Surgical Repair of Anterior Vaginal Wall Prolapse

  • Shlomo Raz


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.


Cystocele Rectocele Hysterectomy Enterocele 

Supplementary material

Video 3.1

Four-corner bladder and bladder neck suspension for lateral defect cystocele. The procedure is used for the repair of cystocele when the lateral defect is predominant. Two oblique incisions are made in lateral vaginal wall extending to the bladder base. The periurethral and perivesical fasciae are dissected laterally, and the retropubic space is entered to expose the attachment of the urethropelvic and vesicopelvic fascia to the arcus tendineus fascia pelvis. #0 monofilament polypropylene sutures are used to incorporate a wide segment of vesicopelvic fascia and perivesical fascia at the bladder base. A second suture is applied to incorporate the urethropelvic fascia, periurethral fascia, and perivesical fascia at the bladder neck and urethra. Multiple passes of the needle allow the incorporation of a strong anchor of tissue. A small puncture is performed in the suprapubic area, and a double-pronged passer is used to transfer the sutures from the vagina to the suprapubic area. After cystoscopy, the sutures are tied without tension (MP4 550184 kb)

Video 3.2

Cystocele repair using interlocking polypropylene sutures (CRISP). The procedure is done for the repair of central and lateral defect cystocele. After exposure of the anterior vaginal wall, four #2-0 polypropylene sutures are applied to the lateral pelvic wall and arcus tendineus fascia pelvis (two at the bladder base and two at the bladder neck area) including the lateral perivesical fascia. The central defect repair is done with #2-0 polypropylene sutures in a mattress fashion. The central defect sutures are tied after interlocking each of them with the laterally placed sutures. The lateral sutures are tied individually creating a net of polypropylene sutures to support the anterior vaginal wall (MP4 211616 kb)

Video 3.3

Transvaginal hysterectomy for vaginal prolapse. The cervix is grasped with a four-pronged tenaculum (Lahey clamp) and retracted. A circular incision is made on the cervix using a coagulation knife. Anteriorly, the cervix and anterior uterus are dissected from the bladder wall without entering the peritoneum. Posterior cervix and posterior uterus are dissected free from the vaginal and rectal wall. The posterior peritoneum is entered (cul-de-sac). We isolate the clamp and tie the sacrouterine–cardinal complex using #0 delayed absorbable sutures. We isolate the clamp and tie the uterine pedicle. After performing the same maneuver on both sides, the uterus is everted, the anterior peritoneum is opened, and the bladder is retracted anteriorly. The broad ligaments are clamped and tied. Laparotomy pads are inserted into the peritoneum and the bladder retracted anteriorly. Vault suspension sutures of #1 PDS (polydioxanone) are applied from outside the vaginal wall lateral to the cuff, to the prerectal fascia, and to the origin of the sacrouterine–cardinal ligaments (lateral to the sacrum, medial to the levators, and distal to the sacrospinous ligament). The end of the needle is passed back 1–2 cm from the original entrance. Purse-string sutures are applied to the prerectal fascia, the sacrouterine–cardinal complex stump, the broad ligaments, and the perivesical fascia at the bladder base (pubocervical). Two purse-string sutures are applied and tied to close the cul-de-sac. After closure of the vaginal cuff, the vault suspension sutures are tied, providing depth and support to the vaginal cuff (MP4 624982 kb)

Video 3.4

Enterocele repair. The vaginal cuff is marked with absorbable sutures. A vertical incision is made at the cuff of the vagina. The vaginal wall is dissected free to expose the enterocele sac. The enterocele sac is open and laparotomy pads are inserted to retract the anterior bladder. #1 PDS (polydioxanone) sutures are used. From outside the vaginal wall, the needle enters the peritoneum to incorporate the prerectal fascia origin, origin of the sacrouterine–cardinal ligaments (lateral to the sacrum, medial to the levators, and distal to the sacrospinous ligament). The end of the needle is passed back 1–2 cm from the original entrance. The same maneuver is performed in the contralateral side. Two purse-string sutures are applied to the prerectal fascia, lateral peritoneum, and the bladder base and tied. After excision of excess vaginal wall, the vault suspension sutures are tied to provide depth and support to the cuff (MP4 624246 kb)

Video 3.5

Rectocele repair. The posterior fourchette is excised, and an inverted triangular excision of the posterior vaginal wall is excised to expose the distal posterior vaginal wall and area. A strip of the posterior vaginal wall is excised to expose the prerectal and pararectal fascia. With an anterior retractor, the length of the posterior vaginal wall is exposed. Delayed absorbable sutures are used to incorporate the edge of the vaginal wall and pararectal fascia. Multiple running, locking sutures are used. In the distal 3 cm of the vagina, figure-of-eight sutures incorporate the edge of the vaginal wall, the pararectal fascia, and the perineal membrane, narrowing the levator hiatus and elevating the distal vagina. The perineal defect is repaired with multiple vertical mattress sutures (MP4 237617 kb)

