Atlas of Vaginal Reconstructive Surgery, 1st ed.

3. Surgical Repair of Anterior Vaginal Wall Prolapse

Shlomo Raz¹

(1)

Division of Pelvic Medicine and Reconstructive Surgery, UCLA School of Medicine, Los Angeles, CA, USA

Electronic supplementary material

The online version of this chapter (doi:10.1007/978-1-4939-2941-2_3) contains supplementary material, which is available to authorized users.

Keywords

CystoceleRectoceleHysterectomyEnterocele

3.1 Cystourethrocele

3.1.1 Indications

Anterior vaginal wall defects, or cystoceles, are very common. Approximately 50 % of women seeking routine gynecologic or urologic care have some degree of anterior prolapse. Most of these defects are asymptomatic, but as the leading edge of the prolapse extends beyond the hymen, the defect may become symptomatic. The cystocele may present itself as a vaginal bulge, or it may present with urinary symptoms of urgency, frequency, stress or urge incontinence, or even obstructive voiding symptoms. Risk factors for primary or secondary prolapse are age, menopausal status, parity, collagen defects, prior hysterectomy, increased body mass index, smoking, and chronic pulmonary disease.

3.1.2 Diagnosis

Many women with pelvic organ prolapse present with lower urinary tract symptoms that include stress incontinence with urethral hypermobility or incompetence, but some women are continent owing to a kinking or obstruction of the urethra. This symptom can be noted when a woman has to reduce her prolapse to void. This subset of women with an anatomic urethral obstruction may have symptoms of hesitancy, dribbling, poor stream, a sense of incomplete emptying, or urinary frequency with overflow incontinence. Additionally, a subset of patients with vaginal prolapse may experience urge incontinence that has developed de novo or from the obstruction of prolapse.

Evaluation should include a full medical and surgical history; a review of urinary, bowel, and sexual function symptoms; a voiding diary; urinalysis; and a post-void residual. On physical examination, the vaginal wall should be assessed for thickness, erosion, and friability. Each component of the vaginal vault—the anterior, posterior, apical, or superior areas—should be evaluated for the degree of prolapse, with evaluation for cervical-uterine prolapse, urethral hypermobility, and overt or occult incontinence. Transvaginal cystocele repair is rarely performed as a solitary surgery, as most patients require repair of other compartments or urethral supporting procedures (slings or suspensions).

The patient generally senses a bulging mass through the introitus, with or without stress urinary incontinence. On physical examination with a full bladder, the bladder base is seen bulging through the introitus at rest (Fig. 3.1). An increase in the protrusion can be detected when the patient coughs or strains. The degree of urethral hypermobility or any simultaneous rectocele, enterocele, or uterine prolapse should be properly diagnosed.

Fig. 3.1

Physical examination of a patient with significant cystocele coming outside the introitus. The patient has significant urethral mobility, enterocele, and rectocele that will be corrected at the time of the cystocele repair

Cystoscopy may show hypermobility and funneling of the bladder neck and marked descent of the bladder base and trigone. The use of light during cystoscopic examination can be helpful in defining a cystocele defect, as sometimes they can be difficult to differentiate from an enterocele.

Radiological studies including a voiding cystourethrogram or video-urodynamics (VCUG) will show the bladder base to be descended well beyond the inferior rami of the symphysis. The bladder neck may be funneled, and stress-induced urinary incontinence may be present. During straining, the cystocele is further enlarged (Fig. 3.2). Commonly, patients void normally with low residuals, but some (particularly those with prior surgery) may show an obstructive pattern and an increase in post-void urinary residual. CT urogram or kidney ultrasound is indicated to rule out partial ureteral obstruction or hydronephrosis. MRI provides in a quick and noninvasive way to assess the degree of cystocele, diagnose rectocele or enterocele, and rule out hydronephrosis or any other pelvic pathology (Figs. 3.3, 3.4, and 3.5).

Fig. 3.2

Standing lateral cystogram of a patient with severe cystocele. The bladder base slides well below the inferior rami of the symphysis during straining. The inter-ureteric ridge is seen at the trigonal area

Fig. 3.3

Dynamic MRI showing the bladder descending below the inferior rami of the pubic bone. The urethra is also mobile and outside the vaginal canal

Fig. 3.4

Sagittal MRI showing significant dilatation of the ureter in a patient with severe cystocele and urinary retention

Fig. 3.5

During cystoscopy, transillumination of the bladder helps to outline the entire bladder wall in a patient with a severe vaginal bulge due to cystocele. This maneuver helps to define and diagnose an enterocele as a source of a large anterior and vault prolapse

3.1.3 Surgical Repair Techniques

This chapter describes five techniques of cystocele repair:

1.

2.

3.

4.

5.

The five techniques have many steps in common, and the differences are described in more detail.

We have abandoned the use of mesh for the repair of cystoceles or any other prolapse, relying instead on delayed absorbable sutures (polydioxanone [PDS]) and monofilament polypropylene sutures.

3.1.3.1 Repair of the Central Defect Only

Figures 3.6, 3.7, 3.8, 3.9, 3.10, 3.11, 3.12, 3.13, 3.14, 3.15, and 3.16 illustrate the surgical repair of a central defect alone.

Fig. 3.6

Anterior vaginal wall exposure in a patient with significant central defect cystocele after prior lateral defect repairs

Fig. 3.7

Diagram showing the anterior vaginal wall and the extent of the incision that will be done from the bladder neck to the bladder base

Fig. 3.8

Intraoperative photograph of the incision of the anterior vaginal wall. Usually a coagulation knife is used; we have not found it necessary to inject vasoconstrictors or do hydrodissection of the anterior vaginal wall

Fig. 3.9

Diagram of the anterior vaginal wall after dissection of the two lateral flaps. The periurethral fascia is seen superiorly and the cardinal–sacrouterine complex is seen inferiorly. The vesicopelvic fascia laterally support the bladder to the arcus tendineus fascia pelvis

Fig. 3.10

Intraoperative photograph of the exposure of the anterior vaginal wall after the lateral dissection. Good hemostasis should be obtained. The dissection is carried out over the perivesical fascia, taking care to avoid bladder perforation

Fig. 3.11

The bladder is retracted to expose the vaginal cuff and the bladder base. The area of the cardinal–sacrouterine complex at the cuff is approximated to the midline using figure-of-eight delayed absorbable sutures

Fig. 3.12

Diagram showing the approximation of the perivesical fascia to the midline using horizontally placed figure-of-eight sutures

Fig. 3.13

Diagram showing the appearance of the anterior bladder wall after tying the central sutures

Fig. 3.14

Operative photograph showing the view of the anterior vaginal wall after the central sutures have been tied

Fig. 3.15

The excess of the anterior vaginal wall is excised using scissors or a coagulation knife

Fig. 3.16

The anterior vaginal wall is closed using delayed absorbable sutures. The sutures include the perivesical fascia in order to prevent any dead space or hematoma formation

3.1.3.2 CRISP Procedure: Cystocele Repair Using Interlocking Sutures of Polypropylene

In this technique (Figs. 3.17, 3.18, 3.19, 3.20, 3.21, 3.22, 3.23, 3.24, 3.25, 3.26, 3.27, 3.28, 3.29, and 3.30), the lateral defect is repaired by applying interrupted monofilament sutures to the lateral arcus tendineus fascia pelvis to incorporate the lateral margin of the bladder wall (vesicopelvic fascia). The central defect is repaired by using mattress monofilament sutures from the bladder neck to the bladder base. The central defect sutures are tied after interlocking each of them with the laterally placed sutures. The final result is a net of monofilament sutures supporting the lateral and central defects.

Fig. 3.17

Diagram showing the principles of the CRISP surgical procedure. The lateral sutures (black–blue) are applied to the vesicopelvic fascia and the arcus tendineus fascia pelvis and the central sutures (red) to the perivesical fascia

Fig. 3.18

Exposure of the anterior vaginal wall in a patient with lateral and central defect cystocele. The apex and the posterior vaginal wall also will be repaired

Fig. 3.19

A vertical incision is made in the anterior vaginal wall from the bladder neck to the bladder base

Fig. 3.20

The bladder is retracted, and exposure of the lateral anterior bladder wall exposes the attachment of the bladder to the arcus tendineus

Fig. 3.21

A #3-0 figure-of-eight monofilament nonabsorbable suture incorporates the arcus tendineus, levator, and the vesicopelvic fascia laterally. Four sutures will be applied: two at the bladder base and two at the bladder neck. White arrow indicates the tip of the needle as the suture is applied

Fig. 3.22

Retracting the bladder exposes the left side insertion of the bladder to the lateral pelvic wall (arcus tendineus)

Fig. 3.23

Two figure-of-eight sutures are applied to the bladder base and bladder neck, incorporating the arcus tendineus area and levator musculatures. The arrow indicated the margin of the arcus tendinous fascia pelvis

Fig. 3.24

The four lateral sutures and the central defect are seen. The arrows point to are of placement of the four lateral sutures

Fig. 3.25

The bladder is retracted posteriorly to expose the perivesical fascia, where the central defect sutures will be applied. The arrows point toward the dissected vaginal wall after the bladder is retracted

Fig. 3.26

Sequentially the perivesical fascia is approximated with horizontal mattress sutures from the bladder neck to the bladder base

Fig. 3.27

Exposure of the central and lateral suture placement with reduction of the cystocele defect

Fig. 3.28

The central sutures are tied. Prior to tying, each suture is transferred and interlocked with the lateral suture at the same level, providing a net of support to the anterior bladder wall

Fig. 3.29

The lateral sutures are tied after including one of the central sutures, completing the interlocked net of sutures

Fig. 3.30

The vaginal wall is excised in an asymmetric fashion. Most of the lateral vaginal flap is excised, and the right flap will cover the area of reconstruction, preventing protrusion of nonabsorbable sutures in the midline incision

3.1.3.3 Four-Corner Bladder and Bladder Neck Suspension for Lateral Defect Cystocele

This operation is indicated for patients with a moderate cystocele with a mainly lateral defect. The advantage of the operation is that the bladder and bladder neck are supported to the superior rami of the pubic bone, using nonabsorbable sutures. Four #0 monofilament polypropylene sutures are used to incorporate the urethropelvic and periurethral fascia at the bladder neck and the vesicopelvic and perivesical fascia at the bladder base. The sutures will provide lateral support to the anterior vaginal wall, including the urethra, bladder, and bladder base. The sutures are transferred and tied in the suprapubic area. Figures 3.31, 3.32, 3.33, 3.34, 3.35, 3.36, 3.37, 3.38, 3.39, 3.40, 3.41, 3.42, 3.43, 3.44, 3.45, and 3.46 illustrate this technique.

