The Obstetrician & Gynaecologist 2007;9:4:233-242
doi: 10.1576/toag.9.4.233.27353
Copyright © 2007 by the Royal College of Obstetricians and Gynaecologists.
Mesh-free anterior vaginal wall repair: history or best practice?
Geoff R McCracken, MRCOG, Clinical Fellow1 and
Guylaine Lefebvre, MD, Chief of Staff2
1. 15014 Cardinal Carter South, St Michael's Hospital, 30 Bond Street, Toronto, Ontario, Canada Email: mccrackengeoff{at}hotmail.com (corresponding author)
2. St Michael's Hospital, Toronto, Ontario, Canada
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Abstract
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Key content:- Surgical correction of anterior vaginal wall prolapse is a common gynaecological procedure, with traditional anterior colporrhaphy changing little over the past 100 years.
- Within the literature, terminology is confusing, both on anatomical structures and classification of anterior vaginal wall prolapse.
- Synthetic meshes have become available but the evidence to support their use is limited and long-term adverse effects are not clear.
- The paravaginal repair is an alternative to consider and can be approached vaginally, abdominally or laparoscopically.
Learning objectives:
- To revise the relevant anatomy of the anterior vaginal compartment and the classification of anterior vaginal wall prolapse.
- To review the evidence for the use of permanent mesh in pelvic floor surgery.
- To learn about the surgical options for correction of anterior vaginal wall prolapse without the use of vaginal mesh.
Ethical issues:
- Should permanent meshes be used for anterior vaginal wall prolapse outside a clinical research setting?
Please cite this article as: McCracken GR, Lefebvre G. Mesh-free anterior vaginal wall repair: history or best practice? The Obstetrician & Gynaecologist 2007;9:233–242.
Keywords anterior colporrhaphy / anterior vaginal wall prolapse / paravaginal repair / pelvic floor surgery / synthetic mesh
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Introduction
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The purpose of this review is to re-evaluate meshless surgical procedures for anterior vaginal wall prolapse and to determine whether they still have a place in modern gynaecological practice. Anterior vaginal wall prolapse is common. As many as 50% of parous women demonstrate pelvic organ prolapse on examination.1 It is estimated that 11% of women have a lifetime risk of surgery for pelvic organ prolapse.2 The aetiology is complex and multifactorial (Box 1). Anterior vaginal prolapse is defined as the ‘pathological descent of the anterior vaginal wall and overlying bladder base’.3 The International Continence Society prefers the terminology ‘anterior vaginal prolapse’ over ‘cystocele’ because physical examination does not allow exact identification of the structures behind the vaginal wall.3
Surgical correction of anterior vaginal wall prolapse is one of the oldest gynaecological procedures performed. In 1913, Kelly4 described the plication of the internal orifice of the urethra and urethral sphincter muscle with midline plication for anterior vaginal wall repair: thus, anterior colporrhaphy was born. However, successful treatment of anterior vaginal wall prolapse continues to be one of the most challenging surgical procedures in gynaecology. This is mainly because of the high recurrence rates, with reports of up to 40% of women requiring further corrective surgery after standard anterior colporrhaphy.5,6
One of the main difficulties in reviewing the success of anterior colporrhaphy is the marked variation in technique. Recently, the high rate of recurrence has led to the development of synthetic meshes, with reported cure rates in uncontrolled studies of between 93–100%.7,8 However, within the specialty there is a level of concern about the long-term benefits and morbidity associated with their use.
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Surgical techniques using synthetic mesh
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Synthetic meshes have been used with increasing frequency in gynaecological surgery, both vaginally and abdominally, over the last 30 years.9 The use of synthetic mesh in the management of urodynamic stress incontinence in the form of tension-free vaginal tape (TVT) is an example of its widespread acceptance, with good evidence supporting its use.10 In addition, the National Institute for Health and Clinical Excellence (NICE) has recommended TVT as a first-line surgical procedure alongside the ‘gold standard’ Burch colposuspension.11 However, this should not be extrapolated to the use of synthetic meshes in the management of anterior vaginal wall prolapse.
The success of abdominal sacrocolpopexy with mesh for the management of vaginal vault prolapse is also well demonstrated, with large case series reporting success rates between 85–100%.12–18 This is not equivalent to vaginal mesh insertion. Sacrocolpopexy is an intra-abdominal procedure performed in a sterile operating field, compared with vaginal surgery, which involves a contaminated field. Visco et al.19 suggested that there was a four-fold increase in mesh erosion or infection when mesh was introduced vaginally compared with the abdominal route.
