We describe a new transvaginal technique for cystocoele repair. We prospectively evaluated patients with moderate and high-grade cystocoele who underwent repair with the new transvaginal repair between 2000 and June 2009. Preoperative evaluation included history and physical examination using the Pelvic Organ Prolapse Quantification, urine culture, residual urine measurement, urodinamycs and cystoscopy. We performed the repair in 76 patients with a mean age of 65.24 years (range, 36 to 84 years), wit anatomical cure in 72 (95%) patients. Four (5%) patients had recurrent cystocoele, 3 (4%) patients claimed residual sensory urgency and 4 (5%) stress urinary incontinence (SUI) after the operation. The operation is safe, simple, and provides good anatomic results with minimal complications

Anton Maričić

Antun Gršković

Dražen Rahelić

Maksim Valenčić

Romano Oguić

Stanislav Sotošek

HRČAK - Portal of Croatian Scientific and Professional Journals

Coll. Antropol. 34 (2010) Suppl. 2: 191–194Professional paperModified Extensive Anterior Vaginal Wall Repairfor CystocoeleMaksim Valen~i}, Anton Mari~i}, Romano Ogui}, Dra`en Raheli}, Stanislav Soto{ek andAntun Gr{kovi}Department of Urology, University Hospital of Rijeka, Rijeka, CroatiaA B S T R A C TWe describe a new transvaginal technique for cystocoele repair. We prospectively evaluated patients with moderate andhigh-grade cystocoele who underwent repair with the new transvaginal repair between 2000 and June 2009. Preopera-tive evaluation included history and physical examination using the Pelvic Organ Prolapse Quantification, urine cul-ture, residual urine measurement, urodinamycs and cystoscopy. We performed the repair in 76 patients with a mean ageof 65.24 years (range, 36 to 84 years), wit anatomical cure in 72 (95%) patients. Four (5%) patients had recurrent cysto-coele, 3 (4%) patients claimed residual sensory urgency and 4 (5%) stress urinary incontinence (SUI) after the operation.The operation is safe, simple, and provides good anatomic results with minimal complications.Key words: cystocoele, anterior colporaphy, urodinamycsIntroductionEstimating the true incidence of pelvic floor disordersis difficult, because many women accept uterovaginalprolapse as an inevitable consequence of childbirth andageing1. It is obvious that the incidence of genital pro-lapse increases with age. Symmonds et al. Reported intheir study that 60% of patients with vaginal vault pro-lapse were over 60 years of age2. Over a half of womenaged >75 years may think that their symptoms are nor-mal for elderly people3. In the USA over 200,000 surger-ies are performed yearly for the treatment of POP. Themajority of these procedures are performed on the olderwoman5. The estimated demand for care of pelvic floordisorders has been projected to increase by 45% over thenext 30 years. Pelvic floor surgery is considered an inter-mediate risk procedure with perioperative mortality ra-tes from 0.0% to 4.1% and complication rates from 15.5%to 33.0%5. Surgical techniques to address anterior de-fects are the anterior colporrhaphy and paravaginal re-pair. Repair of the anterior vaginal wall is associatedwith the highest long-term failure rates of all the vaginalwall defect repairs, reaching over 60%. In this article wedescribe an own, modified extensive anterior vaginal wallrepair in women with cystocoele.Patients and MethodsWe retrospectively analyzed the records of 76 patientswho between 2000 and 2009 underwent an operation forcystocoele. We have been performing an own, modified,extensive anterior vaginal wall repair. The average age ofthe patients was 65.24 years (range: 36 to 84 years, me-dian: 60.0 years). Preoperative evaluation included clini-cal history, physical examination using the Pelvic OrganProlapse Quantification, urine culture, residual urinemeasurement, urodinamycs and cystoscopy. Evaluationhas been performed with the patient in the