Fig. 3.31

Exposure of the anterior vaginal wall in a young patient with a lateral defect and mainly anterior vaginal wall prolapse. The uterus is mobile to the mid-vagina. Because of the young age of the patient, no hysterectomy is contemplated

Fig. 3.32

Dissection is carried out around the periurethral fascia toward the inferior rami of the pubic bone. A pair of curved scissors is inserted as far lateral as possible, parallel to the urethra in a superior direction, just behind the posterior aspect of the pubic bone

Fig. 3.33

A finger in the retropubic space allows the exposure of the detached urethropelvic and vesicopelvic fascia from the arcus tendineus fascia pelvis

Fig. 3.34

Diagram showing the application of four #0 nonabsorbable monofilament sutures. At the bladder base, the sutures incorporate the vesicopelvic fascia in the retropubic space and with a wide passage of the needle under the vaginal wall to incorporate the perivesical fascia medial to the incision and at the bladder base. At the level of the bladder neck, the sutures incorporate the urethropelvic fascia in the retropubic space, the perivesical fascia at the level of the bladder neck, and the periurethral fascia at the level of the proximal and midurethra

Fig. 3.35

A long forceps is used to retract medially the vaginal wall, exposing the vesicopelvic fascia detached from the arcus tendineus fascia pelvis

Fig. 3.36

At the bladder base, #0 monofilament nonabsorbable suture is used to incorporate the detached vesicopelvic fascia from the arcus tendineus

Fig. 3.37

A wide segment of the perivesical fascia is incorporated at the bladder base. Multiple passes of the needle incorporate again the vesicopelvic and perivesical fascia

Fig. 3.38

A forceps in the retropubic space exposes the detached urethropelvic fascia at the level of the bladder neck

Fig. 3.39

At the level of the bladder neck, a #0 monofilament suture incorporates the urethropelvic fascia

Fig. 3.40

The perivesical fascia at the bladder neck and the midurethral periurethral fascia are incorporated with the suture

Fig. 3.41

The same maneuver is done in the contralateral side. An oblique incision is made in the left periurethral and perivesical area, and the retropubic space is entered with scissors, detaching the urethropelvic and vesicopelvic fascia from the arcus tendineus

Fig. 3.42

The four sutures have been applied: two at the bladder base and two at the bladder neck and urethra. Pulling the sutures should confirm a strong anchor of tissue, to the point that the patient can be moved over the table

Fig. 3.43

(a) A small puncture is performed in the suprapubic area. (b) Under finger control in the retropubic space, a double-pronged passer is transferred from the suprapubic to the vaginal area. (c) The double passer is brought outside the vaginal incision, and the sutures will be transferred through the needle holes

Fig. 3.44

The four sutures have been transferred to the suprapubic puncture area

Fig. 3.45

After closure of the anterior vaginal wall with interrupted #2-0 delayed absorbable sutures, a posterior repair and uterine suspension procedure have been performed

Fig. 3.46

Cystoscopy is performed after injection of indigo carmine. Keeping the cystoscope in a 45-degree angulation, the sutures in the suprapubic area are tied sequentially without tension. A vaginal packing soaked in antibiotics is inserted

3.1.3.4 Combination of Central and Lateral Defect Repair

Central and lateral defect cystocele correction using a combination of four-corner suspension and central defect repair is shown in Figs. 3.47, 3.48, 3.49, 3.50, 3.51, 3.52, 3.53, 3.54, 3.55, 3.56, and 3.57.

Fig. 3.47

In a patient with significant cystocele, a strip of the anterior vaginal wall has been excised to expose the perivesical fascia from the bladder neck to the bladder base

Fig. 3.48

The central defect is repaired by sequentially applying delayed absorbable sutures (PDS) to the perivesical fascia

Fig. 3.49

The centrally placed sutures are tied to approximate the perivesical fascia to the midline

Fig. 3.50

The excess of the vaginal wall is excised and the anterior vaginal wall is closed with interrupted #2-0 delayed absorbable sutures. The green dotted line depicts the line of excision of the excess of vaginal wall

Fig. 3.51

The anterior vaginal wall is closed and two oblique incisions are made laterally from the midurethral area to the bladder base

Fig. 3.52

Curved Mayo scissors are applied under the inferior pubic bone and parallel to the urethra, pointing the tip superiorly. White arrows indicate the lateral vaginal wall incision in the right side

Fig. 3.53

The retropubic space is entered, detaching the urethra and vesicopelvic fascia from the arcus tendineus

Fig. 3.54

In a similar fashion as described above, #0 monofilament nonabsorbable sutures are applied to the bladder base, the bladder neck, and periurethral area. Each pass includes the detached vesicopelvic and perivesical fascia at the bladder base and the urethropelvic fascia and periurethral fascia at the bladder neck and midurethral area. The placement of these sutures is similar to the four-corner bladder and bladder neck suspension (see Fig. 3.42)

Fig. 3.55

The four sutures are transferred from the vagina to the suprapubic area using a double-pronged passer

Fig. 3.56

The anterior vaginal wall is closed with interrupted #2-0 delayed absorbable sutures. A posterior repair has been performed

Fig. 3.57

Cystoscopy is performed after intravenous injection of indigo carmine. The suprapubic nonabsorbable sutures are tied sequentially, keeping the cystoscope in a 45-degree angulation in order to prevent unnecessary bladder and urethral overcorrection. A vaginal packing soaked with antibiotics will be inserted in the vagina. The suprapubic puncture is closed with a #4-0 delayed absorbable suture

3.1.4 Postoperative Care

The vaginal packing and urethral catheter are removed 24 h after surgery. The urethral catheter is removed by the patient 2–7 days after surgery, depending on the extent of the procedure. The patient is allowed to walk, drive, climb stairs, shower, or take baths but is prohibited from heavy lifting or straining. Antibiotics, pain medication, and stool softeners are prescribed.

3.1.5 Intraoperative Complications

As in other vaginal procedures, the potential complications during surgery include bleeding, urethral or bladder perforation, and ureteral obstruction due to misplaced sutures. In these procedures, special attention should be given to the ureters because of their close proximity. The bladder and trigone should be retracted at the time of placement of midline sutures over the perivesical fascia. Cystoscopy should confirm the patency of both ureteric orifices; if in doubt, a stent should be inserted. If ureteric obstruction is found, the suspension or perivesical fascia sutures should be removed and replaced.

Bladder injury at the time of dissection should be repaired primarily using multiple layers of delayed absorbable sutures and prolonged bladder drainage. With an anterior bladder injury, a Penrose drain may be inserted in the retropubic space, using a percutaneous technique.

3.1.6 Postoperative Complications

Postoperative complications are similar to those with other vaginal reconstructive procedures. Prolonged urinary retention is rare and is managed by reinsertion of the indwelling catheter for a longer period. If the problem persists after 2 weeks, the patient is started on a program of self-intermittent catheterization until adequate bladder emptying resumes.

De novo or recurrent stress incontinence may develop as a result of inadequate support of the bladder neck and urethra. Stress incontinence also may result from an open, incompetent, nonfunctional proximal sphincteric area (intrinsic sphincter dysfunction). In this situation, the urethra is generally well supported. A fascial sling (with a donor site from the fascia lata or abdominal wall) should be used in this situations.

Recurrent prolapse of the bladder is rare and may result from inappropriate positioning of the sutures or from poor quality of tissues, especially when severe atrophic vaginitis is present. Another repair will be necessary using PDS sutures, biological graft, and very rarely abdominal wall fascia.

Concomitant surgical procedures such as hysterectomy or repair of an enterocele or rectocele are required in more than 75 % of patients with grade IV cystocele. Repair of the cystocele without repair of the other abnormalities may lead to their further aggravation, requiring another surgery. Secondary enterocele or rectocele (not present prior to surgery) may occur, as the transfer of the anterior vaginal wall to a high, supported position may facilitate the herniation of a weakened cul-de-sac and posterior vaginal wall.

Vaginal shortening may occur if excess vaginal wall is removed. If the concept of this surgery as a bladder suspension is kept in mind, very little vaginal tissue is excised, and this complication can be avoided.

Pain in the suprapubic area is rare and may result from nerve entrapment, tight knots, or a low-grade infection. Transfer of sutures in the midline will prevent damage to the ilioinguinal nerves.

Because these surgical procedures do not use mesh, complications with the use of synthetic materials such as chronic draining sinus, granulating tissue, infection of the mesh, urethral or bladder penetration by the synthetic material, and vaginal pain are obviated.