In 2004 Maher and Baessler20 performed a literature review for the Cochrane Database, looking at the surgical management of pelvic organ prolapse. They concluded that there was evidence, although limited, to suggest that polyglactin (absorbable) mesh can reduce the risk of recurrent cystocele, but the extent of adverse effects on the bladder, bowel and sexual function were unknown. They followed with a review article in 200621 on surgical management of anterior vaginal wall prolapse.7,22–30 They ultimately concluded that there was level 1 and 2 evidence to support the use of absorbable mesh for anterior vaginal wall prolapse in terms of decreasing recurrent prolapse but, again, the evidence was limited and longer-term adverse effects were not considered. They also stated that no recommendation could be made from the available literature on the efficacy and safety of synthetic permanent mesh in the management of anterior vaginal wall prolapse.
The pore size of the mesh is a crucial consideration. Pores should be >75 microns to facilitate passage of macrophages, fibroblasts, blood vessels and collagen fibres.31,32 Mesh composition is also important. Monofilament materials are considered safer than multifilaments, which have interstices of <10 microns, which will harbour bacteria that inflammatory cells are too large to reach.33 Polypropylene monofilament meshes are the most common manufactured meshes. Examples include: Prolene® (Ethicon Ltd, Livingston, UK), Marlex® (Bard Ltd, Crawley, UK) and Gynemesh® (Ethicon Ltd, Livingston, UK).
Significant complications have been associated with vaginal mesh, including:
- Infection and sinus tract formation: there is little in the literature on infection rates, per se, but there is a four-fold increase in mesh erosion or infection when mesh is used vaginally compared with abdominally.19
- Tape erosion: rates of 20–25% have been reported, with 1.4–2% of all patients requiring mesh excision.7,23,34
- Dyspareunia: Milani et al.35 found a 12.5% increase in de novo dyspareunia following anterior vaginal wall repair. They conclude from this case series that use of prolene mesh for prolapse repair should be abandoned.
- ‘Hispareunia’: a new term coined for the symptom of painful sexual intercourse experienced by the male partner, caused by the mesh fibres.
Lower urinary tract symptoms, such as urgency, urge urinary incontinence and voiding dysfunction, have not been examined in relation to the presence of vaginal mesh. The ideal mesh would be resistant to infection, cause minimal tissue reaction, be noncarcinogenic and resistant to mechanical stress or shrinkage and would allow normal function of the surrounding tissues. This mesh does not yet exist.
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Pelvic floor anatomy
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A sound anatomical knowledge of the pelvic floor, in particular the anterior compartment, is imperative before embarking on the repair of anterior vaginal wall prolapse. The difficulty with understanding the anatomy is that gynaecologists and anatomists have long debated the histological and anatomical relationship of the vagina, urethra and bladder, with the result that there is a myriad of terms and classifications of tissues. Table 1 attempts to categorise many of the terms used. Opinion can be divided into two groups: those who believe that the vagina and bladder are invested in fascial compartments and those who do not believe in fascial compartments.
Beneath the anterior vaginal mucosa lies a loose layer of connective tissue, the lamina propria. Beneath this is the vaginal muscularis, a fibromuscular layer consisting of smooth muscle, collagen and elastin. The pubocervical fascia is the layer of tissue that develops when separating the vaginal mucosa from the vaginal muscularis layer. Within the literature, the terms pubocervical fascia and vaginal muscularis are interchangeable. The muscularis layer is then surrounded by an adventitial layer composed of collagen, elastin and adipose tissue and containing blood vessels, lymphatics and nerves (Figure 1).
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Figure 1
Normal vaginal wall65 A = vaginal wall epithelium; B = vaginal wall muscularis; C = peritoneum (Reproduced with permission from Lippincott Williams & Wilkins)
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Farrell's study36 on the histological components of the tissue referred to as ‘fascia’ revealed that it consists of moderately dense connective tissue with smooth muscle, similar to the deep aspects of the vaginal wall. They also found that it is an artifact of the surgical dissection used to separate the vaginal wall from the underlying organs.36 This is often quoted as a reason for failure of anterior repair. However, it is a visible layer of tissue that can be used surgically to reconstruct a platform on which the bladder will lie. Failure to do so leaves only vaginal mucosa or detrusor fibres, which will inevitably fail.
