Uterosacral Shelf For Cystocele Repair

Innovation
Author Information

Parulekar SV
(Professor and Head, Department of Obstetrics and Gynecology, Seth G S Medical College & KEM Hospital, Mumbai, India.)

Abstract

Approximately 11% of women will undergo pelvic reconstructive surgery for pelvic organ prolapse and/or urinary incontinence during their lifetime. Cystocele in women is one of the common problems associated with uterovaginal prolapse. It occurs when the fascia between urinary bladder and vagina is weakened allowing the bladder to herniate into the vagina. While usually not lifethreatening, cystocele is often associated with deterioration in quality of life and may contribute to bladder and sexual dysfunction. It was conventionally repaired by plication of the pubovesicocervical fascia from the right and left sides in the midline. The next step in its evolution was site specific repair, in which the type of defect in the fascia was repair instead of plicating the fascia indiscriminately. The third step was use of biological and synthetic meshes. However the meshes have their own problems and complications. A novel approach of using the uterosacral ligaments to perform a cystocele repair after a vaginal hysterectomy is described here.

Introduction

Genital prolapse in women was known to Hippocrates and Galen. Heming first operated on the anterior vaginal wall in 1831. Howard Kelly of Baltimore championed the concept of plication of pubovesicocervical fascia in the midline for repair of a cystocele.[1] In 1909, George R. White of Georgia published an account of cystocele repair using a transvaginal paravaginal approach.[1,2] A. Cullen Richardson and associates of Georgia developed the concept of classifying fascial defects as proximal, distal, central, and lateral.[2,3] This encouraged gynecologists to identify and repair each vaginal defect and to return support attachments to their original anatomic location. Emphasis was focused on he hernial nature of prolapse and led to the abandonment of absorbable suture in favor of permanent suture in repairs.[4-8] The results of site specific repair of a cystocele are far superior to those of plication of the fascia.[9-12] Postoperative complications and urinary disturbances are also much less. Subsequently the trend has been moving towards use of biological or synthetic meshes for the repair. Meshes behave differently in the subvaginal space than in the abdominal wall. Infection, erosion and extrusion rates are higher and so is the risk of litigation. We prefer a site specific repair to the use of a mesh. In case the fascia is too weak to be repaired adequately to provide a satisfactory repair, the uterosacral ligaments may be used to provide the required support to the urinary bladder. A novel approach of using the uterosacral ligaments to perform a cystocele repair after a vaginal hysterectomy is described here.

Operative Technique
  1. While performing the vaginal hysterectomy, the uterosacral ligaments are clamped, cut and ligated quite close to the uterus, so that maximum possible lengths of the ligaments is made available for use during anterior colporrhaphy. One end of a ligature on each ligament is kept long and held with a hemostat.
  2. Epinephrine in saline (1:300000) is infiltrated under the vaginal mucosa overlying the cystocele.
  3. A midline incision is made in the anterior vagina overlying the cystocele.
  4. A flap of the anterior vagina are raised on each side by sharp dissection, separating the vagina from the fascia overlying the urinary bladder.
  5. The dissection is carried out laterally up to the white lines on the two sides.
  6. Hemostasis is achieved. This is important, as a failure to do so may result in formation of a hematoma between the urinary bladder and the uterosacral ligaments fixed below it. Infection in the hematoma would result in formation of an abscess and its complications.
  7. The uterosacral ligaments are fixed under the urinary bladder.
  8. Two sutures of No. 1 polyglactin are passed through the terminal cut part of each ligament. They are then passed through the vagina lateral to the urethra. When the sutures are tied on each side, the ligaments get fixed under the urinary bladder.
  9. The gap between the two uterosacral ligaments is closed with interrupted sutures of No. 1-0 polypropylene passed through adjacent edges of the ligaments.
  10. Lateral edge of each uterosacral ligament is sutured to the white line of that side with interrupted sutures of No. 1-0 polypropylene.
  11. Redundant part of the vaginal mucosa is excised. The vaginal edges are sutured to each other in midline with interrupted sutures of No. 1-0 polyglactin.
  12. The center of the vault of the vagina is suspended from the uterosacral ligaments in midline with a suture of No. 1-0 polyglactin.
  13. The transverse edge of the anterior vagina is sutured to the transverse edge of the posterior vagina with interrupted sutures of No. 1-0 polyglactin.


Figure 1. Anterior colporrhaphy dissection has been done. The urinary bladder (U), left uterosacral ligament (LUSL) and the right uterosacral ligament (RUSL) are seen.