In spite of cystoscopic patency of ureters at the time of surgery, ureteric obstruction during surgery can result from kinking or obstruction of the ureters by the sutures. Undoing the surgical steps, suture removal, and release of any folds of the perivesical tissues should restore ureteric patency. If a complex surgical procedure has been performed and the cystoscopy shows ureteric obstruction with inability to pass a stent or guidewire, a ureteric reimplantation may be indicated. After complex reconstruction we prefer not to explore the area of ureteric obstruction transvaginally in order to avoid undue damage to an otherwise good anatomical repair. Discovery of ureteric obstruction after surgery requires full evaluation and possible percutaneous nephrostomy or later ureteric reimplantation.

3.1.7 Fascia Lata Lateral and Central Defect Repair in Patients with Recurrent Cystocele

After multiple failed cystocele repairs, it is not uncommon to find during the exploration of the anterior vaginal wall an absent periurethral fascia and a very thin bladder wall. Also commonly found is a lateral defect due to a detached and attenuated connective tissue that connects the bladder to the arcus tendineus fascia pelvis. Applying sutures for repair of the central defect or the lateral defect in the absence of perivesical tissue will end in another failed procedure.

We have designed a procedure using autologous fascia lata to repair the central and lateral defect in patients with multiple failed surgeries for cystocele (Figs. 3.58, 3.59, 3.60, 3.61, 3.62, 3.63, 3.64, 3.65, 3.66, 3.67, 3.68, and 3.69). We use two segments of autologous fascia lata that are approximated with interrupted sutures to form a large rectangular graft. At the end of both segments of fascia, a #1 delayed absorbable suture is applied. The paravesical space is entered in each side. A small suprapubic puncture is performed, and using a double-pronged passer, the sutures are transferred under finger control from the vagina to the suprapubic area. The graft is secured with interrupted sutures to the periurethral fascia and the base of the bladder to prevent displacement. Tying the suprapubic sutures will provide a central and lateral defect repair in patients with recurrent cystocele with absent tissue for a standard cystocele repair.

Fig. 3.58

Dynamic MRI of the patient with recurrent symptomatic cystocele. The patient had a cystocele repair with mesh resulting in erosion of the anterior vaginal wall and mesh removal. Subsequently she underwent two cystocele repairs that failed a few months later

Fig. 3.59

Two segments of autologous fascia lata 10 cm long are obtained from the thigh through a 4–5-cm incision in the skin. The Crawford fascial stripper is used (see chapter on sling for incontinence using fascia lata)

Fig. 3.60

The two segments of fascia are approximated using delayed absorbable sutures in order to create a wide rectangular fascial graft

Fig. 3.61

The two joint segments of fascia are seen

Fig. 3.62

A vertical incision is made in the anterior vaginal wall from the bladder neck to the bladder base

Fig. 3.63

The bladder wall is exposed and an absent periurethral fascia is found

Fig. 3.64

Using scissors, the paravesical space is entered in each side and all adhesions are freed

Fig. 3.65

Due to significant adhesions of the bladder in midline, two small punctures are performed in the suprapubic area. Under finger control in the retropubic space, a double-pronged passer is transferred from the suprapubic to the vaginal area

Fig. 3.66

The delayed absorbable sutures at the end of the fascial construct are transferred through the eyes of the needle passer. The passer is pulled back to the suprapubic area

Fig. 3.67

Several #3-0 delayed absorbable sutures are used at the bladder base and bladder neck to secure the fascial segment to the perivesical tissues and prevent displacement

Fig. 3.68

The anterior vaginal wall is closed with delayed absorbable sutures

Fig. 3.69

View of the suprapubic punctures after the sutures are tied. The skin will be closed with a delayed absorbable suture

The procedure is minimally invasive, uses strong autologous tissue, and avoids the use of mesh. It provides an excellent lateral and central defect repair in patients with multiple failed cystocele repairs.

Postoperative care and complications of the procedure are similar to other anterior vaginal wall procedures.

3.2 Vaginal Hysterectomy for Uterine Prolapse

3.2.1 Indications

Vaginal hysterectomy is in general indicated in cases of severe vaginal prolapse with concomitant uterine descent. Operations to provide support of the uterus are indicated in selected patients in particular patient that refuse to have hysterectomy or minimal uterine prolapse. In patients with uterine prolapse, the sacrouterine and cardinal ligaments, which normally are responsible for uterine support, are separated, detached, or stretched, allowing vault prolapse to occur. After completion of the hysterectomy, a defect is created between the perivesical and prerectal fascia, so it is important on completion of the vaginal hysterectomy to correct two defects, providing support of the vaginal cuff (vault suspension) and approximating the perivesical fascia to the prerectal fascia to close the posterior cul-de-sac. Uterine prolapse is rarely an isolated condition, and associated pelvic floor relaxation and prolapse of the bladder and rectum are very common.

Vaginal hysterectomy is not routinely indicated in patients with good uterine support who are suffering from stress incontinence. Relative contraindications include uterine size out of proportion to vaginal accessibility, adnexal tumor, acute or subacute pelvic inflammation, endometriosis, or malignancy of the ovaries or uterus.

3.2.2 Diagnosis

The diagnosis of uterine prolapse is easily made when physical examination reveals significant uterine descent. A clinical history of pelvic discomfort, vaginal mass, dyspareunia, or stress urinary incontinence associated with uterine prolapse is very common. Any history of vaginal bleeding must be fully evaluated to rule out uterine carcinoma. A bimanual pelvic examination will help to grade the degree of uterine prolapse from minimal (to mid-vaginal area) to moderate (mid-vagina to introitus) or severe (when the uterus is always outside the introitus). Any associated pelvic abnormality such as cystocele, rectocele, enterocele, stress incontinence, or pelvic floor relaxation should be clearly defined because they need to be repaired at the time of hysterectomy. If required, imaging by ultrasound or MRI may help to rule out other pelvic pathology (Fig. 3.70).

Fig. 3.70

Dynamic MRI of a patient with severe uterine prolapse without urethral or bladder prolapse. The uterus is seen coming out of the vaginal introitus

3.2.3 Surgical Technique

In patients with significant uterine prolapse, associated pathology such as cystocele or rectocele is very common and should be repaired simultaneously. If a cystocele is present, we perform the vaginal hysterectomy first, close the vaginal cuff, and then proceed with the cystocele repair. Figures 3.71, 3.72, 3.73, 3.74, 3.75, 3.76, 3.77, 3.78, 3.79, 3.80, 3.81, 3.82, 3.83, 3.84, 3.85, 3.86, 3.87, 3.88, 3.89, 3.90, 3.91, 3.92, 3.93, 3.94, 3.95, 3.96, 3.97, and3.98illustrate the technique of vaginal hysterectomy for severe uterine prolapse as an independent procedure.

Fig. 3.71

A urethral catheter is used to empty the bladder. A ring retractor with multiple hooks is used to retract the vaginal margins. The cervix is grasped with two multiple-toothed tenacula (Lahey clamps), and the mobility of the uterus is once more assessed. One tenaculum is applied on the anterior margin of the cervix and one on the posterior margin. This maneuver will align the cervix and prevent accidental injury of the uterine pedicle during the initial dissection. The anterior and posterior cervical dissection can be performed in an avascular cleavage plane

Fig. 3.72

Using a coagulation knife, a circumferential incision is made around the cervix, exposing the anterior cervical fascia

Fig. 3.73

The posterior vaginal wall is also incised using the coagulation knife to expose the posterior cervical fascia. The incision is extended laterally

Fig. 3.74

The dissection is started over the glistening anterior surface of the cervix. Using Metzenbaum scissors, the plane between the anterior cervix and the posterior bladder wall and perivesical fascia is opened. Care is taken to stay close to the anterior cervical fascia to prevent accidental bladder injury

Fig. 3.75

The dissection is continued over the anterior surface of the cervix toward the anterior peritoneal fold, opening the vesicouterine space. A retractor is inserted in this space

Fig. 3.76

Diagram showing the posterior dissection of the cervix before entering the cul-de-sac

Fig. 3.77

With upward traction over the cervix, the dissection is carried out over the posterior cervical fascia until the peritoneal fold is reached. Care is taken to avoid lateral dissection in order to avoid damage to the uterine pedicle. The peritoneum is entered and a deep retractor is inserted in the cul-de-sac

Fig. 3.78

With deep retractors in the anterior vesicouterine space and the posterior open cul-de-sac, lateral traction is applied to the cervix to expose the sacrouterine–cardinal complex

Fig. 3.79

Diagram showing the isolation of the cardinal and sacrouterine ligaments

Fig. 3.80

The tip of a large right-angle clamp is introduced into the cul-de-sac to isolate the distal sacrouterine–cardinal complex. With the cervix under slight traction, using a curved Phaneuf clamp, the cardinal and sacrouterine ligaments are isolated and clamped 1–2 cm from the cervical junction. The ligaments are tied with figure-of-eight #0 delay absorbable sutures. The suture ends are left long, clamped, and secured lateral to one of the grooves of the ring retractor

Fig. 3.81

Diagram showing the isolation of the uterine pedicle

Fig. 3.82

With slight lateral traction on the cervix, the uterine artery and vein are identified and isolated using a right-angle clamp. Using a Phaneuf clamp, the pedicle is clamped and cut, and the pedicle is ligated as they run lateral to the cervix. The suture ends are left long, clamped, and secured to one of the grooves of the ring retractor

Fig. 3.83

Diagram of the eversion of the fundus of the cervix to expose the anterior peritoneum and broad ligaments