Suggested Reading

  1. Baessler K, Maher CF. Mesh augmentation during pelvic-floor reconstructive surgery: risks and benefits. Curr Opin Obstet Gynecol. 2006;18:560–6.CrossRefPubMedGoogle Scholar
  2. 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.Google Scholar
  3. Barber MD, Maher C. Epidemiology and outcome assessment of pelvic organ prolapse. Int Urogynecol J. 2013;24(11):1783–90.CrossRefPubMedGoogle Scholar
  4. 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.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 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.CrossRefPubMedGoogle Scholar
  6. 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.CrossRefPubMedGoogle Scholar
  7. Cervigni M, Natale F. The use of synthetics in the treatment of pelvic organ prolapse. Curr Opin Urol. 2001;11:429–35.CrossRefPubMedGoogle Scholar
  8. DeLancey JO. Structural anatomy of the posterior pelvic compartment as it relates to rectocele. Am J Obstet Gynecol. 1999;180(4):815–23.CrossRefPubMedGoogle Scholar
  9. DeLancey JOL. Fascial and muscular abnormalities in women with urethral hypermobility and anterior vaginal wall prolapse. Am J Obstet Gynecol. 2002;187:93–8.CrossRefPubMedGoogle Scholar
  10. 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.CrossRefPubMedGoogle Scholar
  11. 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.CrossRefPubMedGoogle Scholar
  12. Huebner M, Hsu Y, Fenner DE. The use of graft material in vaginal pelvic floor surgery. Int J Gynaecol Obstet. 2006;92:279–88.CrossRefPubMedGoogle Scholar
  13. 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.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 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.Google Scholar
  15. Kahn MA, Stanton SL. Posterior colporrhaphy: its effects on bowel and sexual function. Br J Obstet Gynaecol. 1997;104:82–6.CrossRefPubMedGoogle Scholar
  16. Karram M, Maher C. Surgery for posterior vaginal wall prolapse. Int Urogynecol J. 2013;24(11):1835–41.CrossRefPubMedGoogle Scholar
  17. Lantzsch T, Goepel C, Wolters M, Koelbl H, Methfessel HD. Sacrospinous ligament fixation for vaginal vault prolapse. Arch Gynecol Obstet. 2001;265:21–5.CrossRefPubMedGoogle Scholar
  18. Maher C. Anterior vaginal compartment surgery. Int Urogynecol J. 2013;24(11):1791–802.CrossRefPubMedGoogle Scholar
  19. Maher C, Baessler K. Surgical management of posterior vaginal wall prolapse: an evidence-based literature review. Int Urogynecol J. 2005;17:84–8.CrossRefGoogle Scholar
  20. Maher C, Baessler K. Surgical management of anterior vaginal wall prolapse: an evidence based literature review. Int J Gynaecol Obstet. 2006;17:195–201.Google Scholar
  21. 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.CrossRefGoogle Scholar
  22. 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.Google Scholar
  23. Maher C, Feiner B, Baessler K, Schmid C. Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev. 2013;30:4.Google Scholar
  24. 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.CrossRefGoogle Scholar
  25. 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.CrossRefGoogle Scholar
  26. 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.CrossRefPubMedGoogle Scholar
  27. 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.CrossRefPubMedGoogle Scholar
  28. 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.CrossRefGoogle Scholar
  29. 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.CrossRefPubMedPubMedCentralGoogle Scholar
  30. Richter LA, Carter C, Gutman RE. Current role of mesh in vaginal prolapse surgery. Curr Opin Obstet Gynecol. 2014;26(5):409–14.CrossRefPubMedGoogle Scholar
  31. 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.Google Scholar
  32. 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.CrossRefPubMedGoogle Scholar
  33. Sze EH, Karram MM. Transvaginal repair of vault prolapse: a review. Obstet Gynecol. 1997;89:466–75.CrossRefPubMedGoogle Scholar
  34. Tarr ME, Paraiso MF. Minimally invasive approach to pelvic organ prolapse: a review. Minerva Ginecol. 2014;66(1):49–67.PubMedGoogle Scholar
  35. 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.CrossRefPubMedGoogle Scholar
  36. 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.Google Scholar
  37. 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.CrossRefPubMedGoogle Scholar
  38. 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.CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Shlomo Raz
    • 1
  1. 1.Division of Pelvic Medicine and Reconstructive SurgeryUCLA School of MedicineLos AngelesUSA

Personalised recommendations