The lateral aspects of the anterior wall of the vagina are attached by fibrous connections to the levator ani muscles at the arcus tendineus fasciae pelvis (Figure 2), which extends from the pubic symphysis to each ischial spine. It is often visualised as a white line overlying the obturator internus.
As described by Delancy,37 there are three levels of pelvic organ support:- I: the upper vagina is supported by the uterosacral and cardinal ligaments.
- II: anteriorly, the upper two-thirds of the vagina lie adjacent to and support the bladder base by a hammock-like configuration, whereby the pubocervical fascia attaches to the arcus tendineus fasciae pelvis.
- III: the distal third of the vagina is fused with the urethra and is supported by connections to the perineal membrane and its muscular components: the compressor urethrae and urethrovaginal sphincter.
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Types of anterior vaginal wall prolapse
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There are essentially two types: midline and paravaginal.
Midline defect
Nichols and Randall38 suggested that overdistension of the vagina during vaginal delivery, along with ageing and the menopause, result in thinning of the vaginal tissue and lead to central weakness. This is seen clinically as anterior vaginal wall prolapse with loss of the vaginal rugal folds (Figure 3).
Paravaginal defect
In 1909, White39 described the paravaginal repair, which addressed repair of anterior vaginal wall prolapse resulting from detachment of the lateral attachments of the vagina to the arcus tendineus fasciae pelvis – otherwise known as the ‘white line’. The clinical sign for this type of prolapse is the preservation of the vaginal rugal folds (Figure 4).
There is a paucity of evidence showing correlation between clinical findings and subsequent surgical findings. Further, in effect, many or most anterior vaginal wall defects are a combination of midline, unilateral and bilateral defects.
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Classification of anterior vaginal wall prolapse
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Within the literature there is much confusion regarding the classification of anterior vaginal wall prolapse. Standardisation of the terminology to describe pelvic organ prolapse is essential for logical comparison between different studies. There are three main systems of classification:The Beecham and Baden–Walker systems are generally used in clinical settings, whereas the POPQ system is considered to be a research tool. The POPQ system provides a validated, precise method of assessing pelvic organ prolapse and has been formally accepted by the International Continence Society, the American Urogynecologic Society and the Society of Gynecologic Surgeons. However, it is still used in fewer than 50% of clinical studies.43 The probable reason for this low rate is the perception that it is an onerous task to use the system.
When assessing the anterior vaginal wall using the POPQ system, the woman should be in a semi-reclined lithotomy position. There are two reference points (Table 4). Point Aa is located in the midline of the anterior vaginal wall, 3 cm proximal to the external urethral meatus, corresponding to the approximate location of the ‘urethrovesical crease.’ The range of locations of point Aa relative to the hymen is reported to be –3 to +3 cm. Point Ba represents the most distal (i.e. most dependent) position of any part of the upper anterior vaginal wall from the vaginal cuff or anterior vaginal fornix to point Aa. By definition, point Ba is at –3 cm in the absence of prolapse and would have a positive value equal to the position of the cuff in women with total post-hysterectomy vaginal eversion.
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Aims of surgery
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It is important to obtain a thorough history and examination and perform diagnostic tests in consultation with the woman before she is considered for a surgical correction of anterior vaginal wall prolapse. Ultimately, the goals of surgery should be:- relief of symptoms
- correction of the anterior vaginal wall defect
- maintenance or improvement of bladder and sexual function
- prevention of new bladder or sexual problems or iatrogenic pelvic support defects
- long-term anatomical and functional success, with no need for future pelvic reconstructive surgery.
These goals can be adjusted for individual women, such that expectations and risks are clearly outlined. The woman who has severe incontinence with minimal anterior vaginal wall prolapse will not be cured by anterior repair alone. The elderly woman who is prepared to have no future sexual function of the vagina may be well served by a generous repair that will significantly narrow the vagina, trading sexual function for improved long-term support of the vagina.
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Surgical methods of mesh-free vaginal reconstruction
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Evidence is largely lacking for surgical methods used in vaginal reconstruction. Much of the literature is based on case series with small numbers of women, short periods of follow-up and poor definitions of cure. It is hoped that this will improve as the POPQ, as well as validated prolapse questionnaires such as the PISQ questionnaire 44 are increasingly used. The wide variety of surgical treatments available for anterior vaginal wall prolapse indicates the lack of consensus as to the optimal management. Here we consider and describe five procedures to correct anterior vaginal wall prolapse without using mesh.