Fig. 3.84

The cervix is retracted upward and the fundus of the uterus is everted and brought outside the introitus. The thin, semilunar folds of the peritoneum can now be visualized attaching to the uterus. These folds are held with forceps, incised with scissors, and spread open. A retractor is inserted in the anterior peritoneum. The uterus is now attached only by the broad ligaments on each side

Fig. 3.85

The anterior retractor is now introduced in the anterior peritoneal space. The finger encircles the broad ligaments

Fig. 3.86

If the adnexa are to be left behind, the broad ligaments are now clamped close to the uterine body

Fig. 3.87

The broad ligaments have been incised. The utero-ovarian ligament, the fallopian tube, and the round ligament are visible in succession from anterior to posterior and can be clamped, divided, and ligated with #0 delay absorbable sutures in one pedicle

Fig. 3.88

After completion of the hysterectomy, three pedicles are observed on each side: the anterior includes the broad ligament, the middle includes the uterine artery, and the posterior includes the cardinal and sacrouterine ligaments. The closure of the cuff is performed with a pair of purse-string sutures to approximate the perivesical fascia to the prerectal fascia. The vault suspension will be done with a pair of culdosuspension sutures (to support the cuff) using #1 delay absorbable sutures, as described in the following section on enterocele repair

Fig. 3.89

A #1 slow absorbable suture (PDS) is placed through the posterolateral vaginal wall, high on the lateral fornix, and a few centimeters from the margin of the vaginal incision

Fig. 3.90

With the suture in the peritoneum, the suture is successively passed through the prerectal fascia 4–5 cm from the cuff (to help correct a rectocele) and to the ipsilateral origin of the sacrouterine–cardinal complex. The sutures must incorporate a strong bite of tissue, and two passes of the needle are used. The suture is applied in pararectal fascia, medial to the levator musculature, lateral to the sacrum, and distal to the sacrospinous ligament and coccygeus muscle. The suture is brought outside the vaginal lumen 1 cm from the original site of entry. An identical suture is placed on the opposite side, starting from the contralateral vaginal fornix. These vault suspension sutures are left untied. The arrow indicates the distance of 14 cm between the introitus and the place of placement of the sutures in the groove lateral to the sacrum and distal to the sacrospinous ligaments

Fig. 3.91

Placement of the vault suspension suture at the origin of the sacrouterine ligaments in the pararectal area, lateral to the sacrum, medial to the levators, and distal to the sacrouterine ligaments

Fig. 3.92

Diagram of the placement of the purse-string sutures that will approximate the perivesical fascia to the prerectal fascia and close the peritoneal cavity

Fig. 3.93

Two purse-string sutures of #1 slow absorbable suture are applied distal to the vault suspension sutures. Posteriorly and distally, they incorporate the prerectal fascia

Fig. 3.94

The purse-string suture incorporates the sacrouterine–cardinal complex 1 cm inside the vaginal cuff and the prerectal fascia. The distal suture placement ensures adequate vaginal depth

Fig. 3.95

The anterior segment of the purse-string suture includes the broad ligaments, the bladder base (the pubocervical fascia), and lateral peritoneum. Care should be taken not to apply the sutures high or lateral to the paravesical groove because of the close proximity to the ureter

Fig. 3.96

A second purse-string suture is applied, the laparotomy pads are removed, and the purse-string sutures are tied. Prior to tying the sutures, the broad ligament sutures are approximated to the midline to keep the pedicles in an extraperitoneal location. In Figure 3.85 the vaginal cuff is closed with multiple running, locking, delay absorbable sutures after cutting the ends of the purse-string sutures. The vault suspension sutures are seen lateral to the closed cuff

Fig. 3.97

After copious irrigation with antibiotic solution. the vaginal cuff is closed with multiple locking runs of delay absorbable sutures

Fig. 3.98

If no other vaginal surgery is planned, the vault suspension sutures are cinched down and tied individually. Tying these suspension sutures pulls the vaginal cuff cephalad and posterior, restoring the normal axis of the vagina and providing vaginal depth. The vagina is packed with antibiotic-impregnated dressing

3.2.4 Postoperative Care

Intravenous antibiotic prophylaxis is given before surgery. In selected patients further antibiotic therapy may be required. The vaginal packing is removed the morning after surgery. Patients are discharged after normal oral food intake is restored, usually on the second day after surgery. Pain medication and a stool softener are prescribed. The patient can immediately resume normal activities like walking, driving, or cooking. Strenuous activities and impact exercises are restricted for 1 month.

3.2.5 Intraoperative Complications

Potential complications at the time of surgery include bleeding (which may be severe if the uterine artery or vein is lacerated prior to completion of the lateral exposure of the cervix), ureteric injury, and bladder laceration.

3.2.6 Postoperative Complications

Complications after hysterectomy are not different from those of other vaginal surgery. A rare complication is postoperative ureteric obstruction, with the most commonly involved segment being the distal pelvic ureter immediately preceding its entrance into the bladder. Bladder fistulae are now seen less frequently and usually occur either cranially along the bladder base or at the trigone. Vaginal shortening may occur because of improper closure of the cuff, poor quality of the tissues, or excessive trimming of the vaginal wall during the closure of the cuff.

3.3 Transvaginal Repair of Enterocele and Vault Prolapse

An enterocele is a herniation of the peritoneum and its contents at the posterior vaginal wall or vaginal cuff. In unusual cases can be present with the uterus in place (Fig. 3.99a). Although a congenital enterocele may be present in a woman without previous vaginal surgery, most enteroceles are acquired as a result of a defect created at the vaginal apex by the separation or weakness of the sacrouterine ligaments after hysterectomy. A simple enterocele is an enterocele sac without vault prolapse; discontinuity between the perivesical and prerectal fasciae allows the peritoneum to herniate through the posterior cul-de-sac. Concomitant vault prolapse defines a complex enterocele (Fig. 3.99b). Most enteroceles are associated with vault prolapse of the vaginal cuff to the mid-vagina or outside the introitus. Often the enterocele defect may be more prominent in the distal posterior vagina and not at the cuff (Fig. 3.99c).

Fig. 3.99

(a) An enterocele is a herniation of the peritoneum and its contents at the level of the vaginal vault. (b) Concomitant vault prolapse defines a complex enterocele. Often the enterocele defect may be more prominent in the distal posterior vagina and not at the cuff. (c) Enterocele formation is most common after a hysterectomy but may occur after any surgery that displaces the vagina anteriorly (e.g., Burch colposuspension or sacrocolpopexy)

3.3.1 Indications

Enterocele formation is most common after a hysterectomy, but it may occur after any surgery that displaces the vagina anteriorly (e.g., Burch colposuspension or sacrocolpopexy). Anterior displacement of the proximal vagina, often in association with pelvic floor relaxation, exposes the cul-de-sac to increase the intra-abdominal pressure, thereby predisposing to enterocele formation. Patients with symptomatic enterocele typically note a vaginal bulge and often complain of vaginal discomfort or dyspareunia. In extreme cases, incarceration and bowel obstruction may occur.

The goal of surgery is to restore the herniated contents of the sac to the peritoneal cavity, to close the defect of the posterior cul-de-sac (by approximating the prerectal and perivesical fasciae), and to support the cuff to a normal anatomical and physiological location (S5) with restoration of the normal vaginal axis.

3.3.2 Diagnosis

Physical examination reveals a bulging mass at the vaginal apex or posterior vagina. The herniation most often lies posterior to the cervix or at the vaginal apex in post-hysterectomy patients. Based upon physical examination alone, it may be difficult to differentiate among cystocele, enterocele, and high rectocele. Very often the enterocele appears as a high continuation of the bulge in the posterior vaginal wall. The enterocele sac may contain bowel visible through the attenuated vaginal wall. With a finger in the rectum, the impulse of the enterocele hernia sac may be felt against the fingertip in the vagina during coughing (analogous to the impulse felt during examination for an inguinal hernia). Examination in the standing position may help to confirm the diagnosis in doubtful cases. Furthermore, placing a cystoscope and shining a light in the bladder can often help to differentiate between cystocele and enterocele (Fig. 3.100).

Fig. 3.100

Placing a cystoscope and shining a light in the bladder can often help to differentiate between cystocele and enterocele

Sagittal cuts during dynamic MRI are not only useful in differentiating between the different types of vaginal prolapse (cystocele, rectocele, or enterocele) but also in differentiating the contents of a vault prolapse. A herniation of the small bowel is defined as enterocele (Fig. 3.101); herniation of the omentum is defined as an omentocele or fatocele (Fig. 3.102); herniation of the colon is defined as a sigmoidocele (Fig. 3.103).

Fig. 3.101

A herniation of the small bowel is defined as an enterocele (arrows). (a) Sagittal T2 MRI of the pelvis showing a well-supported bladder and behind it a herniation of the cul-de-sac. The content of the hernia sac is small bowel (enterocele). (b) At the time of surgery, the hernia sac is open confirming the preoperative diagnosis of enterocele (the sac contains only small bowel)

Fig. 3.102

Herniation of the cul-de-sac with omentum is defined as an omentocele or fatocele. (a) Sagittal MRI of a patient with a hernia of cul-de-sac containing only fatty tissue. The arrowindicates the large hernia sac filled with omentum (gray on MRI). (b) At the time of surgery opening the cul-de-sac, only omentum is found in the hernia sac

Fig. 3.103

Herniation of the cul-de-sac with the colon is defined as a sigmoidocele. (a) Sagittal MRI of a patient suffering from vault prolapse and herniation of the sigmoid colon in the cul-de-sac. The arrow indicated the segment of sigmoid colon contained into the hernia sac. (b) During surgical exploration the opening of the peritoneal sac reveals that most of the hernia sac is occupied by the sigmoid colon

3.3.3 Preoperative Considerations

Enterocele is commonly associated with other vaginal abnormalities (e.g., cystocele or rectocele) that should be repaired simultaneously. Proper bowel preparation is required in case of accidental injury to the rectum or small bowel. After general or spinal anesthesia is induced, the patient is placed in the dorsal lithotomy position. The lower abdomen and the vagina are prepped and draped in a sterile fashion. Perioperative antibiotics are given.

