Tips & Tricks in Common Surgeries: Cystocele

Cystocele or Anterior Vaginal Wall Prolapse Repair

The current terminology for cystocele is prolapse or descent of the anterior vaginal wall due to a defect in the supports of anterior vaginal wall. It is also called anterior compartment defect. The upper two-thirds of the anterior vaginal wall is supported by the levator ani muscle and endopelvic fascia, which extends from the cervix and vagina medially to the arcus tendinous fascia pelvis laterally (the bladder and urethra are supported by the vagina). Defect of any of these specific supports can lead to prolapse of the genital organs. Therefore, during repair, the site of defect should be identified and site-specific repair is to be done. The anterior vaginal wall defect may be central, paravaginal, transverse, or distal due to defect in the vertical portion of the endopelvic fascia, detachment of the arcus tendinous fascia pelvis from the vaginal wall, split of the pubocervical fascia or breaking of the vaginal supportive fascia near the symphysis pubis respectively. During repair, attention should be given to reconstruct the identified defect. In addition, reconstruction of the associated apical or posterior defect need to be done to reduce the risk of recurrence. Thus, before surgery, proper pre-operative assessment is mandatory (surgical correction should only be done if symptomatic prolapse).

Steps of Anterior Repair (Paravaginal Repair)

1. The initial step is to involve the patient in the decision-making process and let them explain their expectations from the surgery. The final outcome of surgery and possible complications are also explained to the patient.
2. Proper pre-operative measures are taken, including control of any co-morbidities, antibiotic prophylaxis, thromboprophylaxis if necessary, and in post-menopausal women, application of oestrogen.
3. The surgical site should be exposed properly through proper positioning (lithotomy) and use of appropriate retractors. Ensure adequate lighting. Catheterize the bladder.
4. The urethrovesical junction should be identified and marked by marker pen. Vertically extend the marking from just below the neck up to the lower limit of prolapse. The area of neck must be avoided otherwise it may lead to voiding dysfunction.
5. Infiltrate the vagina with a mixture of 20 ml of saline and 20 ml of local anesthetic or vasopressin (20 units in 100 ml of saline). Blenching of vaginal mucosa indicates desired vasoconstriction which minimizes blood loss.
6. One Allis clamp is placed just below the level of the neck of the bladder approximately 1cm away from the urethral meatus, and another is placed at the lower end of the marking in the midline. Avertical incision is made along the marking line on the vaginal wall, deepening it just above the bladder. Infiltrated saline can be visible and may confused with urine. Alternatively, an invested T incision can be made with a transverse incision being extended from the lower end of the vertical incision lateral to the cervix on either side.
7. The vaginal wall is carefully dissected from the bladder by sharp and blunt dissection. Dissection of the vaginal mucosa from the bladder may start from below and proceed laterally and upwards up to the level of bladder neck for adequate separation of the bladder, but precaution must be taken to avoid excessive mobilization as excess correction may lead to voiding dysfunction. Pubocervical or paravaginal repair is then performed.
8. In most locations, repair using native tissue is preferable as a primary procedure, irrespective of facilities. In addition, many countries have restrictions or ban of the use of synthetic mesh or grafts due to mesh complications.
9. Plicate the fascia starting from below the urethra-bladder neck and proceed gradually up to the cervix. Adequate bite should be taken to take fascia from the left side and then fascia from the right side and tie in the midline by interrupted suture with vicryl 2-0. This should extend up to the level of the cervix. At this part, near the apex, care needs to be taken to prevent recurrence of the cystocele or anterior vaginal prolapse. Here, first to take the pubocervical fascia from the left side, then the cardinal-uterosacral ligament of the left side, and then the apex of cervix; next take the pubocervical fascia of the right side, then the cardinal-uterosacral ligament of right side, and finally the pubocervical ligament of right side and tie it in the midline.
10. Next, the excess vaginal wall is trimmed. After securing hemostasis, the vaginal wall is repaired either by continuous or by interrupted vicryl 2-0 suture. Excision of too much vaginal wall may lead to dyspareunia. It is surprising that the vagina, which seems excess during surgery, nicely undergoes remodeling over the course of time.
11. At the end of surgery, a vaginal pack is to be inserted for post-operative hemostasis.
12. Post-operatively, a urethral catheter can be removed after 24 hours and then post void residual (PVR) urine is measured. If significant PVR on two occasions, reinsert catheter and allow the patient to be discharged home. Consider TWO after 48 hours by a district nurse. Local policies and guidelines regarding PVR management should be followed.
13. Prophylactic antibiotic use depends on personal choice of the surgeon and the facility’s infection prevention policy.
14. Though there is no restriction for mobilization, the patient should be advised to not lift any weight greater than 5 lbs and to avoid sexual intercourse for one to one and a half months. The patient may resume normal work after 4-6 weeks.

Tips & Tricks for Anterior Vaginal Wall Repair

1. Avoid the bladder neck during dissection of the vaginal mucosa. The point of dissection should start at least 1 cm below it. This region represents the urethrovesical junction and over correction here may lead to post-operative voiding dysfunction and retention.
2. Blenching of the vaginal mucosa after infiltration of the local anesthetic agent gives a clue that adequate infiltration is being done.
3. Diluted local anesthetic, when injected beneath the vaginal mucosa, serves the purpose of hydro-dissection. This helps provide easy access to the correct plane and subsequently the dissection becomes easier with a lesser amount of bleeding.
4. Sharp dissection is preferable to blunt in separating the vaginal mucosa from the underlying fascia and bladder wall. Blunt dissection may cause more injury to the bladder.
5. Optimum correction is the key to a good outcome. Over correction may lead to voiding dysfunction.

The surgeon must not be tempted to remove the sagging redundant vagina after cystocele correction. Excision of too much vaginal wall may lead to dyspareunia and as mentioned earlier, the vaginal tissue which seems excess during surgery will nicely undergo remodeling over the course of time.