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Surgical Repair of Anterior Vaginal Wall Prolapse ; When, Why, and How I Place Vaginal Mesh

Surgical Repair of Anterior Vaginal Wall Prolapse ; When, Why, and How I Place Vaginal Mesh. Mickey Karram MD Director of Urogynecology The Christ Hospital Professor of Ob/ Gyn & Urology University of Cincinnati Cincinnati, Ohio U.S.A. Objectives.

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Surgical Repair of Anterior Vaginal Wall Prolapse ; When, Why, and How I Place Vaginal Mesh

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  1. Surgical Repair of Anterior Vaginal Wall Prolapse; When, Why, and How I Place Vaginal Mesh Mickey Karram MD Director of Urogynecology The Christ Hospital Professor of Ob/Gyn & Urology University of Cincinnati Cincinnati, Ohio U.S.A

  2. Objectives Discuss the anatomy of the anterior vaginal wall, retropubic space, and inner groin Review clinical presentation and preoperative evaluation of a patient with symptomatic cystocele Discuss surgical dissection plans and various techniques to transvaginally repair anterior vaginal wall prolapse with and without mesh Review outcomes of suture repairs vs mesh augmented repairs

  3. Cystocele Ahlfelt states that the only problem in plastic gynecology left unsolved by the gynecologist of the past century is the permanent cure of cystocele George R. White 1909

  4. Specific Surgical Goals: Maintain or Create a Well Supported Functional Vagina What is normal vaginal length? What is normal vaginal caliber? What is normal relationship between perineum and posterior vaginal wall? What is normal vaginal axis? What is the most important aspect of your repair? How do you determine who needs an augmented repair?

  5. Types of Anterior Vaginal Wall Prolapse True cystocele (distention cystocele) Displacement cystocele

  6. Etiology of Cystocele Separation of paravaginal attachment of the pubocervical fascia from the white line Loss of vagina’s attachment to the cervix Tearing of pubocervical fascia that results in herniation of the bladder through this layer

  7. Anterior Vaginal Prolapse Weber And Walters (Obstet Gynecol 1997;89:311-8) “Pubocervical fascia is really vaginal muscularis and adventitia.”

  8. Obturator Canal Ilium Obturator Foramen Ischiopubic Ramus Pubic symphysis Ischium

  9. Transobturator Landmarks Adductor longus Urethra Obturator canal Safe entry zone of Transobturator needle

  10. Vaginal Repair of Enterocele

  11. Anatomy of Anterior Vagina

  12. How Does a Patient with Anterior Vaginal Wall Prolapse Present Completely asymptomatic Typical symptoms of prolapse with no functional derangements A variety of functional rerangements without prolapse symptoms Combination of prolapse symptoms and functional derangements Rarely presents in complete isolation

  13. Pre-operative Evaluation History Good physical exam Objective assessment of lower urinary tract function Cystourethroscopy Imaging studies

  14. Anterior and Posterior Vaginal Wall Prolapse Extent of dissection for cystocele repair (lateral to inferior pubic ramus and dissection of bladder base off of vaginal cuff) Extent of dissection for rectocele repair (lateral to rectal gutter and proximally to preperitoneal space of cul-de-sac)

  15. Surgical Repair of Cystocele • Vaginal approaches (anterior colporrhaphy with vesical neck plication) • Abdominal approaches • Vaginal paravaginal repairs • Mesh augmented repairs • Mesh overlay • Trocar based mesh kit • Direct access mesh kit

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