3.3.4 Surgical Technique for Enterocele Repair

Repair of an enterocele must reduce the herniated contents of the sac, close the defect of the posterior cul-de-sac by restoring continuity between the prerectal and perivesical fasciae, restore the normal axis of the vagina, and support the vaginal vault (vault suspension) in order to prevent recurrent prolapse. Numerous surgical techniques have been described for enterocele repair, including transabdominal enterocele repair involving obliteration of the cul-de-sac followed by sacrocolpopexy, transvaginal sacrospinous fixation, laparoscopic or robotic enterocele repair using sutures or mesh, and simple colpocleisis. This chapter discusses our technique of transvaginal enterocele repair, illustrated in Figs. 3.104, 3.105, 3.106, 3.107, 3.108, 3.109, 3.110, 3.111, 3.112, 3.113, 3.114, 3.115, 3.116, 3.117, 3.118, 3.119, 3.120, 3.121, 3.122, 3.123, 3.124, 3.125, and 3.126. In this technique, two pairs of #1 delay absorbable sutures (PDS preferable) are placed. The first pair is vault suspension sutures that will provide support and depth to the vaginal vault to the area of S5, restoring the normal vaginal axis. The second pair is applied in a purse-string fashion to close the enterocele sac and approximate the prerectal fascia to the perivesical fascia.

Fig. 3.104

(a) A ring retractor is positioned, the labia minora are retracted, and a urethral catheter is placed. The enterocele bulge is grasped with two Allis clamps. (b) #2-0 delay absorbable sutures are applied to the vaginal vault as marking sutures to further help in the placement of the vault suspension sutures

Fig. 3.105

(a, b) A vertical incision is made over the vaginal wall, extending anterior to the bladder base and posterior to the prerectal area

Fig. 3.106

(a, b) Using sharp dissection, the peritoneal sac is dissected free from the vaginal wall, posterior from the rectum and anterior toward the bladder base. The dissection is extended to isolate the base of the sac. Care should be taken to avoid bladder injury during the anterior dissection or rectal injury during the posterior dissection. A rectal finger can help during this phase of the surgery. Illumination of the bladder lumen with a cystoscopic light can help to define the bladder base. In case of doubt, the bladder should be irrigated in order to rule out perforation. Branches of the uterine artery are very often found at the base of the enterocele sac; they must be coagulated or suture ligated

Fig. 3.107

(a, b) The peritoneal sac is opened, exposing the content. The bowel, omentum, or both are freed of any adhesions to the hernia sac. (c) Two laparotomy pads are inserted to reduce the peritoneal content, and the bladder is retracted anteriorly. A right-angle long retractor (Heaney) is placed over the iliococcygeus muscle (first laterally and then sliding inferiorly) to expose the groove between the rectum, the medial aspect of the sacrum, and the laterally located levator muscle. A third retractor is used to retract the rectum medially to facilitate the exposure. By forward and backward movement of the pararectal retractor, it is easy to identify the steplike feeling of the hard sacrospinous ligament transitioning to the soft iliococcygeus muscle

Fig. 3.108

Posterolateral to the cuff, from outside the vaginal wall at the level of the most dependent part of the cuff, a #1 delayed absorbable suture (polydioxanone [PDS]) is used to enter the peritoneal sac. With the needle in the peritoneum, the lateral prerectal fascia is incorporated 4–5 cm from the open cuff. Tying the vault suspension sutures will elevate and support the rectal wall, preventing secondary rectocele

Fig. 3.109

(a) The point of anchoring sutures for the vault suspension (blue dot) will be 12–14 cm from the introitus in the groove lateral to the sacrum, medial to the iliococcygeus muscle, and distal to the sacrospinous ligament. The suture will incorporate the origin of the sacrouterine ligaments just distal to the coccygeus, providing a fibrous, strong anchoring tissue that will not cause postoperative pain; there are no vessels or nerves in the area. (b) Anatomical drawing showing the point of insertion of the vault suspension sutures, distal to the sacrospinous ligaments, lateral to the sacrum, and medial to the iliococcygeus muscle

Fig. 3.110

The needle is transferred lateral to medial, distal to the sacrospinous ligament, lateral to the sacrum, lateral to the rectum, and medial to the iliococcygeus muscle. At least two passes of the needle are done to provide a strong anchoring point

Fig. 3.111

(a) The needle is brought from inside the peritoneal cavity to outside the vaginal cuff, at least 1 cm from the original entrance. (b) Diagram of the final application of the vault suspension sutures with a point of insertion and exit in the posterolateral vaginal wall at the cuff

Fig. 3.112

A #1 PDS suture is inserted in the right posterior lateral aspect of the vaginal cuff

Fig. 3.113

The bladder has been retracted superiorly and the rectum medially. A Heaney posterior retractor exposes the right pararectal space. Palpation and forward and backward movement of the retractor help to localize the steplike feeling of the sacrospinous ligament. Just distal to the ligament and lateral to the sacrum, the strong avascular area where the sutures will be inserted is seen. The distance between the introitus and the selected point of insertion of the sutures is 12–14 cm

Fig. 3.114

(a) Exposure of the right pararectal space showing the point of insertion of the vault suspension sutures (blue dot). (b) The sutures incorporate the origin of the sacrouterine ligaments, lateral to the sacrum and distal to the sacrospinous ligament. A strong anchor of tissue is obtained

Fig. 3.115

The needle is transferred from the peritoneum to outside the vaginal wall, at least 1 cm from the original entrance

Fig. 3.116

The anterior vaginal wall is retracted and the rectum and posterior peritoneum are exposed. The two vault suspension sutures are seen in each side of the vaginal wall

Fig. 3.117

Two #1 PDS sutures will be used to apply a purse-string suture to close the vaginal cuff. The first pass of the suture includes the prerectal fascia posterior to the distal segment of the cuff

Fig. 3.118

After including the lateral peritoneum, the needle incorporates the bladder base to include the peritoneum and the pubocervical fascia. A large segment of tissue is incorporated

Fig. 3.119

Lateral peritoneal sutures are applied without incorporating the vaginal wall. The posterior peritoneum and prerectal fascia will be incorporated to complete the purse string. Two sutures will be applied

Fig. 3.120

Diagram showing the application of the purse-string sutures. The sutures will be tied individually to close the peritoneal sac and approximate the prerectal to the perivesical fascia

Fig. 3.121

After removal of the laparotomy pads from the peritoneum, traction is applied to the purse-string sutures, and they are tied individually. Optionally, the excess of peritoneum can be excised. Any posterior vaginal wall defect should be repaired at this time

Fig. 3.122

Diagram of the closed peritoneal sac, showing the dissected excess vaginal wall on each side

Fig. 3.123

Diagram showing the closed cuff after excision of the excess vaginal wall; #2-0 delayed absorbable sutures are used

Fig. 3.124

The vault suspension sutures are tied individually. Traction is applied to eliminate any slack of the sutures

Fig. 3.125

The vaginal cuff is seen retracted high and posterior, restoring the normal vaginal axis toward S5

Fig. 3.126

Diagram of the final repair, showing an elevated vaginal cuff and closed peritoneal sac

3.3.5 Intraoperative Complications

Bleeding or injury to the ureters, bladder, or bowel can occur with any vaginal prolapse surgery. Ureteric injury is most likely during placement of the culdosuspension and the purse-string sutures, even though the anterior retraction of the bladder should protect the ureters. Placement of the vault suspension sutures should be done pointing the needle holder posteriorly toward the sacrum will also prevent ureteric obstruction. Intraoperative cystoscopy with intravenous injection of indigo carmine may be performed to assure the patency of the ureters. Urinary tract bleeding (blood in the Foley catheter) requires cystoscopy to rule out bladder injury. If the patient had adequate bowel preparation, any bowel injury can be repaired primarily. In case of stool contamination due to inadequate bowel preparation, a multiple-layer primary closure can be attempted with broad-spectrum antibiotic coverage, but colostomy may be required for extensive injury.

3.3.6 Postoperative Care

Most enterocele repairs can be performed as outpatient surgery. The vaginal packing is removed after 2 h. An oral cephalosporin or fluoroquinolone is administered for several days only if required. A voiding trial can be done after 24 h.

3.3.7 Postoperative Complications

Delayed complications include vaginal foreshortening, dyspareunia, ileus, or bowel obstruction.

Recurrent enterocele is unusual (less than 5 %). It may occur because of poor-quality tissues or technical failure and can be repaired in a similar fashion or using an abdominal approach.

3.4 Posterior Vaginal Wall Repair

3.4.1 Indications

In patients with good posterior vaginal support, herniation of the rectum into the vagina is prevented by the levator musculature and the strong prerectal and pararectal fasciae. When these fasciae and the levator sling are weakened, pelvic floor relaxation (PFR) develops. The distal half of the posterior vaginal wall is mainly supported by the levator sling. It pulls forward the distal vagina, creating an angulation of 45° with the vertical line. The proximal vagina is in a flat position of 100–110° with the horizontal line (Fig. 3.127). We like to compare the normal vaginal axis to the shape of a banana with the curvature pointing posteriorly toward the S4–S5 vertebra (Fig. 3.128). During surgery for PFR and rectocele, the final repair should restore the vaginal canal to the normal axis with preservation of vaginal depth and support with the prevention of stenosis.

