Vaginal paravaginal repair. Mallipeddi et al17 reported on 45 patients undergoing vaginal paravaginal repair over 2 years, with 35 women followed for a mean of 1.6 years. Incontinent patients had a Kelly plication performed at the time of vaginal paravaginal repair. Recurrence rates were 3% for cystocele, 14% for rectocele, and 20% for enterocele.
Young et al18 followed 100 women for as long as 36 months after bilateral paravaginal repair using 1 to 6 expanded polytetrafluoroethylene (Gore-Tex) CV-0 sutures and midline colporrhaphy. Two patients had grade 1 or 2 failure at the lateral fixation points, but 21 patients had recurrent midline defects, all but 1 inside the hymen. Several patients had bloody discharge from the permanent sutures.
Sacrocolpopexy. Brubaker19 retrospectively reviewed 65 women who underwent sacrocolpopexy for apical prolapse. Three months postoperatively 19 patients (29%) had persistent anterior wall defects.
Uterosacral suspension. Shull et al20 also found the anterior segment to have the most recurrent defects. In that study, which had an average follow-up of a little over a year, 289 patients underwent vaginal uterosacral ligament repair of the apex, and 264 had an anterior wall defect preoperatively. At the time of furthest follow-up, 26 patients (9%) had failure at this site. This study confirmed that the anterior compartment is the most likely site to fail, and also that it fails the quickest.
Sacrospinous ligament suspension (SSLS). Morley and DeLancey21 found a 22% cystocele recurrence rate in 71 women 1 year after SSLS, with most of them asymptomatic. Shull22 reported a 30% incidence of cystoceles after SSLS. Paraiso and colleagues23 reported on 243 women undergoing SSLS and pelvic reconstructive surgery. Of these, 217 patients underwent concomitant anterior colporrhaphy. Follow-up at 74 months found 37% with symptomatic recurrence at the anterior wall, 13% at the posterior wall, and 8% at the apex.
Vaginal versus abdominal repair
Few studies have compared vaginal and abdominal repair of pelvic organ prolapse, including anterior wall prolapse.
In a trial by Benson et al,24 women with prolapse to or beyond the hymen were randomized to bilateral sacrospinous vault suspension and vaginal paravaginal repair (n = 48) or abdominal sacrocolpopexy with abdominal paravaginal repair (n = 40). One third of patients in each group also underwent anterior colporrhaphy. After a mean follow-up of 2.5 years, 16 of 20 women required reoperation for recurrent cystocele—12 (29%) from the vaginal group and 4 (10.5%) from the abdominal group. Vaginal vault eversion recurred in 5 women from the vaginal group and 1 from the abdominal group.
Investigators concluded that the anterior wall was the most likely site of failure because of the posterior placement of the vaginal apex with SSLS, predisposing the anterior wall to greater pressures and to neuropathy caused by lateral dissection of the anterior wall. Earlier studies have demonstrated that neuropathy may occur after extensive dissection of the vaginal wall and may affect the strength and integrity of the muscular support tissues.25,26
Allografts and xenografts
The difficulty of repairing anterior wall prolapse has led some pelvic surgeons to use mesh for cystocele repair. When Julian27 randomized 24 patients with recurrent cystocele to transvaginal repair with and without polypropylene (Marlex) mesh, 4 patients in the control group and no patients in the mesh group had recurrences (P <.05). However, 3 patients (25%) had mesh-related complications.
Weber et al28 randomized patients to standard midline plication, plication of the paravaginal tissue more laterally, or standard plication plus polyglactin 910 (Vicryl) mesh. Among 83 patients who returned for follow-up, there were no differences in anatomic outcome. Weber and colleagues concluded that there is little benefit to using mesh to correct cystoceles.
Still, although the overall cure rate was low (30–46%), most patients had cystocele to the hymen and not beyond, with significant improvement of symptoms. Although this cannot be defined as an anatomic cure, it is encouraging that the majority of patients appear to have benefited from surgery.
Sand et al29 randomized 161 women with the anterior wall to or beyond the hymen to traditional anterior colporrhaphy with or without Vicryl. The 2-inch square mesh was not placed over the repair as described above, but was folded into the anterior colporrhaphy stitches. At 1 year, 16 (22%) of 73 women with mesh and 28 (40%) of the 88 women without mesh had recurrent central cystoceles beyond the midvagina (P = .02). No women had cystoceles beyond the hymen or vaginal erosions.
Difficulty of interpreting the evidence
Because of the broad range of study designs, small number of patients per series, variety of concomitant procedures, and wide range of variables used to describe recurrence and success, it is difficult to draw conclusions from the literature. The evidence does suggest that the risks of wide vaginal dissection required for vaginal paravaginal repair outweigh the benefits. As a result, we have abandoned this technique. As mentioned above, it remains unclear whether graft materials will prove to be of long-term benefit for either midline plication or paravaginal repair.