Paravaginal Defect Repair

The goal of the paravaginal defect repair is to correct anterior vaginal wall prolapse that results from loss of lateral support by reattaching the lateral vaginal sulcus to its normal lateral attachment site. The lateral vagina attaches to the levator ani muscle on each side along a line from the anterior pubic rami to the ischial spine known as the "white line" or arcus tendineus fasciae pelvis (ATFP). The ATFP is formed from a condensation of the obturator internus and levator ani fascia and is composed primarily of organized fibrous collagen, making the lateral connective tissue attachment of the vagina more dense than the superior/ apical connective tissue support of the cardinal and uterosacral complex. The paravaginal defect repair can be performed retropubically or vaginally.

Retropubic Approach

The retropubic approach for the repair of paravaginal defects can be performed via laparotomy or laparoscopy. In our opinion, the surgical technique for these two approaches, other than the means of access to the retropubic space, should be identical.

The patient is placed in modified lithotomy position using low leg holders such as Allen stirrups and is draped to allow both abdominal and vaginal access. The bladder is drained with a Foley catheter. The abdomen may be entered through either a transverse or vertical abdominal incision or via laparoscopy. The retropubic space is entered, and the bladder is retracted medially to expose the lateral aspect of the retropubic space. The pubic bone, obturator muscle, obturator fossa, and neurovascular bundle are identified. Blunt dissection is used to identify the lateral vagina, urethra, and ischial spine. The normal site of lateral vaginal attachment on the pelvic sidewall from the interior aspect of the superior pubic ramus to the ischial spine is then identified. If the lateral vagina is avulsed from this attachment site,then a paravaginal defect is present. Because physical examination is less than perfect in identifying paravaginal detachment, a bilateral assessment of paravaginal support should be made in all patients in whom paravaginal defects are suspected.

The surgeon's nondominant hand is then placed into the vagina and used to elevate the lateral superior vaginal sulcus to its site of normal attachment along the course of the ATFP. Typically, four to six simple interrupted stitches of nonabsorbable suture (No. 0 or 2-0) are used to reattach the lateral vagina to the ATFP. The first suture is placed through full thickness (excluding the vaginal epithelium) of the lateral vaginal apex and then through the ATFP and the aponeurosis of the levator ani muscle just distal to the ischial spine. This suture is tied and cut. Additional sutures are placed at 1-cm intervals through the lateral vaginal wall and into the levator ani aponeurosis along the entire course of the ATFP. In patients with a cystocele and genuine stress incontinence, many surgeons combine an abdominal paravaginal repair with a Burch colposuspension (Figure 83.3). At the end of the procedure, cystoscopy should be performed to document ureteral patency and the absence of intravesical sutures. Closed-suction drainage of the retropubic space is rarely indicated. Postoperatively, the bladder is drained with either a transurethral or suprapu-bic catheter until normal voiding occurs.

Paravaginal Defect

Figure 8-3.3. A, Retropubic approach to the paravaginal defect repair. The avulsed vaginal sulcus has been sutured to the arcus tendineus fascia pelvis bilaterally. B,The paravaginal repair has been combined with a Burch colposuspension to provide preferential support to the urethrovesical junction. (Reprinted from Cundiff GW, Addison WA. Management of Pelvic Organ Prolapse in Obstetrics and Gynecology Clinics of North America 1998;25:914, Copyright © 1998, with permission from Elsevier.]

Figure 8-3.4. Vaginal paravaginal repair. Marking sutures placed at urethrovesical junction and vaginal apices. (Reprinted from Shull BL, Benn SJ, Kuehl TJ.Surgical management of prolapse of the anterior vaginal segment: an analysis of support defects, operative morbidity and anatomic outcomes. Am J Obstet Gynecol, 1994;171:1429-39, Copyright © 1994, with permission from Elsevier.)

Figure 8-3.3. A, Retropubic approach to the paravaginal defect repair. The avulsed vaginal sulcus has been sutured to the arcus tendineus fascia pelvis bilaterally. B,The paravaginal repair has been combined with a Burch colposuspension to provide preferential support to the urethrovesical junction. (Reprinted from Cundiff GW, Addison WA. Management of Pelvic Organ Prolapse in Obstetrics and Gynecology Clinics of North America 1998;25:914, Copyright © 1998, with permission from Elsevier.]

Figure 8-3.4. Vaginal paravaginal repair. Marking sutures placed at urethrovesical junction and vaginal apices. (Reprinted from Shull BL, Benn SJ, Kuehl TJ.Surgical management of prolapse of the anterior vaginal segment: an analysis of support defects, operative morbidity and anatomic outcomes. Am J Obstet Gynecol, 1994;171:1429-39, Copyright © 1994, with permission from Elsevier.)

Figure 8-3.5. Vaginal paravaginal repair. A right-angle retractor is in the retropubic space, retracting the bladder medially.The suture is through the arcus tendineus fasciae pelvis approximately 2 cm ventral to the ischial spine. (Reprinted from Shull BL,Benn SJ, Kuehl TJ.Surgical management of prolapse of the anterior vaginal segment: an analysis of support defects, operative morbidity and anatomic outcomes. Am J Obstet Gynecol, 1994;171:1429-39, Copyright © 1994, with permission from Elsevier.)