Anterior colporrhaphy +/– Kelly plication
Anterior colporrhaphy is recommended for midline defects and has been the traditional choice for the past century. The principle of the procedure is to plicate the layers of vaginal muscularis and adventitia that overlie the bladder. There are many variations of the procedure, which differ according to the shape of vaginal incision, how far the dissection extends laterally, the layers that are dissected, where the plication sutures are placed and the type of sutures used. The technique described below is the variation used within our department and which has evolved from the procedure used at the Mayo Clinic, Rochester, Minnesota. This method is known as the modified Kennedy anterior repair. See Box 2 for some ‘pearls and pitfalls’ of this procedure.
Method
- If a vaginal hysterectomy or vault repair has been performed, straight clamps are placed on either side of the vaginal wall at the medial border of the anterior vaginal vault. Otherwise, a transverse incision is made in the vaginal mucosa near the apex. An additional clamp is placed below the external urethral meatus. If there is loss of the urethrovesical angle, the clamp is placed approximately 1 cm below the external urethral meatus, otherwise the angle is left undisturbed and the clamp placed below the urethrovesical angle.
- Using Metzenbaum scissors and toothed pickups, the vaginal epithelium, including the muscularis, is separated in the midline to the level of the anterior clamp. The vagina is incised vertically in the midline.
- Allis clamps (also known as Allis forceps) are then placed along the cut edge. The vaginal muscularis (pubocervical fascia) is carefully dissected from the vaginal epithelium (Figure 5A). The surgeon should ensure that the vaginal muscularis is not removed from the underlying detrusor muscle. It is important to be in the correct dissection plane for two reasons: first, bleeding tends to occur if the dissection is in the adventitial layer as described in the anatomical section and, second, the aim is to harvest as much vaginal muscularis as possible, as this forms the basis of the repair.
- The vaginal muscularis is plicated using 2–0 absorbable suture material in an interrupted fashion (Figure 5B). If there is loss of the urethrovesical angle, a plicating suture at the urethrovesical junction is placed to restore anatomy (the Kelly plication).
- The redundant vaginal wall is then resected and the vaginal edges re-opposed using 2–0 absorbable suture in an interrupted fashion, being careful to avoid the urethra and yet, at the same time, to pick up underlying vaginal muscularis to close the dead space (Figure 5C and Figure 5D).
Choice of suture is mainly dependent on the surgeon. The rationale for using absorbable suture is that, ultimately, the woman's own fascia will provide anatomical support, while some centres prefer to use delayed absorbable suture to facilitate this process.
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Figure 5A
Dissection of vaginal mucosa from vaginal muscularis (cervicopubic fascia). (Adapted with the permission of the Mayo Foundation for Medical Education and Research. All rights reserved)68
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Figure 5B
Plication of vaginal muscularis (cervicopubic fascia) and Kelly plication. (Adapted with the permission of the Mayo Foundation for Medical Education and Research. All rights reserved)68
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Figure 5C and Figure 5D
Closure of vaginal mucosa with obliteration of the dead space between the mucosa and vaginal muscularis. (Adapted with the permission of the Mayo Foundation for Medical Education and Research. All rights reserved)68
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Methods of paravaginal repair
Paravaginal repair was first described by White39 and is recommended for paravaginal defects. It was not until the 1970s, when Richardson45 described an abdominal retropubic approach, that paravaginal repair became widely accepted. The procedure has now evolved into vaginal paravaginal repair, as described by Shull46 in 1989. More recently, laparoscopic approaches have been described.
The abdominal approach
The principles for abdominal and laparoscopic approaches are essentially the same. See Box 3 for some pearls and pitfalls of the abdominal approach.
- The retropubic space is entered and the bladder and vagina pulled medially to reveal the lateral defect due to avulsion of the vagina from the arcus tendineus fasciae pelvis. Figure 6 demonstrates the appearance of the defect.
- The surgeon's non-dominant hand is placed in the vagina and elevates the antero-lateral vaginal sulcus and retracts the bladder medially.
- A non-absorbable monofilament suture is placed through the full thickness of the vagina and then into the obturator internus fascia or arcus tendineus fasciae pelvis 1–2 cm anterior to the ischial spine and 3–4 cm below the obturator canal. Subsequent sutures are placed 1 cm apart towards the pubic ramus (Figure 7). The obturator canal limits the distal aspect of the repair.