Fig. 3.127

Diagram of the posterior vaginal anatomy, with the distal third of the vagina in a 45-degree angulation and the proximal vagina in a more horizontal axis ending at the sacrococcygeal area

Fig. 3.128

(a) Sagittal dynamic MRI view of the pelvis in a young patient, showing the indentation of the levator (pubococcygeus and puborectalis) on the vagina, creating the elevation and angulation in its distal third. The size of the levator hiatus, the distance between the inferior rami of the pubic bone and the levator notch, is normally about 5.5 cm. The white broken linefollows the axis of the vagina. (b) Rotating the same image 90° imitates the findings of the vaginal examination in the supine position; the vaginal canal has a banana shape with the distal vagina elevated and the proximal vagina reaching the sacrococcyx. The dotted blue line depicts the levator hiatus (the arrow points toward the beginning of the line)

The components of PFR include the development of a rectocele, widening and laxity of the levator hiatus, and perineal tearing and herniation. Several factors contribute to the weakening of posterior wall pelvic support. Childbirth and the passage of the child’s head through the vagina causes stretching, damage, and tearing of the prerectal and pararectal fascia and weakening of the levator musculature, widening the levator hiatus and causing loss of the normal posterior angulation (banana shape) of the vaginal axis (Fig. 3.129). In this situation, the proximal vaginal axis, which is at a horizontal axis in the pelvis, may be changed to reside more vertically. Additionally, the pelvic organs slide downward along the vaginal axis as a result of loss of estrogen, aging, and chronic abdominal straining, facilitating further development of PFR.

Fig. 3.129

Diagram of the common abnormality found in patients with pelvic floor relaxation. There is widening and descent of the levator hiatus and levator plate

Perineal body laxity caused by attenuation of the perineal musculature usually accompanies a rectocele, and therefore reconstruction of the posterior fourchette and perineum is carried out at the same time.

Surgery to the anterior vaginal wall or the vaginal cuff like in sacrocolpopexy can result in anterior displacement of the vagina, which can change the vaginal axis, thereby placing the posterior vaginal wall in the most dependent position, under the direct impact of intra-abdominal forces. Therefore, repair of PFR, when it is present, should be performed, as it will help to maintain the normal vaginal axis, prevent further prolapse, and improve the outcome of the anterior or vaginal vault surgery.

Many symptoms have been associated with PFR. Common presenting complaints are constipation, poor evacuation of stool secondary to stool pocketing in the rectocele, or the feeling of a vaginal bulge. Some patients require digital reduction of a rectocele in order to evacuate properly. Surgical correction may not cure these symptoms, but most patients who are symptomatic from PFR will be satisfactory candidates for repair. Repair of asymptomatic PFR at the time of surgery for incontinence surgery, anterior vaginal prolapse, or vaginal hysterectomy always should be considered, yet one must balance a risk of postoperative dyspareunia with worsening prolapse in unrepaired cases. It is our belief that simultaneously correcting posterior pelvic floor prolapse will result in restoration of the normal vaginal axis, will resist postoperative recurrence of prolapse, and may improve the results of anti-incontinence surgery as it creates a more solid pelvic floor.

3.4.2 Classification

Rectoceles (one of the components of PFR) may be classified as to their position in the vagina (low, medium, or high). The exact severity of the rectocele is graded according to the level of saccular protrusion. The Baden–Walker system and the pelvic organ prolapse–quantification classification can assess objectively the degree of posterior vaginal prolapse. Similarly, perineal tears are graded on a scale of I to IV:

· Grade I: a tear in the hymenal ring

· Grade II: a tear involving the perineal body but not the anal sphincter

· Grade III: a tear into the anal sphincter

· Grade IV: a tear into the anal mucosa

3.4.3 Preoperative Considerations

The patient begins a clear liquid diet 48 h prior to surgery and takes a laxative the night before surgery. Broad-spectrum antibiotics are administered intravenously immediately before surgery. The patient is anesthetized and placed in the lithotomy position. In selected patients with poor tissues or multiple surgeries, the rectum is copiously irrigated with an antibiotic solution prior to preparation and draping.

3.4.4 Diagnosis

The diagnosis of posterior relaxation starts with a good clinical history of traumatic deliveries, prior surgeries, defecatory changes such as constipation or stool incontinence, sensation of a posterior bulge, and the need for splinting the vagina or perineum to facilitate defecation. Clinical symptoms or findings do not always correlate to function; however, severe posterior vaginal prolapse may be asymptomatic, or mild prolapse can be very symptomatic. In complex cases with multiple surgical failures, unclear diagnosis, or disproportion of findings and symptoms, an objective evaluation in addition to the physical examination can be warranted. Figures 3.130, 3.131, 3.132, and 3.133illustrate some of the objective diagnostic options.

Fig. 3.130

(a) Physical examination of a patient with wide-open genital hiatus and a large posterior protrusion causing vaginal pressure, a bulge coming out of the vagina, and defecatory dysfunction with constipation and the need to splint the vagina in order to defecate. (b) Resting MRI using a T2 sequence showing the posterior vaginal wall (rectum) filled with gas. On straining, there is a displacement and a large herniation of the posterior vaginal wall emerging from the introitus (rectocele)

Fig. 3.131

Filling rectogram in the standing lateral position, showing the anterior bulge of a large rectocele

Fig. 3.132

(a) T2 sagittal view of the pelvis at the midline after the rectum and vagina were filled with a liquid gel. The bladder, urethra, vagina, and rectum are well defined. (b) On straining, a significant rectocele is visualized coming out of the introitus

Fig. 3.133

In a patient with multiple failed surgeries and significant perineal laxity, an MRI defecogram shows the descent of the perineum and the increase convexity of the posterior levator due to the severe levator and fascial weakness

3.4.5 Surgical Technique

Figures 3.134, 3.135, 3.136, 3.137, 3.138, 3.139, 3.140, 3.141, 3.142, 3.143, 3.144, 3.145, 3.146, 3.147, 3.148, 3.149, 3.150, 3.151, 3.152, 3.153, and 3.154 show the surgical technique for posterior vaginal wall repair.

Fig. 3.134

A Foley catheter has been inserted, and a ring retractor with six hooks exposes the vaginal canal. A retractor is placed anteriorly to expose the length of the posterior vaginal wall. A large posterior defect is present

Fig. 3.135

Surgical picture outlining the surgical incisions: (1) a V-shaped incision in the perineum; (2) an inverted V-shaped incision in the vaginal wall, with the tip reaching 3 cm from the introitus (the level of the levator hiatus); (3) a straight incision extending to the vaginal cuff

Fig. 3.136

Diagram depicting the triangular excision of the perineal skin and posterior fourchette

Fig. 3.137

(a) Two Allis clamps are placed at the margin of the introitus at the posterior fourchette, in the 5 o’clock and 7 o’clock positions. (b) A V-shaped incision is made from the posterior fourchette with the tip extending to the central tendon and external anal sphincter. The width of the V will depend on the degree of separation or widening of the posterior fourchette. (c) The skin is dissected free and the posterior fourchette is excised between the Allis clamps

Fig. 3.138

Diagram showing the second step of the surgery: the excision of a triangular segment of the posterior vaginal wall extending 3 cm from the introitus

Fig. 3.139

Two Allis clamps are applied on the distal posterior vaginal wall. The upper Allis is usually applied 3–4 cm from the introitus, at the level of the levator hiatus. An oblique incision (blue line) is made from the levator hiatus distally toward the excised mucocutaneous junction at the posterior fourchette

Fig. 3.140

Scissors are used to dissect the vaginal wall laterally, thereby exposing the attenuated prerectal fascia and the area of the perineal membrane that extends 3 cm into the vaginal canal

Fig. 3.141

Diagram of the triangular island of posterior vaginal wall (3–4 cm high) as it is excised

Fig. 3.142

The triangular island of vaginal wall will be sharply excised, revealing the prerectal fascia and the extension of the perineal membrane into the posterior distal vagina

Fig. 3.143

Scissors are used to dissect under the vaginal wall toward the vaginal cuff to expose the prerectal fascia. With the anterior retractor under upward traction, a strip of the posterior vaginal wall is excised (with the width depending on the size of the posterior defect). The surgeon should be careful to refrain from excising an excessive amount of posterior vaginal wall, to avoid causing vaginal narrowing

Fig. 3.144

Diagram of the posterior vaginal wall after excision of the strip

Fig. 3.145

Diagram of the vaginal canal and rectum with the laterally located paravaginal fascia or pillar of the rectum

Fig. 3.146

Diagram of the vagina and rectum after excision of a strip of posterior vaginal wall. The prerectal fascia is exposed

Fig. 3.147

Diagram of the closure of the rectocele defect using multiple running, locking #2-0 slow absorbable suture. We incorporate the edge of the vaginal incision; after insinuating the needle under the vaginal wall, strong segments of the pararectal and prerectal fasciae are incorporated

Fig. 3.148

Diagram of the closure of the rectocele defect. The suture includes the edge of the vaginal wall, the prerectal fascia, and the pillars of the rectum (pararectal fascia)

Fig. 3.149

Surgical photograph demonstrates the closure of the rectocele defect. The anterior vaginal wall is retracted upward, and the posterior rectal wall is retracted downward, both with the use of Haney or right-angle retractors. This maneuver facilitates the repair by protecting the rectum, reducing the rectocele, and allowing exposure of the prerectal and pararectal fasciae. The rectocele repair is undertaken by incorporating the prerectal and pararectal fasciae from the apex of the posterior vagina toward the levator hiatus, using a running, locking #2-0 slow absorbable suture. Each needle passage incorporates only the edge of the vaginal wall and generous amounts of the prerectal and pararectal fasciae bilaterally. The suture stops at the level of the triangular excision in the distal vagina, usually 3–4 cm from the introitus

