Vaginal or pelvic prolapse is a common problem in the United States including approximately 3 million women with Grade III or IV prolapse. The grading system is shown in
Vaginal prolapse risk increases with age, parity, obesity, previous hysterectomy and vaginal delivery. Symptoms of anterior prolapse (cystocele), uterine prolapse and enterocele consist of discomfort in the vaginal area which increases with standing for long periods (usually a dropping sensation), difficulty emptying or urinary retention, recurrent infections, vaginal skin erosion and low back pain. Ureteral obstruction is rare but is reported. Rectocele often presents with fecal trapping or the need for digital splinting with defecation. Patients may complain of constipation although they only improve about 50% of the time with repair. Women with either anterior or posterior prolapse may complain of dyspareunia as well. Repair of pelvic prolapse is indicated in the instances of urinary retention and ureteral obstruction but most often the decision for repair is based on patient's symptoms and their interference with activities of Vaginal Prolapse The New Frontier By: Joseph W. Babiarz, M.D. daily living and for relief of discomfort.
Repair of Cystoceles:
Physiologic support of the bladder relies on the pubocervical fascia, a condensation of bladder and vaginal tissue lying between the bladder and vaginal skin. The pubocervical fascia slings from one pelvic sidewall to the other and also attaches anteriorly to the pubis under the urethra and posteriorly to the cervix much like a trampoline under the bladder. Two separate defects result in cystoceles. Centrally the fascia may weaken and the bladder "drops through" creating what is called a "central defect". Secondly, the attachments to the pelvic sidewall may tear free allowing the whole trampoline to collapse and slide down into the vagina creating what is called a "lateral defect". In most instances both occur. Traditional repair such as an anterior colporrhaphy repair only the central defect and use previously weakened tissues. This would likely account for its poor long term success. More recent improvements such as a paravaginal repair, which consist of reattaching the pubocervical fascia to the pelvic sidewall, rely on previously attenuated tissue as well. While this is an improvement it is somewhat cumbersome and has a significant failure rate.
Three years ago Leach presented data showing improvement in success with graft augmentation of grade 3 and 4 cystocele repairs. (Kobach KC, Leach GE, Govier FE, J Urol 2002 Nov, 168(5):2063-8.) One year ago Sirls presented data reaffirming the result with greater than 90% success. (Sirls, L: NCSAUA presentation 11/2004.) For the last 18 months we have been performing graft augmented cystocele repairs. The initial vaginal dissection to free up the bladder is similar to traditional techniques but is carried aggressively laterally and posteriorly. Concomitant enterocele repair with vaginal hysterectomy can be performed. The space outside the bladder but behind the pubis is then entered and the site of previous attachment of the pubocervical fascia of the pelvic sidewall is exposed. Dissolvable long lasting sutures (3 per side) are placed into the pelvic sidewall at the previous site of attachment of the pubocervical fascia and a segment of biological graft (rectus fascia or dermis) or artificial graft (soft wide purl polypropylene) is fashioned to fit from pelvic sidewall to pelvic sidewall and from bladder base to bladder neck. The sutures on each side are brought through the graft and tied such that a new trampoline is installed under the bladder in a tension free manner. The vagina is then closed over the graft. Simultaneous correction of stress incontinence can be done using a mid urethral synthetic or biologic sling if stress incontinence were noted preoperatively by history or physical exam or urodynamics.
Building on the success of graft augmented repairs; American Medical Systems has designed a system that allows suspended graft augmentation of the bladder without the need to place individual sutures into the pelvic sidewall The initial dissection is as described above. The Perigee graft which is placed below the bladder is shown in Figure 1a. Percutaneous "needles" are passed from outside the skin to the retropubic space where they capture the mesh support straps and pull them back out through the obturator foramen at two different sites on each side Figure 1b. Position A is the distal support at the level of the bladder neck while position B is the proximal support at the level of the bladder base. Tissue ingrowth and friction fixes these straps in place. The vagina is closed over this as the straps are pulled tight to create a tension free "trampoline" under the bladder Figure 1c. Again simultaneous stress urinary incontinence repair can be done.
