Paravaginal repair

Abstract

Pelvic organ prolapse is defined as the descent of one or more of the pelvic organs including the uterus, vagina, bladder or bowel due to laxity of pelvic fascial structures and/or disruption of attachments to the pelvic sidewall. Usually defects arise together as the fascia has several interconnected layers. As the endopelvic fascia weakens and releases from the arcus tendinous fascia pelvis (ATFP), cystocele due to lateral paravaginal prolapse occurs. The pubocervical fascia is contiguous with the circular muscular layers of the vagina and attaches to the endopelvic fascia laterally. This can also weaken centrally producing a midline or central cystocele defect. Optimal surgical management requires addressing both lateral and central cystocele if present, with the goal of preventing persistent and/or recurrent prolapse. Central cystocele repair is addressed in Chap. 6. Reconstitution of the fascial attachments between the vagina and AFTP can be accomplished from the vaginal or abdominal approach depending on surgeon preference. Due to the FDA warning, most surgeons are veering away from synthetic mesh due to risk of erosion and extrusion, although synthetic mesh has been associated with less anatomical recurrence. This anatomic success has not been shown to correlate with subjective outcomes; therefore biologic graft or native repairs are used to avoid the risk of operative re-intervention for mesh complications. There are several surgical techniques utilized by surgeons today for paravaginal repair. We will describe our technique in this chapter, as well as surgical indications, preoperative preparation, alternate surgical techniques and surgical risks. In the end, it is important to educate your patient on all risks and benefits of each option and what would suit her needs best.