dorsal litho-tomy position and all quantifications have been obtainedunder a strong Valsalva maneuver causing maximal pro-lapse of the vaginal tissue. Stage II cystocoele has beendiagnosed in 12, stage III in 31 and stage IV in 33 pa-tients (Table 1).191Received for publication January 10, 2010All patients underwent a modified extensive anteriorvaginal wall repair. The operation is performed in thedorsal lithotomy position with candy-cane stirrups. Aweighted vaginal speculum is placed, and labial retrac-tion sutures of 2–0 silk are used for maximal exposure. A16-Fr Foley catheter is placed per urethra. A ring retrac-tor with four hooks is placed to expose the introitus. Theanterior vaginal wall is grasped and everted through theintroitus. The limbs of the T-formed incision are locatedon the anterior vaginal wall just outside of the reflectionof the lateral walls of the vagina. The horizontal part ofthe T-formed incision is located directly under the blad-der neck, wherefrom a single incision is carried to thelevel of the vaginal apex in the midline (Figure 1). Thecut edges of the vaginal wall in the midline are graspedwith Allis clamps. Lateral and anterior dissection is car-ried out first. The entire bladder base with attached fas-cia should be dissected free of the vaginal wall. Poste-riorly, the dissection is carried to the level of the vaginalapex in the region of the cardinal ligaments. A 1–0 poly-propylene suture is placed in the helical pattern thatcatches the urethropelvic ligament, pubocervical liga-ments and cardinal ligament with the vaginal wall troughthe edge of endopelvic fascia at both sides. The suturesare tied at both ends (Figure 2).Repair starts with the reapproximation of the area ofthe cardinal ligaments, in the midline with a 1–0 braidedsynthetic nonabsorbable suture, catching the polypropy-lene suture. Attention is now turned to the urethropelvicligament, lateral to the bladder neck on either side. Ahorizontal stitch of 1–0 braided synthetic nonabsorbablesuture is used to plicate this fascia toward the midline,catching the polypropylene suture also. The cystocoele isreduced manually and the remaining perivesical fascia isthen plicated from the level of the bladder neck to thecardinal ligaments with interrupted horizontal suturesof 1–0 braided synthetic nonabsorbable sutures (Figure3). The sutures repairing the central defect are now tied.M. Valen~i} et al.: Modified Repair of Cystocoele, Coll. Antropol. 34 (2010) Suppl. 2: 191–194192TABLE 1DISTRIBUTION OF CYSTOCOELE RELATIVE TO THE AGE AND STAGEAge 30–39 40–49 50–59 60–69 70–79 >80Stage 1 0 0 0 0 0 0Stage 2 1 0 3 1 7 0Stage 3 0 5 13 6 6 1Stage 4 0 1 3 7 20 2Total 1 (1%) 6 (8%) 19 (25%) 14 (18%) 33 (44%) 3 (4%)Fig. 1. Incision of the vaginal wall.Fig. 2. Polypropylene suture of the pubocervical fascia and vagi-nal wallFig. 3. Plication of the pubocervical fasciaThe ends of the polypropylene suture are cut as short aspossible to avoid a later perforation of the vaginal wall.The limbs of the T-formed incision are closed with inter-rupted 2–0 absorbable sutures. The excess vaginal wall istrimmed, and the vaginal wall is reapproximated with in-terrupted 2–0 absorbable suture. The vagina is packedwith antibiotic-impregnated gauze. The vaginal pack isremoved in 24 hours. Three days after surgery Foleycatheter is removed. When the residual urine is less than50 cc the patient is discharged from the hospital. The pa-tient may resume all regular activities immediately post-operatively, except heavy lifting, running, and sexual in-tercourse for four weeks.ResultsThe mean operative time was 55 min (range 45 to 80min). No intraoperative or immediate postoperative com-plications have been observed. The average follow-upwas 60.14 months (range 3–120 months, median 61.5months), with 72 (95%) anatomical cures. In our serieswe had 4 (5%) patients with recurrent cystocoele, 2 ofthem with initial stage 