16.2: Surgical Options for Anterior Compartment Prolapse

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Vaginal Approach

Anterior Vaginal Repair (Anterior Colporrhaphy)

An incision is made in the vaginal epithelium below the urethral meatus to the cervix or vaginal vault. A diamond-shaped incision is sometimes made. The cystocele is dissected off the overlying vaginal skin using scissors and blunt dissection. The underlying pubocervical fascia is then reduced using vicryl 3/0 sutures, known as fascial plication. Many surgeons place an additional plication layer of support using a delayed absorbable suture such as PDS in the levator connective tissue medial to the iscniopubic rami. Skin edges are trimmed and closed using polyglycolic sutures (Vicryl, Ethicon).

Mid-urethral tapes such as the TVT or TOT should be placed through a separate incision to prevent the tape from migrating up towards the bladder neck.

Vaginal Paravaginal Repair

Some surgeons perform an extensive dissection stretching from the pubis anteriorly to the ischial spine posteriorly. Up to four sutures are placed along the white line. This is the vaginal paravaginal repair.

Abdominal Approach

Abdominal Paravaginal Repair

This is the abdominal approach to anterior compartment prolapse. It is employed when another intra-abdominal procedure eg. sacrocolpopexy or hysterectomy is being performed. Through a Pfannenstiel incision, the retropubic space is opened and the bladder swept medially, exposing the pelvic sidewall, very similar to a burch colposuspension procedure. Two fingers are placed in the vagina and it is elevated digitally. The pubocervical fascia is reattached to the pelvic sidewall using interrupted polydioxanone (PDS, Ethicon) sutures from the pubis to just anterior to the ischial spine.