLAPSE OF THE ANTERIOR COMPARTMENT
forms of mesh in the suburethral position may be due as
much to tissue reactivity as to operative technique.
Experience with the complications of artificial slings in
the suburethral position (e.g. erosion) should act as a warning to surgeons planning to use mesh for cystocele repair.
Although the use of mesh is very tempting, widespread
introduction should be preceded by careful clinical trials.
COMPLICATIONS OF ANTERIOR
WALL SURGERY
Direct complications with these procedures remain rare.
An injury rate of 0.5% –2.0% of cases has been reported.39
Obviously damage to the bladder and urethra at the time of
operation has been described. These are easily corrected
surgically and apart from the need for continuous urinary
drainage for 10 days are unlikely to have any long-term
consequences. The use of nonabsorbable suture material is
uncommon, which should minimise complications secondary to suture placement into the lumen of the bladder.
Recurrent urinary tract infections secondary to penetration
of the bladder wall with chromic suture material have been
reported. Diagnosis with the help of ultrasound or at the
time of cystoscopy is easily achieved. Removal at the time
of cystoscopy should be straightforward.40
In an assessment of urinary function after colporrhaphy
Stanton et al.41 demonstrated a reduction in the symptoms
of urge, stress and a resolution of the presenting symptoms.
These patients had no alteration in flow rate, maximum
voiding pressure or residual urine and no increase in
detrusor instability. However, in an earlier report from
a tertiary practice, Delaere et al.42 reviewed a series of
85 women referred after having developed complications
as a result of anterior vaginal repair. Iatrogenic or persistent urinary stress incontinence occurred in 72%. In addition 40% had bladder outlet obstruction and 25% had
detrusor instability. Of this entire group 23% were troubled by recurrent urinary tract infections.
One can assume that the paravaginal repairs will mirror
the complications of their abdominal and vaginal counterparts. On purely theoretical grounds the abdominal approach could cause denervation injury to the bladder,
which might produce detrusor overactivity.
It would seem that because of a paucity of information
about the true complication rates and reluctance on the part
of the patients to complain we might be underestimating
the size of the problem. There is a need for national
registers to report complications in the same way as the
‘Yellow card’ system for drug therapy.
The anatomical alterations that lead to vaginal prolapse
are starting to be better understood and applied by surgeons.
A number of different operations have been described in
the past to repair the anterior vaginal wall, the most
common of which is still the anterior colporrhaphy. As
a result of the anatomical studies described above, the role
71
of the paravaginal repair has increased in prominence in the
last 15 years. It is not established whether anterior wall
defects occur alone or possibly always in combination with
a level I defect. If this is the case the standard approach
may be to combine the operation with a vault supporting
procedure. Unfortunately, the patient groups that are included in most of the available reports are so diverse in
terms of previous surgery, the presence or absence of
incontinence and the number of repair procedures performed concurrently, that any comparison of different
surgical approaches is impossible. There is a need for a
properly randomised study of anterior repair alone vs anterior repair with paravaginal repair and paravaginal repair alone. All the new techniques using mesh will also
need a similar level of scrutiny. Hopefully grant-awarding
bodies such as the Medical Research Council will show
renewed interest in clinical studies that address surgical
issues such as the management of the anterior wall. Proper
funding will allow us to find better ways to manage this
condition.
References
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