With either repair hospital stay is usually 1 day, even with vaginal hysterectomy. Complications are rare but include infection, graft erosion, dyspareunia, change in voiding pattern, injury of adjacent structures and fistulae. In both instances long term success exceeds 90% and patients should return to normal activity in 3 weeks. In general, normal vaginal axis, depth and function are restored, which is important to sexually active patients.
Repair of Vault Prolapse/Rectocele:
Prolapse of the vaginal vault causes significant discomfort especially in extreme cases and especially for woman who desire to be sexually active. Rectoceles, while generally less symptomatic, often cause symptoms necessitating repair. Goals of repair of both vault prolapse and rectocele include cessation of symptoms, prevention of recurrent prolapse and restoration of normal horizontal vaginal anatomy (axis, depth, and caliber) and function, especially for younger, sexually active women.
Posterior vaginal support is provided by the rectovaginal septum, a fusion of posterior vaginal fascia and prerectal fascia which extend from the perineal body to the cervix. Attenuation leads to rectocele. Vaginal vault support is provided primarily by the cardinal ligaments which originate from the posterior lateral pelvic wall and the sacral ligaments
Historical rectocele repair includes site-specific repair where the rectovaginal septum is dissected out and reattached to the perineal body, and posterior colporrhaphy, where the pararectal fascia or levators are sewn together in the midline. Both have a high failure rate (30-50%) and fusion of the levators in the midline can cause significant vaginal narrowing and dyspareunia. Historical repairs for vaginal vault prolapse include sacrospinous fixation, ileococcygeal suspension and abdominal sacrocolpopexy. Sacrospinous fixation is a vaginal procedure accomplished by suturing the vaginal vault to the sacrospinous ligament which is located more posterior than the normal vaginal axis. This results in an abnormally posterior dislocated vaginal axis and is technically difficult, risks injury to the pudendal neurovascular complex and has a high rate of cystocele. Ileococcygeal suspension is a vaginal procedure accomplished by suturing the vaginal vault to the levator muscles (pelvic diaphragm). While it creates a normal horizontal axis, it can be technically difficult and has a significant failure rate. Sacral colpopexy is an abdominal procedure using mesh graft to attach the vagina anterior and posterior to the sacrum. While it enjoys a high rate of success, it is a major abdominal procedure requiring increased recovery time and with increased rates of complications.
Similar to cystocele, graft augmentation of rectocele repair has been described. However, because of the lack of well defined lateral points of attachment we have not adopted this. More recently the Apogee device has been introduced which accomplishes both fixation of the vaginal vault along the horizontal vaginal axis and repair of a rectocele with graft augmentation. The procedure begins with a standard posterior dissection where the posterior vaginal wall is dissected off of the underlying rectocele. If enterocele is present it is repaired. Long "needles" are passed posterior lateral to the rectum in the pararectal space to enter the pelvis near the ischial spine. The mesh straps of the Apogee device shown in Figure 2 are attached to the needles on each side and the straps are brought from the pelvis into the paravaginal space where tissue ingrowth and friction hold them in place. The proximal edge of the fascia is fixed to the vaginal vault apex. As the straps are pulled taunt, the vaginal apex is pulled deep into the pelvis along its normal horizontal axis. The distal portion of the mesh is fixed to the perineal body repairing the rectocele. Vaginal wall is closed over this. The result is a deep horizontal functional vagina. Risks are similar to the Perigee procedure as is the recovery.
Vaginal prolapse is an uncomfortable and debilitating problem. Recent advances using graft to augment a repair offer long term results with rapid recovery and functional results. Patients will be spared the second cystocele, rectocele or vault prolapse repair which was often required later in life. As one recent patient stated "I feel like a new woman".