3 and one with stage 4. In 2 pa-tients the cause of the recurrence was the postoperativeperforation of the vaginal wall trough a long end of thepolypropylene suture left, with consequent vegetations,what made a suture extraction necessary. The other 2 pa-tients had a dehiscence of the polypropylene sutures.Three (4%) patients claimed residual sensory urgencyand 4 (5%) stress urinary incontinence (SUI) after theoperation.Discussion and ConclusionOlder woman are at high risk for developing condi-tions of the pelvic floor that require intervention. Con-sideration of conservative treatment modalities is recom-mended, however, surgery should not be avoided basedon age alone4. The use of numerous materials and tech-niques has been described to reinforce or replace inade-quate anterior vaginal tissue. There are few randomizedprospective studies available that have proved significantbenefit with the use of reinforcement material over ante-rior colporrhaphy alone. Several studies reported excel-lent results and low erosion rates with transvaginal im-plantation of polypropylene mesh for the correction ofanterior vaginal wall, with 75–94% anatomic cure, but2.1–24% mash erosion also8–12. We have been performinganterior colporaphy using nonabsorbable sutures for theplication of the pubocervical fascia. This suture repre-sents a nucleus for the development of a strong fibrousbridge between the bladder neck and vaginal apex as asupport of the anterior vaginal wall and bladder. The op-eration is safe, simple, and provides good anatomic re-sults with minimal complications.R E F E R E N C E S1. BIDMEAD J, CARDOZO LD, BJU International, 82 (1998) 18. —2. SYMMONDS RE, WILLIAMS TJ, LEE RA, ET AL, Am J Obstet Gy-necol, 140 (1981) 852. — 3. GJORUP T, HENDRIKSEN C, LUND E, ETAL, J Chron Dis, 40 (1987) 1095. — 4. GERTEN KA, RICHTER HE, ClinObstet Gynecol, 50 (2007) 826. — 5. HAMILTON BOYLES S, WEBERAM, MEYN L, Am J Obstet Gynecol, 188 (2003) 108. — 6. LUBER KM,BOERO S, CHOE JY. Am J Obstet Gynecol 184 (2001) 1496. — 7. AB-RAMS P, Incontinence (Health Publications Ltd, Paris, 2005). — 8.HOENIL J, JAE WK, NOH HP, ET AL, J Obstet Gynecol Res 33 (2007)700. — 9. AMRUTE KV, EISENBERG ER, RASTINEHAD AR, ET AL,Neurourol Urodyn, 26 (2007) 53. — 10. GAURUDER-BURMESTER A,KOUTOUZIDOU P, ROHNE J, ET AL, Int Urogynecol J, 18 (2007) 1059.— 11. ORESKOVIC S, KALAFATIC D, GRSIC HL, GOJEVIC A,GREGOV M, BABIC I, Coll Antropol, 33(1) (2009) 201. — 12. VALENCICM, SPANJOL J, MARICIC A, MARKIC D, FUCKAR D, BOBINAC M, CollAntropol, 32(Suppl 2) (2008) 207.M. ValencicDepartment of Urology, University Hospital of Rijeka, T. Strizica 3, 51000 Rijeka, Croatiae-mail: maksim.valencic@ri.t-com.hrM. Valen~i} et al.: Modified Repair of Cystocoele, Coll. Antropol. 34 (2010) Suppl. 2: 191–194193TABLE 2RESULTS OF MODIFIED EXTENSIVE ANTERIOR VAGINAL WALLREPAIR FOR CYSTOCOELEAnatomical cure 72 (95%)Recurrent cystocoele 4 (5%)Sensory urgency 3 (4%)SUI 4 (5%)MODIFICIRANA PRO[IRENA PREDNJA VAGINALNA PLASTIKA U LIJE^NJU CISTOCELES A @ E T A KU ovoj studiji opisujemo novu tehniku za transvaginalni popravak cistocele. Prospektivno smo pratili bolesnice scistocelom umjerog i visokog stupnja, koje su bile podvrgnute novoj metodi transvaginalnog popravka izme|u 2000godine i lipnja 2009. Prijeoperacijska evaluacija uklju~uje anamnezu i fizikalni pregled koriste}i pregled u spekulimazatim urinokulturu, mjerenje ostatnog urina, urodinamiku i cistoskopiju. Izvr{ili smo popravak u 76 bolesnika srednjedobi od 65.24 godine (raspon od 36 do 84 godine). Popravak je bio uspje{an u 72 (95%) bolesnice. U ~etiri (5%) bolesniceiamli smo povratak cistocele, 3 (4%) bolesnice imale su i dalje urgenciju, a 4 (5%) stres inkontinenciju (SUI) nakonoperacije. Operacija je sigurna, jednostavna, a daje anatomski dobre rezultate s minimalnim komplikacijama.M. Valen~i} et al.: Modified Repair of Cystocoele, Coll. Antropol. 34 (2010) Suppl. 2: 191–194194