Fig. 3.150

(a) The perineal membrane inserts into the descending rami of the ischiopubis. Each half joins in the middle to form the perineal body, which extends 3–4 cm from the introitus inside the vagina. Perineal trauma such as vaginal delivery causes the loss of connection of each half, widens the levator hiatus, facilitates the formation of a rectocele, and decreases the size of the perineal body. The diagram depicts the separation of the perineal membrane and shortening of the perineal body. (b) Diagram of the pelvic floor showing a wide levator hiatus

Fig. 3.151

(a) Diagram of the application of interrupted figure-of-eight sutures over the distal vagina, incorporating the perineal membrane and resulting in a narrower levator hiatus. Usually two or three sutures are required. They will elevate the distal vagina and rebuild the perineum. (b) Diagram depicting the repair of the distal vagina with figure-of-eight sutures approximating the perineal membrane and narrowing the levator hiatus. (c) Diagram of the reconstructed and narrowed levator hiatus. The levator muscles are not directly incorporated in the sutures

Fig. 3.152

The distal sutures have been applied, creating the narrowing of the wide levator hiatus and elevation of the distal vagina

Fig. 3.153

(a) Vertical mattress sutures of #2-0 slow absorbable suture are used to approximate the bulbocavernosus, superficial transverse perinei muscles, and external anal sphincter muscles, allowing reconstruction of the urogenital diaphragm and support of the central tendon. (b) Diagram showing the reconstructed perineum after the repair

Fig. 3.154

(a) The skin of the perineum is approximated with a vertical line of delay absorbable sutures. Local anesthesia is injected to improve postoperative pain. (b) Diagram of the complete posterior vaginal wall and perineal reconstruction

3.4.6 Postoperative Care

The surgery can be performed in the outpatient setting. The vaginal packing is removed 2 h after surgery. Stool softeners are continued for 1 month postoperatively. Oral antibiotics are administered if required for 2 weeks after surgery. Routine use of sitz baths is encouraged. Resumption of sexual relations is postponed for at least 1 month after surgery. Estrogen creams may facilitate wound healing and improve viscoelasticity.

3.4.7 Postoperative Complications

Recurrent rectocele is an uncommon complaint, but despite the best surgical efforts, it may occur in up to 10 % of patients. Dyspareunia and vaginal narrowing can be avoided by meticulous surgical technique, avoidance of over-resection of vaginal tissue, not leaving painful ridges, and not placing sutures directly into the levator musculature. Rectal injury should be repaired in layers, including the use of a Martius flap if required. Rectovaginal fistula is a very uncommon occurrence.

3.5 Repair of Perineal Hernia

3.5.1 Indications

Perineal herniation is an often-overlooked condition in which the perineal musculature loses its supporting properties because of trauma, atrophy, weakness, or neuropathy. The vaginal examination may be normal or may have concomitant abnormalities. The main diagnostic feature is the presence of a bulge of the perineal musculature when the patient is straining. The normally flat perineum (Fig. 3.155) bulges on straining, appearing as a convex deformity. The herniation combines weakness and separation of the levator musculature in the perineum and loss of the fascial and muscle support (Fig. 3.156). The distal colon and the small bowel are often included in the hernia sac. Neuropathic pelvic floor damage such as sacral arc injury or pudendal neuropathy can cause significant perineal herniation through paralysis of the pelvic musculature.

Fig. 3.155

Diagram of the normal anatomy of the perineum showing the flat space between the posterior fourchette and the rectum

Fig. 3.156

In patients with perineal hernia, the normally flat perineum is weak with significant convexity, creating the bulging typical of a perineal hernia, with increased distance from the rectum to the posterior fourchette

Presenting symptoms include perineal pressure, constipation, and the need to use pressure to reduce the perineal herniation. The physical examination reveals the finding of the perineum bulging on straining. The vaginal examination reveals no prolapse or often other organ prolapse (Fig. 3.157). The distance between the posterior fourchette and the anal sphincter is increased and further increases with strain. Dynamic MRI has helped to better define the condition by objectively demonstrating the type and degree of the perineal defect (Figs. 3.158 and 3.159).

Fig. 3.157

Physical examination demonstrating the bulge of the perineum in a patient prior to surgery. The bulge may be spontaneous or induced by finger traction

Fig. 3.158

Sagittal resting MRI of the midline pelvis showing the rectum, anal canal, and perineum

Fig. 3.159

Straining sagittal MRI of the pelvis showing significant herniation of the perineum. The patient has a normal vaginal examination after multiple reconstructive surgeries, but she complains of perineal pressure and severe constipation, with the need to apply perineal pressure in order to defecate

3.5.2 Preoperative Considerations

The bowel should be properly prepared before surgery. Mechanical preparation of the distal colon is advisable. Broad-spectrum antibiotics are used in the perioperative period.

The patient is in the lithotomy position.

3.5.3 Surgical Technique

Figures 3.160, 3.161, 3.162, 3.163, 3.164, 3.165, 3.166, 3.167, and 3.168 illustrate the surgical technique for the repair of a perineal hernia.

Fig. 3.160

Intraoperative photograph of the perineum of a patient suffering from a significant perineal hernia. The vaginal examination was unremarkable, but the distance between the posterior fourchette and the anal sphincter was 8 cm

Fig. 3.161

A vertical incision is made in the perineum. The incision is extended as an inverted V around the anal canal

Fig. 3.162

Dissection is carried out laterally to expose the perineal musculature, including the transverse perineum and the external anal fibers

Fig. 3.163

In the posterior perineum, the ischiorectal fossa is entered on each side

Fig. 3.164

The levator musculature in the posterior perineum is exposed. Horizontally placed mattress sutures using #2-0 delay absorbable sutures approximate the external anal sphincter and perirectal fascia to the transverse perineal musculature and fascia at the posterior fourchette. Strong bites of tissue are taken. A finger in the rectum may facilitate the placement of the sutures

Fig. 3.165

Horizontal interrupted figure-of-eight sutures approximate the perirectal fascia at the anal canal to the posterior fourchette, closing the perineal defect and shortening the distance between the anal canal and posterior fourchette

Fig. 3.166

The perineal sutures are tied, providing a shorter perineum and a strong perineal shelf. Rectal examination can confirm the strength of the repair

Fig. 3.167

The perineal skin is closed in two layers with delay absorbable sutures

Fig. 3.168

The distance between the rectum and posterior fourchette is measured now to be only 3 cm

3.5.4 Postoperative Care

A vaginal packing is inserted at the end of the procedure and left in place for 2 h. Long-acting local anesthesia is injected to improve postoperative pain. Ice packs, parenteral antibiotics, stool softeners, and pain medication are used in the perioperative period.

3.5.5 Postoperative Complications

Potential complications include pain, infection of the perineal and perirectal area, fistula, or recurrent hernia. Bowel changes should improve with a good anatomical repair, but patients can continue to have defecatory dysfunction in spite of a good repair.

3.6 Transvaginal Pararectal Repair of Rectal Prolapse

3.6.1 Indications

Rectal prolapse is a disabling condition in which the rectal mucosa or the whole rectal wall protrudes through the anal canal. It can present with symptoms of constipation, loss of stool, rectal bleeding, or rectal pain. The prolapse may be minor, requiring only medical treatment, but if the protrusion is symptomatic or severe, surgical treatment is indicated. The main option for treatment is a rectopexy to the sacrum using sutures or mesh and, when indicated, concomitant colonic resection.

We have developed a minimally invasive transvaginal pararectal procedure to correct rectal prolapse. This operation restores the posterior rectal wall and vaginal axis to the normal 100-degree angulation with the horizontal line, helping to prevent further prolapse. The surgery is an outpatient procedure with 23-h stay. No complications (e.g., perirectal abscess, rectal fistula, or de novo defecatory dysfunction) have occurred. This kind of minimally invasive transvaginal procedure always can be tried prior to abdominal surgery.

3.6.2 Preoperative Considerations

Prior to preparation and draping, the rectum is irrigated with copious antibiotic solution until clear. Perioperative antibiotics are given.

3.6.3 Surgical Technique

The patient is placed in lithotomy position. After preparation and draping, a large Hegar dilator is inserted in the rectum and is fixed to the drapes with a Penrose drain to allow access and easy palpation of the rectal wall at the time of surgery (Fig. 3.169). After exposure of the posterior vaginal wall, two incisions are made laterally, and the pararectal space is entered (Figs. 3.170 and 3.171). A row of three to four delayed absorbable sutures is applied to the sacrospinous ligaments and the iliococcygeus muscle on each side (Fig. 3.172). After insertion of an Hegar dilator in the rectum, the preplaced sutures are applied to the posterolateral wall of the rectum in a sequential fashion, fixing the distal rectum for a distance of 10 cm to the lateral levator musculature (Figs. 3.173, 3.174, 3.175, and 3.176).

