Anterior and Posterior Colporrhaphy

Anterior colporrhaphy: Vaginal repair to correct anterior vaginal wall prolapse (cystocele)

Posterior colporrhaphy: Vaginal repair to correct posterior vaginal wall prolapse (rectocele or perineocele)

• Can be combined with other prolapse repairs
• Goal: Restore anatomy and alleviate symptoms

• Common symptoms of cystocele
  • Vaginal bulge or pressure
  • Voiding difficulty
• Physical examination
  • Pelvic examination in lithotomy with Valsalva effort → descent of anterior vaginal wall measured using a standardized grading system, called the Pelvic Organ Prolapse Quantification (POP-Q) system
  • Anterior prolapse is often associated with apical prolapse, so important to thoroughly investigate for other prolapse

• Repair
  • Expose the vaginal muscularis from overlying vaginal epithelium and plicate the vaginal muscularis underlying the bladder
  • The old term for the vaginal muscularis is pubovaginal fascia. Several studies have demonstrated that o there is no real fascia in this area, this term is a misnomer
• Dissection
  • From bladder neck to cervix or vaginal apex and laterally to the ischiopubic rami, exposing entirety of the anterior vaginal wall prolapse
  • Can be performed with uterus in situ, posthysterectomy or after a concurrent vaginal hysterectomy and should include a concomitant colpopexy (apical repair) for improved durability

1. Patient is in dorsal lithotomy position and is surgically prepped.
2. Place transurethral Foley catheter for recognition of bladder neck and urine drainage.
3. Use Allis clamps to grasp vaginal epithelium at apex and bladder neck. A weighted speculum, a Lone Star™ retractor, or both can aid in exposure.
4. Inject local anesthetic (such as 0.5% or 1% lidocaine or 0.25% bupivacaine, generally with 1:200,000 epinephrine) subepithelially.
5. Incise the vaginal epithelium from bladder neck to the apex of the prolapse with a scalpel. Alternatively, start with a small transverse incision at the apex and undermine upward using Metzenbaum scissors toward the bladder neck, and incise the epithelium.

 

 

6. Dissect the underlying vaginal muscularis from the overlying epithelium to the margins of the dissection bilaterally.
   • Place Allis clamps along epithelial edge and use Metzenbaum scissors to carefully dissect fibromuscular layer away by using forefinger for traction
   • Assistant can maintain traction medially on underlying fibromuscular tissue with atraumatic forceps

7. Plication of the prolapsed vaginal tissue in one or two layers of mattress sutures with 2–0 delayed absorbable suture.
   • Avoid tension
   • Avoid taking excessively deep bites with the plication sutures. The trigone and ureteric orifices underlie the plication sutures
   • If particularly large prolapse, can place initial purse-string sutures

8. Trim excess vaginal epithelium.

 

9. Reapproximate vaginal epithelium with 3–0 delayed absorbable suture in interrupted, subcuticular, or running fashion.
10. Cystoscopic evaluation of urethra for bladder integrity and ureteral patency

• Cystotomy or ureteral compromise (risk 0–2%)
• Urinary tract infection
• Voiding dysfunction
• Intravesical or urethral suture placement
• Fistula formation
• Blood loss

Concurrent stress urinary incontinence

• Antiincontinence procedures can be performed along with anterior colporrhaphy
• Recommend anterior colporrhaphy be performed before tensioning a midurethral sling, or performing a bladder neck suspension or retropubic urethropexy
• If concurrently placing a sling, attention should be given to fixing the sling under the midurethra. This can be accomplished by using a separate incision or simply tacking the sling in place with 3-0 Vicryl sutures

Synthetic Mesh Versus Native Tissue Repair

• Improved anatomic outcomes with mesh but not subjective outcomes. Both repairs have about 85–90% subjective success rates
• No difference in quality of life or dyspareunia
• Disadvantages of mesh
  • Mesh erosion 4–10%; surgery for erosion 6.3%
  • Mesh with increased operating room time; increased estimated blood loss
  • Total reoperation rate is doubled compared with nonmesh repair