English

Modified Extensive Anterior Vaginal Wall Repair for Cystocoele

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Coll. Antropol. 34 (2010) Suppl. 2: 191–194Professional paperModified Extensive Anterior Vaginal Wall Repairfor CystocoeleMaksim Valen~i}, Anton Mari~i}, Romano Ogui}, Dra`en Raheli}, Stanislav Soto{ek andAntun Gr{kovi}Department of Urology, University Hospital of Rijeka, Rijeka, CroatiaA B S T R A C TWe describe a new transvaginal technique for cystocoele repair. We prospectively evaluated patients with moderate andhigh-grade cystocoele who underwent repair with the new transvaginal repair between 2000 and June 2009. Preopera-tive evaluation included history and physical examination using the Pelvic Organ Prolapse Quantification, urine cul-ture, residual urine measurement, urodinamycs and cystoscopy. We performed the repair in 76 patients with a mean ageof 65.24 years (range, 36 to 84 years), wit anatomical cure in 72 (95%) patients. Four (5%) patients had recurrent cysto-coele, 3 (4%) patients claimed residual sensory urgency and 4 (5%) stress urinary incontinence (SUI) after the operation.The operation is safe, simple, and provides good anatomic results with minimal complications.Key words: cystocoele, anterior colporaphy, urodinamycsIntroductionEstimating the true incidence of pelvic floor disordersis difficult, because many women accept uterovaginalprolapse as an inevitable consequence of childbirth andageing1. It is obvious that the incidence of genital pro-lapse increases with age. Symmonds et al. Reported intheir study that 60% of patients with vaginal vault pro-lapse were over 60 years of age2. Over a half of womenaged >75 years may think that their symptoms are nor-mal for elderly people3. In the USA over 200,000 surger-ies are performed yearly for the treatment of POP. Themajority of these procedures are performed on the olderwoman5. The estimated demand for care of pelvic floordisorders has been projected to increase by 45% over thenext 30 years. Pelvic floor surgery is considered an inter-mediate risk procedure with perioperative mortality ra-tes from 0.0% to 4.1% and complication rates from 15.5%to 33.0%5. Surgical techniques to address anterior de-fects are the anterior colporrhaphy and paravaginal re-pair. Repair of the anterior vaginal wall is associatedwith the highest long-term failure rates of all the vaginalwall defect repairs, reaching over 60%. In this article wedescribe an own, modified extensive anterior vaginal wallrepair in women with cystocoele.Patients and MethodsWe retrospectively analyzed the records of 76 patientswho between 2000 and 2009 underwent an operation forcystocoele. We have been performing an own, modified,extensive anterior vaginal wall repair. The average age ofthe patients was 65.24 years (range: 36 to 84 years, me-dian: 60.0 years). Preoperative evaluation included clini-cal history, physical examination using the Pelvic OrganProlapse Quantification, urine culture, residual urinemeasurement, urodinamycs and cystoscopy. Evaluationhas been performed with the patient in the dorsal litho-tomy position and all quantifications have been obtainedunder a strong Valsalva maneuver causing maximal pro-lapse of the vaginal tissue. Stage II cystocoele has beendiagnosed in 12, stage III in 31 and stage IV in 33 pa-tients (Table 1).191Received for publication January 10, 2010All patients underwent a modified extensive anteriorvaginal wall repair. The operation is performed in thedorsal lithotomy position with candy-cane stirrups. Aweighted vaginal speculum is placed, and labial retrac-tion sutures of 2–0 silk are used for maximal exposure. A16-Fr Foley catheter is