Vaginal Approach

Paravaginal defect repair using the transvaginal approach can be more challenging than the retropubic approach, but offers the advantage of avoiding an abdominal incision and facilitating a concurrent central defect repair for those women with loss of midline as well as lateral anterior vaginal support. The technique begins similar to that of the central defect repair described above (Figures 8-3.4-8-3.7). The patient is placed in dorsal lithotomy position using candy-cane stirrups. A Foley catheter is used to drain the bladder. A weighted speculum is placed into the vagina. A midline vertical incision is made through the vaginal epithelium from the mid urethra to the vaginal apex. The vaginal epithelium is then sharply dissected off the underlying vaginal muscularis and the dissection is continued laterally to the pelvic sidewall from immediately behind the pubic rami to the level of the ischial spine. Visualization of the adipose tissue of the retropubic space from this transvaginal approach confirms the presence of a paravaginal defect, because normal lateral attachment of the anterior vaginal wall would preclude this. If visualization is limited,

Figure 8-3.5. Vaginal paravaginal repair. A right-angle retractor is in the retropubic space, retracting the bladder medially.The suture is through the arcus tendineus fasciae pelvis approximately 2 cm ventral to the ischial spine. (Reprinted from Shull BL,Benn SJ, Kuehl TJ.Surgical management of prolapse of the anterior vaginal segment: an analysis of support defects, operative morbidity and anatomic outcomes. Am J Obstet Gynecol, 1994;171:1429-39, Copyright © 1994, with permission from Elsevier.)

Figure 8-3.6. Vaginal paravaginal repair.A series of sutures has been placed in the arcus tendineus fasciae pelvis from a point ventral to the ischial spine to the back of the pubic bone. (Reprinted from Shull BL, Benn SJ, Kuehl TJ.Surgical management of prolapse of the anterior vaginal segment: an analysis of support defects, operative morbidity and anatomic outcomes. Am J Obstet Gynecol, 1994;171:1429-39, Copyright © 1994, with permission from Elsevier.]

Figure 8-3.6. Vaginal paravaginal repair.A series of sutures has been placed in the arcus tendineus fasciae pelvis from a point ventral to the ischial spine to the back of the pubic bone. (Reprinted from Shull BL, Benn SJ, Kuehl TJ.Surgical management of prolapse of the anterior vaginal segment: an analysis of support defects, operative morbidity and anatomic outcomes. Am J Obstet Gynecol, 1994;171:1429-39, Copyright © 1994, with permission from Elsevier.]

gentle palpation of the lateral attachment site can be used. The ability of the examining finger to enter the retropubic space indicates a paravaginal defect. Every precaution should be taken to avoid iatrogenic creation of paravaginal defects with dissection, palpation, or retractors.

Figure 8-3.7. Vaginal paravaginal repair. The suture in the arcus tendineus fasciae pelvis near the pubic bone is also sewn into the lateral margin of the pubocervical fascia periurethrally at the site of the marking suture at the urethrovesical junction. (Reprinted from Shull BL, Benn SJ, Kuehl TJ. Surgical management of prolapse of the anterior vaginal segment: an analysis of support defects, operative morbidity and anatomic outcomes. Am J Obstet Gynecol, 1994;171:1429-39,Copyright © 1994, with permission from Elsevier.]

Figure 8-3.7. Vaginal paravaginal repair. The suture in the arcus tendineus fasciae pelvis near the pubic bone is also sewn into the lateral margin of the pubocervical fascia periurethrally at the site of the marking suture at the urethrovesical junction. (Reprinted from Shull BL, Benn SJ, Kuehl TJ. Surgical management of prolapse of the anterior vaginal segment: an analysis of support defects, operative morbidity and anatomic outcomes. Am J Obstet Gynecol, 1994;171:1429-39,Copyright © 1994, with permission from Elsevier.]

Once a paravaginal defect is identified, the normal site of lateral attachment of the vagina should be clearly visualized. This can be facilitated by placing a gauze sponge through the paravaginal defect into the retropubic space and using a narrow Deaver retractor to retract the sponge, underlying adipose tissue and lateral bladder anteriorly. A Briesky-Navratil retractor can then be used to retract the remainder of the bladder medially, thereby clearly exposing the levator ani muscle and the course of the ATFP from the ischial spine to the inferior aspect of the pubic ramus. Four to six interrupted nonabsorbable sutures (No. 0 or 20) are placed through the ATFP and the aponeurosis of the levator ani muscle from the level of the ischial spine to the pubic symphysis at 1-cm intervals and their needles left on. Once all of the stitches are placed through the ATFP, the sponge in the retropubic space is removed. Each stitch is then placed through the lateral edge of the detached vaginal muscularis (pubocervical or vesicopelvic fascia) at their corresponding level and then tied. Once paravaginal support has been assessed and, if necessary, restored on both sides, a midline plication of pubocervical fascia (anterior colporrhaphy), a bladder neck plication, or sling, can be performed, as necessary. The vaginal epithelium is then trimmed and closed. If a vaginal hysterectomy is needed, this should be performed before the paravaginal defect repair. If a vaginal vault suspension or culdoplasty is necessary, these sutures should be placed before the paravaginal defect repair, but not tied until the paravaginal defect repair has been completed. As with the retro-pubic approach, cystoscopy should be performed at the end of the procedure to confirm ureteral patency and the absence of intravesical sutures. Transurethral or suprapubic bladder drainage should continue until normal voiding occurs.

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