Figure 2. No. 1 polyglactin ligature on the RUSL is threaded on a curved needle.


Figure 3. The cystocele is reduced by pressure of a finger.


Figure 4. The RUSL ligament is drawn forward along the right side of the urethra.


Figure 5. The needle is passed through the right flap of the vaginal mucosa, from inside out, at the level a little posterior to the external urinary meatus.


Figure 6. Another suture of No. 1 polyglactin suture is passed through the terminal part of the RUSL and tied.


Figure 7. The suture is passed through the right flap of the vaginal mucosa, from inside out, 5 mm away from the first suture.


Figure 8. The LUSL ligament (aarows) is drawn forward along the left side of the urethra.


Figure 9. No. 1 polyglactin ligature on the LUSL is threaded on a curved needle.


Figure 10. The needle is passed through the left flap of the vaginal mucosa, from inside out, at the same level as the first suture on the right side.


Figure 11. Another suture of No. 1 polyglactin suture is passed through the terminal part of the RUSL and tied. It is passed through the left flap of the vaginal mucosa, from inside out, 5 mm away from the previous suture.


Figure 12. The two sutures on the left side are tied on the external surface of the left flap of vaginal mucosa. The sutures on the right side are tied similarly.


Figure 13. The RUSL (black arrows) and LUSL (white arrows) are seen to be drawn forwards under the base of the urinary bladder.


Figure 14. The two uterosacral ligaments are approximated in the midline with interrupted sutures of No. 1-0 polypropylene.


Figure 15. Approximation of the two uterosacral ligaments in the midline is complete.


Figure 16. The gap between the LUSL and right lateral pelvic wall is demonstrated by passing a finger between the two.

Figure 17. The left edge of the LUSL is sutured to the left white line with interrupted sutures of No. 1-0 polypropylene.


Figure 18. The right edge of the RUSL is sutured to the right white line with interrupted sutures of No. 1-0 polypropylene.


Figure 19. The end result: the two uterosacral ligaments have been sutured to each other in midline, and each one has been sutured to the white line of the respective side laterally.

Discussion

Pelvic endopelvic fascia is fibroelastic connective tissue matrix with varying amounts of smooth muscle. It covers all the pelvic organs It fills the space between the pelvic diaphragm, the pelvic sidewall, and the visceral peritoneum. The endopelvic fascia covering the obturator internus is called as the obturator fascia. It is well defined in the arcus tendineus fascia pelvis (white line). It is condensed to form the pubocervical ligaments, which are attached to the under surface of the superior pubic ramus, the arcus tendineus fascia pelvis and the pericervical ring. This insertion is continuous with and forms part of the pericervical ring. The pubovesicocervical fascia is attached to the pubic tubercles, the pubic arch, the urogenital diaphragm, the white line, the pericervical ring and the cardinal ligaments. It is continuous with the fascia over the urinary bladder and the vagina. Continuity of the fascia, the uterosacral-cardinal ligament complex and vesical fascia is essential for keeping the bladder supported.[1,2] If the fascia gets detached from the white line, a lateral cystocele develops.[9] If it gets separated from the pericervical ring and the uterosacral-cardinal cardinal ligament complex, a central transverse type of cystocele develops.[9] Identification of these defects is easy clinically and during anterior colporrhaphy.
If the endopelvic fascia is too weak, a site specific repair does not often work because there is no specific defect located at any particular site, but all the fascia is weak. In such situation, if the uterosacral-cardinal ligaments are thick, they can be used to support the urinary bladder. In the new operation described here, the uterosacral ligaments are carried forward in the same direction in which they are present normally. That becomes possible because they are lengthened due to genital prolapse. Since they originate from the same endopelvic fascia, being its condensed parts, they can be used effectively for the repair of the cystocele. When they are joined to each other in the midline and fixed under the urinary bladder, they provide a strong and wide shelf for the urinary bladder to rest on. There are gaps between the sides of the ligaments and the obturator fascia, and if these are not occluded, the patient may present with uni- or bilateral cystocele. These gaps are closed by suturing the lateral edges of the uterosacral ligaments to the white lines of the respective sides. This results in reestablishment of continuity of fascia between the white lines laterally and uterosacral ligaments posteriorly. Provision of such a strong support with endogenous tissue does away with the need for synthetic meshes and possibility of complications associated with their use.

References
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Citation

Parulekar SV. Uterosacral Shelf For Cystocele Repair. JPGO 2017. Volume 4 No.10. Available from: http://www.jpgo.org/2017/10/uterosacral-shelf-for-cystocele-repair.html