• Rectocele: Bulge or protrusion of the anterior rectum into the posterior vaginal wall
• Perineocele: Attenuation or defect in perineal body; can also have posterior vaginal wall prolapse with enterocele, so important to evaluate for this on examination

• Common symptoms: Rectocele or perineocele
  • Vaginal bulge or pressure
  • Sexual dysfunction
  • Defecatory dysfunction
    • Stool trapping
    • Fecal incontinence
    • Difficulty with bowel movements
    • Incomplete emptying, splinting
• Physical examination
  • Pelvic examination in lithotomy with Valsalva effort → descent of posterior vaginal wall, measured using a standardized grading system, called the Pelvic Organ Prolapse Quantification (POP-Q)
  • Rectovaginal examination: Anterior rectal protrusion into posterior vaginal or perineal defect
  • Particularly helpful to evaluate for possible enterocele (see image)

Objective

• Expose the vaginal muscularis, perineal body, or both from overlying vaginal epithelium and plicate the defect overlying the rectum
• Restore vaginal and perineal contour
• Approach: Midline plication or a site-specific defect repair
• Dissection: Expose entire length and width of rectocele and perineal body defect, generally to levator laterally

1. Patient in dorsal lithotomy position and surgically prepped
2. Vaginal and rectal examination to determine extent of the defect
3. Use Allis clamps to grasp vaginal epithelium along length of the defect to the perineal body. An anterior retractor, a Lone Star™ retractor, or both, can aid in exposure
4. Inject local anesthetic (such as 0.5% or 1% lidocaine or 0.25% bupivacaine, generally with 1:200,000 epinephrine) subepithelially
5. Incise the vaginal epithelium between your Allis clamps with a scalpel

If planning a perineorrhaphy or perineoplasty, excise a triangular or diamond shaped wedge of vaginal epithelium and perineal skin to demarcate borders of the perineorrhaphy.

6. Dissect the underlying vaginal muscularis from the overlying epithelium to the medial margins of the levator ani laterally and as high as possible on the vaginal cuff superiorly
   • Place Allis clamps along epithelial edge and use Metzenbaum scissors to carefully dissect vaginal muscularis away by using forefinger for traction
   • Assistant can maintain traction medially on underlying fibromuscular tissue
   • Take care to avoid entry into the rectum with periodic digital rectal examinations

7. Plication of the defect

• Midline
  • Plication of the vaginal muscularis in one or two layers of mattress sutures with 0 or 2–0 delayed absorbable suture
• Site-Specific/Defect-Directed
  • Inspection and rectal examination to identify specific defect
  • Repair of each isolated defect with 0 or 2–0 delayed absorbable suture

• Avoid taking large amounts of tissue or excessively deep suture bites
• Avoid overly aggressive plication of levator ani, which can lead to ridge or constriction of the vagina, or significant decrease in genital hiatus, which results in dyspareunia, or both
• Perform serial vaginal and rectal examinations to ensure adequate caliber and no undue tension or ridge and no suture in the rectum

8. Trim excess vaginal epithelium, if necessary
9. Re-approximate vaginal epithelium with 3–0 delayed absorbable suture in interrupted, subcuticular, or running fashion

• Dyspareunia (5–45%)
• Blood loss
• Short-term voiding dysfunction
• Fecal incontinence
• Constipation
• Rectovaginal fistula formation

• Midline and site-specific repairs have been shown to be equivalent¹
• No difference between traditional and site-specific repairs in anatomic and symptomatic outcomes
  • Both improved quality of life
  • No difference in dyspareunia
• Transanal rectocele repair associated with higher rate of recurrence than transvaginal technique²

¹Paraiso MF, et al. Am J Obstet Gynecol 2006;195:1762–71.
²Maher C, et al. The Cochrane database of systematic reviews. 2013;4:CD004014.

• Anatomic cure rate of 76–93%
• No data to support benefit from using synthetic mesh or biologic graft augmentation