The vaginal approach
The vaginal approach to paravaginal repair was described by Mallipeddi.47 See Box 4 for some pearls and pitfalls of this procedure.- The bladder neck and base are marked with sutures in the vaginal epithelium (Figure 8A).
- The vaginal epithelium is sharply dissected off the vaginal muscularis in a similar manner to anterior colporrhaphy. The dissection extends laterally to the pelvic side wall from behind the pubic ramus to the ischial spine.
- If needed, a midline plication of the vaginal muscularis is performed (Figure 8B).
- Careful examination laterally confirms the paravaginal defect by revealing retropubic fat. Blunt finger dissection is used to gain complete access to the retropubic space (Figure 8C).
- A non-absorbable monofilament suture is placed in the white line 1 cm proximal to the ischial spine and a series of 4–6 sutures is placed along the arcus tendineus towards the inner aspect of the symphysis (Figure 8D).
- A three-point closure is then performed, incorporating the arcus tendineus, the lateral edge of the vaginal muscularis and the vaginal epithelium (Figures 8E and D). The sutures are tied sequentially.
- Vaginal tissue is not trimmed until all stitches are tied. After trimming, the anterior vagina is closed in a similar manner as for anterior colporrhaphy.
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Figure 8
Figure 8A Unopened anterior vaginal wall with marking sutures placed at anatomic level of bladder neck and vaginal apex. Figure 8B Anterior vaginal wall opened via a midline incision. Sutures are placed for midline cystocele repair. Figure 8C Midline cystocele repair completed. Bilateral paravaginal defects identified. Figure 8D Bladder retracted medially to expose the lateral pelvic side wall. Permanent sutures have been passed through the white line. Figure 8E The top two sutures have been passed through detached edge of pubocervical fascia. Figure 8F The three-point closure is completed, with all the sutures passed through the pubocervical fascia and inside wall of the vagina (Reproduced with kind permission from Springer Science and Business Media)47
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Transabdominal repair by wedge colpectomy
In 1978, Macer48 described the excision of a triangular wedge from the anterior vaginal wall at the time of abdominal hysterectomy. Although the success rate for grade 1 anterior vaginal wall prolapse has been shown to be as high as 96% with this technique, preoperative grade 2 anterior vaginal wall prolapse was cured in only 75% of women.49 This procedure is included for completeness, but we feel that the indications are severely limited. We find little justification for laparotomy with the goal of resecting redundant vagina for women with pelvic relaxation.
Within many reviews, including Maher's,21 the impression is that paravaginal repair has a better outcome than anterior colporrhaphy, with success rates ranging from 67–100%, compared with 37–100%.27,28,46–63 However, the follow-up time is generally longer for anterior colporrhaphy and, therefore, conclusions about the superiority of one procedure over another cannot be made. There is no consensus regarding the indications for vaginal paravaginal repair. There are no randomised control studies comparing anterior colporrhaphy with paravaginal repair. Although highly successful, vaginal paravaginal repair is technically challenging and is performed in relatively few centres.
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Conclusion
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Repair of anterior vaginal wall prolapse remains one of the most challenging components of pelvic floor reconstruction in terms of initial success and ultimate durability. However, not all anterior vaginal wall repairs are created equal and, indeed, of all operations, there is perhaps the widest difference in individual technique.
It is not suggested that the anterior vaginal wall be treated in isolation, but rather as part of a continuum from apical to posterior wall defects. Both of these defects have been reviewed recently within The Obstetrician & Gynaecologist and we would like to draw attention to Afifi and Sayed's review of post-hysterectomy vaginal vault prolapse.64 Urinary dysfunction should also be considered in planning concomitant surgery.
Any surgeon deciding on the appropriate procedure should select the operation most appropriate to the needs of the woman and pay attention to their own success and failure rates. If their technique is successful and complications are low, there may be little room for improvement. If women have early recurrences or experience complications, a different approach is in order.
There is insufficient evidence, at present, to recommend the use of permanent meshes for the repair of anterior vaginal wall prolapse. It may be wise to restrict the use of vaginally applied mesh to the clinical research or tertiary referral setting until a larger evidence base is available. Efficacy and erosion rates should be considered along with bladder, bowel and sexual function as measures of success.
One hundred years ago, Ahlfelt stated that ‘the only problem in plastic gynaecology left unsolved by the gynaecologist of the past century is that of permanent cure of cystocele’.39 We would argue that this is, sadly, still true today.
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Abstract
Introduction