Fig. 3.169

Exposure of the posterior vaginal wall is obtained using an Heaney retractor. A ring retractor with hooks facilitates the exposure. A Hegar dilator is inserted in the rectum and fixed to the drapes using a Penrose drain

Fig. 3.170

Posterior lateral incisions are made in the vaginal wall at the 5 and 7 o’clock positions. The procedure is done in each pararectal space in a similar fashion

Fig. 3.171

The pararectal space is exposed, freeing the rectum from the iliococcygeus muscles up to the origin of the sacrospinous ligament

Fig. 3.172

With medial retraction of the rectum, multiple sequential #0 delayed absorbable sutures are applied to the levator musculature. The first suture is inserted just distal to the sacrospinous ligament, and two or three more sutures are inserted distally and sequentially, obtaining a strong anchor to the levator musculature

Fig. 3.173

The posterolateral rectal wall is exposed. The Hegar dilator helps in finding the rectal wall itself. The arrow is directed at the rectal wall elevated by the Hegar dilator

Fig. 3.174

The levator sutures are sequentially passed through the posterolateral rectal wall with guidance of the Hegar dilator in the rectal wall, taking care to incorporate the whole rectal wall. The sutures are tied. The rectal wall is now fixed to the lateral pelvic wall for a distance of more than 10 cm

Fig. 3.175

After irrigations with antibiotic solution, the posterior vaginal wall is closed with multiple runs of #2-0 delayed absorbable sutures

Fig. 3.176

A postoperative defecogram shows the restoration of the normal axis of the distal rectum without rectal prolapse

3.6.4 Postoperative Care

The surgery is done as an outpatient procedure. An overnight vaginal packing soaked with antibiotics is inserted in the vagina. The patient is allowed to resume normal activities except heavy lifting or straining. Stool softeners or laxatives are given as required. The Foley catheter is removed the day after surgery unless another anterior vaginal wall procedure was performed.

Suggested Reading

Baessler K, Maher CF. Mesh augmentation during pelvic-floor reconstructive surgery: risks and benefits. Curr Opin Obstet Gynecol. 2006;18:560–6.CrossRefPubMed

Barber MD. Surgical correction of paravaginal defects. In: Vasavada SP, Appell RA, Sand PK, Raz S, editors. Female urology, urogynecology, and voiding dysfunction. New York: Marcel Dekker; 2005. p. 615–30.

Barber MD, Maher C. Epidemiology and outcome assessment of pelvic organ prolapse. Int Urogynecol J. 2013;24(11):1783–90.CrossRefPubMed

Barber MD, Brubaker L, Burgio KL, Richter HE, Nygaard I, Weidner AC, Eunice Kennedy Shriver National Institute of Child Health and Human Development Pelvic Floor Disorders Network, et al. Comparison of 2 transvaginal surgical approaches and perioperative behavioral therapy for apical vaginal prolapse: the OPTIMAL randomized trial. JAMA. 2014;311(10):1023–34.CrossRefPubMedPubMedCentral

Birch C, Fynes MM. The role of synthetic and biological pros- theses in reconstructive pelvic floor surgery. Curr Opin Obstet Gynecol. 2002;14:527–35.CrossRefPubMed

Bjelic-Radisic V, Aigmueller T, Preyer O, Ralph G, Geiss I, Müller G, Austrian Urogynecology Working Group, et al. Vaginal prolapse surgery with transvaginal mesh: results of the Austrian registry. Int Urogynecol J. 2014;25(8):1047–52.CrossRefPubMed

Cervigni M, Natale F. The use of synthetics in the treatment of pelvic organ prolapse. Curr Opin Urol. 2001;11:429–35.CrossRefPubMed

DeLancey JO. Structural anatomy of the posterior pelvic compartment as it relates to rectocele. Am J Obstet Gynecol. 1999;180(4):815–23.CrossRefPubMed

DeLancey JOL. Fascial and muscular abnormalities in women with urethral hypermobility and anterior vaginal wall prolapse. Am J Obstet Gynecol. 2002;187:93–8.CrossRefPubMed

Goldberg RP, Koduri S, Lobel RW, Culligan PJ, Tomezsko JE, Winkler HA, et al. Protective effect of suburethral slings on postoperative cystocele recurrence after reconstructive pelvic operation. Am J Obstet Gynecol. 2001;185:1307–13.CrossRefPubMed

Hefni M, El-Toukhy T, Bhaumik J, Katsimanis E. Sacrospinous cervicocolpopexy with uterine conservation for uterovaginal prolapse in elderly women: an evolving concept. Am J Obstet Gynecol. 2003;188:645–50.CrossRefPubMed

Huebner M, Hsu Y, Fenner DE. The use of graft material in vaginal pelvic floor surgery. Int J Gynaecol Obstet. 2006;92:279–88.CrossRefPubMed

Jelovsek JE, Chagin K, Brubaker L, Rogers RG, Richter HE, Arya L, Barber MD, et al. A model for predicting the risk of de novo stress urinary incontinence in women undergoing pelvic organ prolapse. Obstet Gynecol. 2014;123(2 Pt 1):279–87.CrossRefPubMedPubMedCentral

Johnson N, Barlow D, Lethaby A, Tavender E, Curr E, Garry R. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2006;(2):CD003677.

Kahn MA, Stanton SL. Posterior colporrhaphy: its effects on bowel and sexual function. Br J Obstet Gynaecol. 1997;104:82–6.CrossRefPubMed

Karram M, Maher C. Surgery for posterior vaginal wall prolapse. Int Urogynecol J. 2013;24(11):1835–41.CrossRefPubMed

Lantzsch T, Goepel C, Wolters M, Koelbl H, Methfessel HD. Sacrospinous ligament fixation for vaginal vault prolapse. Arch Gynecol Obstet. 2001;265:21–5.CrossRefPubMed

Maher C. Anterior vaginal compartment surgery. Int Urogynecol J. 2013;24(11):1791–802.CrossRefPubMed

Maher C, Baessler K. Surgical management of posterior vaginal wall prolapse: an evidence-based literature review. Int Urogynecol J. 2005;17:84–8.CrossRef

Maher C, Baessler K. Surgical management of anterior vaginal wall prolapse: an evidence based literature review. Int J Gynaecol Obstet. 2006;17:195–201.

Maher CF, Cary MP, Slack MC, et al. Uterine preservation or hysterectomy at sacrospinous colpopexy for uterovaginal prolapse? Int Urogynecol J. 2001;12:381–5.CrossRef

Maher C, Baessler K, Glazener CM, Adams EJ, Hagen S. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2007;(3):CD004014.

Maher C, Feiner B, Baessler K, Schmid C. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2013;30:4.

Mallipeddi PK, Steele AC, Kohli N, Karram MM. Anatomic and functional outcome of vaginal paravaginal repair in the correction of anterior vaginal wall prolapse. Int Urogynecol J. 2001;12:83–8.CrossRef

Meschia M, Bruschi F, Amicarelli F, Pifarotti P, Marchini M, Crosignani PG. The sacrospinous vaginal vault suspension: critical analysis of outcomes. Int Urogynecol J. 1999;10:155–9.CrossRef

Miskry T, Magos A. Randomized, prospective, double-blind comparison of abdominal and vaginal hysterectomy in women without uterovaginal prolapse. Acta Obstet Gynecol Scand. 2003;82:351–8.CrossRefPubMed

Nüssler E, Kesmodel US, Löfgren M, Nüssler EK. Operation for primary cystocele with anterior colporrhaphy or non-absorbable mesh: patient-reported outcomes. Int Urogynecol J. 2015;26:359–66.CrossRefPubMed

Ottosen C, Lingman G, Ottosen L. Three methods for hysterectomy: a randomized, prospective study of short term outcome. Br J Obstet Gynaecol. 2000;107:1380–5.CrossRef

Ramanah R, Berger MB, Parratte BM, DeLancey JO. Anatomy and histology of apical support: a literature review concerning cardinal and uterosacral ligaments. Int Urogynecol J. 2012;23(11):1483–94.CrossRefPubMedPubMedCentral

Richter LA, Carter C, Gutman RE. Current role of mesh in vaginal prolapse surgery. Curr Opin Obstet Gynecol. 2014;26(5):409–14.CrossRefPubMed

Scarpero HM, Nitti VW. Anterior vaginal wall prolapse: mild/moderate cystoceles. In: Vasavada SP, Appell RA, Sand PK, Raz S, editors. Female urology, urogynecology, and voiding dysfunction. New York: Marcel Dekker; 2005. p. 575–94.

Shull BL, Capen CV, Riggs MW, Kuehl TJ. Bilateral attachment of the vaginal cuff to iliococcygeus fascia: an effective method of cuff suspension. Am J Obstet Gynecol. 1993;168:1669–77.CrossRefPubMed

Sze EH, Karram MM. Transvaginal repair of vault prolapse: a review. Obstet Gynecol. 1997;89:466–75.CrossRefPubMed

Tarr ME, Paraiso MF. Minimally invasive approach to pelvic organ prolapse: a review. Minerva Ginecol. 2014;66(1):49–67.PubMed

van der Ploeg JM, van der Steen A, Oude Rengerink K, van der Vaart CH, Roovers JP. Prolapse surgery with or without stress incontinence surgery for pelvic organ prolapse: a systematic review and meta-analysis of randomised trials. BJOG. 2014;121(5):537–47.CrossRefPubMed

Walters MD, Muir TW. Surgical treatment of vaginal apex prolapse: transvaginal approaches. In: Vasavada SP, Appell RA, Sand PK, Raz S, editors. Female urology, urogynecology, and voiding dysfunction. New York: Marcel Dekker; 2005. p. 663–76.

Weber AM, Walters MD, Piedmonte MR, Ballard LA. Anterior colporrhaphy: a randomized trial of three surgical techniques. Am J Obstet Gynecol. 2001;185:1299–306.CrossRefPubMed

Wu JM, Matthews CA, Conover MM, Pate V, Jonsson FM. Lifetime risk of stress urinary incontinence or pelvic organ prolapse surgery. Obstet Gynecol. 2014;123(6):1201–6.CrossRefPubMedPubMedCentral