placed per urethra. A ring retrac-tor with four hooks is placed to expose the introitus. Theanterior vaginal wall is grasped and everted through theintroitus. The limbs of the T-formed incision are locatedon the anterior vaginal wall just outside of the reflectionof the lateral walls of the vagina. The horizontal part ofthe T-formed incision is located directly under the blad-der neck, wherefrom a single incision is carried to thelevel of the vaginal apex in the midline (Figure 1). Thecut edges of the vaginal wall in the midline are graspedwith Allis clamps. Lateral and anterior dissection is car-ried out first. The entire bladder base with attached fas-cia should be dissected free of the vaginal wall. Poste-riorly, the dissection is carried to the level of the vaginalapex in the region of the cardinal ligaments. A 1–0 poly-propylene suture is placed in the helical pattern thatcatches the urethropelvic ligament, pubocervical liga-ments and cardinal ligament with the vaginal wall troughthe edge of endopelvic fascia at both sides. The suturesare tied at both ends (Figure 2).Repair starts with the reapproximation of the area ofthe cardinal ligaments, in the midline with a 1–0 braidedsynthetic nonabsorbable suture, catching the polypropy-lene suture. Attention is now turned to the urethropelvicligament, lateral to the bladder neck on either side. Ahorizontal stitch of 1–0 braided synthetic nonabsorbablesuture is used to plicate this fascia toward the midline,catching the polypropylene suture also. The cystocoele isreduced manually and the remaining perivesical fascia isthen plicated from the level of the bladder neck to thecardinal ligaments with interrupted horizontal suturesof 1–0 braided synthetic nonabsorbable sutures (Figure3). The sutures repairing the central defect are now tied.M. Valen~i} et al.: Modified Repair of Cystocoele, Coll. Antropol. 34 (2010) Suppl. 2: 191–194192TABLE 1DISTRIBUTION OF CYSTOCOELE RELATIVE TO THE AGE AND STAGEAge 30–39 40–49 50–59 60–69 70–79 >80Stage 1 0 0 0 0 0 0Stage 2 1 0 3 1 7 0Stage 3 0 5 13 6 6 1Stage 4 0 1 3 7 20 2Total 1 (1%) 6 (8%) 19 (25%) 14 (18%) 33 (44%) 3 (4%)Fig. 1. Incision of the vaginal wall.Fig. 2. Polypropylene suture of the pubocervical fascia and vagi-nal wallFig. 3. Plication of the pubocervical fasciaThe ends of the polypropylene suture are cut as short aspossible to avoid a later perforation of the vaginal wall.The limbs of the T-formed incision are closed with inter-rupted 2–0 absorbable sutures. The excess vaginal wall istrimmed, and the vaginal wall is reapproximated with in-terrupted 2–0 absorbable suture. The vagina is packedwith antibiotic-impregnated gauze. The vaginal pack isremoved in 24 hours. Three days after surgery Foleycatheter is removed. When the residual urine is less than50 cc the patient is discharged from the hospital. The pa-tient may resume all regular activities immediately post-operatively, except heavy lifting, running, and sexual in-tercourse for four weeks.ResultsThe mean operative time was 55 min (range 45 to 80min). No intraoperative or immediate postoperative com-plications have been observed. The average follow-upwas 60.14 months (range 3–120 months, median 61.5months), with 72 (95%) anatomical cures. In our serieswe had 4 (5%) patients with recurrent cystocoele, 2 ofthem with initial stage 3 and one with stage 4. In 2 pa-tients the cause of the recurrence was the postoperativeperforation of the vaginal wall trough a long end of thepolypropylene suture left, with consequent vegetations,what made a suture extraction necessary. The other 2 pa-tients had a dehiscence of the polypropylene sutures.Three (4%) patients claimed residual sensory