mesh interposition. A variety of techniques

exist, each with different approaches to reach-

ing the same goal of restoring anatomy and

function. The anterior vaginal wall suspension

and the four corner suspension are techniques

which allow the vaginal plate itself to act as a

support for the bladder base. This addresses

concomitant stress incontinence secondary to

proximal urethra/bladder neck hypermobility.

These techniques are a modification of various

bladder neck suspensions, using principles bor-

rowed from the Pereyra and Raz suspension

procedures.

Depending upon the defective structure, cys-

toceles can be classified as either lateral or cen-

tral/midline. The central or midline cystocele

Figure 34.9. removal of exposed vaginal mesh (extrusion)

results from weakened or damaged pubocervi-

cal fascia, allowing the bladder to prolapse

located under the trigone. this is a difficult location for mesh

through the anterior vaginal wall. A lateral cys-

removal due to potential ureteric injury.

tocele forms when the arcus tendineus fascia

pelvis (ATFP) is torn or is weakened with sub-

complications of mesh for vaginal surgery. No

sequent loss of support to the bladder and lat-

eral

vaginal fornices, resulting

in prolapse

formal guidelines or recommendations for mesh

through the anterior vaginal wall. Lateral vagi-

implantation have followed this warning. It is

nal wall detachments are recognized by loss of

widely believed that mesh can be beneficial

the lateral sulci and midline vaginal rugae, as

when used in the appropriate, carefully selected,

well as elongation of the vaginal wall. The goal

and well-informed patient by an

adequately

of the anterior colporraphy is to eliminate the

trained surgeon (Fig. 34.9).

central defect by reapproximating the pubocer-

vical fascia over the midline and return the

Surgical Management

bladder to its original anatomic position. It

does not address the lateral paravaginal defect

Surgery may be accomplished by a variety of

and may, in fact, worsen it. The goal of the para-

vaginal repair is to support the lateral vaginal

methods according to patient preference and

edges to the

arcus

tendineus fascia

pelvis

surgeon experience, including

vaginal

or

(ATFP). Mesh may be used to correct cystocele

abdominal approaches, with recent introduc-

defects or to

augment

the cystocele

repair

tion of laparoscopic and robotic assistance fur-

(Fig. 34.10).

thering the spectrum of minimally invasive

techniques available. Concomitant procedures

may be performed, as prolapse usually involves

Uterine/Apical Prolapse

more than one compartment and stress inconti-

nence may be addressed in the same setting with

Vaginal vault prolapse represents the extreme

sling or suspension techniques. The goal of sur-

end of the spectrum in pelvic organ prolapse,

gery for pelvic organ prolapse is to restore anat-

rarely but occasionally presenting as total vagi-

omy, to alleviate prolapse symptoms, and

to

nal eversion. Indications for intervention are

improve urinary, bowel, and sexual functions.

driven mainly by the severity of symptoms and

extent of prolapse. The vaginal mucosa can

Anterior Compartment Repair

become irritated and ulcerated due to displace-

ment and friction from undergarments and

The approach to cystocele repair depends upon

physical activity. The goal in any vault prolapse

the grade of the prolapse. Higher-grade cystoce-

repair is to restore the normal axis, position,

les may require additional support from graft or

and

function

of

the

vagina.

This

may