urgencyand 4 (5%) stress urinary incontinence (SUI) after theoperation.Discussion and ConclusionOlder woman are at high risk for developing condi-tions of the pelvic floor that require intervention. Con-sideration of conservative treatment modalities is recom-mended, however, surgery should not be avoided basedon age alone4. The use of numerous materials and tech-niques has been described to reinforce or replace inade-quate anterior vaginal tissue. There are few randomizedprospective studies available that have proved significantbenefit with the use of reinforcement material over ante-rior colporrhaphy alone. Several studies reported excel-lent results and low erosion rates with transvaginal im-plantation of polypropylene mesh for the correction ofanterior vaginal wall, with 75–94% anatomic cure, but2.1–24% mash erosion also8–12. We have been performinganterior colporaphy using nonabsorbable sutures for theplication of the pubocervical fascia. This suture repre-sents a nucleus for the development of a strong fibrousbridge between the bladder neck and vaginal apex as asupport of the anterior vaginal wall and bladder. The op-eration is safe, simple, and provides good anatomic re-sults with minimal complications.R E F E R E N C E S1. BIDMEAD J, CARDOZO LD, BJU International, 82 (1998) 18. —2. SYMMONDS RE, WILLIAMS TJ, LEE RA, ET AL, Am J Obstet Gy-necol, 140 (1981) 852. — 3. GJORUP T, HENDRIKSEN C, LUND E, ETAL, J Chron Dis, 40 (1987) 1095. — 4. GERTEN KA, RICHTER HE, ClinObstet Gynecol, 50 (2007) 826. — 5. HAMILTON BOYLES S, WEBERAM, MEYN L, Am J Obstet Gynecol, 188 (2003) 108. — 6. LUBER KM,BOERO S, CHOE JY. Am J Obstet Gynecol 184 (2001) 1496. — 7. AB-RAMS P, Incontinence (Health Publications Ltd, Paris, 2005). — 8.HOENIL J, JAE WK, NOH HP, ET AL, J Obstet Gynecol Res 33 (2007)700. — 9. AMRUTE KV, EISENBERG ER, RASTINEHAD AR, ET AL,Neurourol Urodyn, 26 (2007) 53. — 10. GAURUDER-BURMESTER A,KOUTOUZIDOU P, ROHNE J, ET AL, Int Urogynecol J, 18 (2007) 1059.— 11. ORESKOVIC S, KALAFATIC D, GRSIC HL, GOJEVIC A,GREGOVM, BABIC I, Coll Antropol, 33(1) (2009) 201. — 12. VALENCICM, SPANJOL J, MARICIC A, MARKIC D, FUCKAR D, BOBINACM, CollAntropol, 32(Suppl 2) (2008) 207.M. ValencicDepartment of Urology, University Hospital of Rijeka, T. Strizica 3, 51000 Rijeka, Croatiae-mail: maksim.valencic@ri.t-com.hrM. Valen~i} et al.: Modified Repair of Cystocoele, Coll. Antropol. 34 (2010) Suppl. 2: 191–194193TABLE 2RESULTS OF MODIFIED EXTENSIVE ANTERIOR VAGINAL WALLREPAIR FOR CYSTOCOELEAnatomical cure 72 (95%)Recurrent cystocoele 4 (5%)Sensory urgency 3 (4%)SUI 4 (5%)MODIFICIRANA PRO[IRENA PREDNJA VAGINALNA PLASTIKA U LIJE^NJU CISTOCELES A @ E T A KU ovoj studiji opisujemo novu tehniku za transvaginalni popravak cistocele. Prospektivno smo pratili bolesnice scistocelom umjerog i visokog stupnja, koje su bile podvrgnute novoj metodi transvaginalnog popravka izme|u 2000godine i lipnja 2009. Prijeoperacijska evaluacija uklju~uje anamnezu i fizikalni pregled koriste}i pregled u spekulimazatim urinokulturu, mjerenje ostatnog urina, urodinamiku i cistoskopiju. Izvr{ili smo popravak u 76 bolesnika srednjedobi od 65.24 godine (raspon od 36 do 84 godine). Popravak je bio uspje{an u 72 (95%) bolesnice. U ~etiri (5%) bolesniceiamli smo povratak cistocele, 3 (4%) bolesnice imale su i dalje urgenciju, a 4 (5%) stres inkontinenciju (SUI) nakonoperacije. Operacija je sigurna, jednostavna, a daje anatomski dobre rezultate s minimalnim komplikacijama.M. Valen~i} et al.: Modified Repair of Cystocoele, Coll. Antropol. 34 (2010) Suppl. 2: 191–194194

Modified Extensive Anterior Vaginal Wall Repair for Cystocoele

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