Recurrent cystocele: Use of fascia lata after failed anterior colporrhaphy

Key Points

Anterior wall defects, or cystoceles, are very common in women, the result of a weakness in the anterior vaginal wall support, which consists of a continuous connective tissue support from each pelvic sidewall laterally and from the anterior pubic symphysis to the sacrum posteriorly.

Despite the large number of women affected by pelvic prolapse, the most appropriate technique for repair of prolapse is still controversial. A myriad of surgical procedures have been developed to repair the various components of pelvic prolapse. The procedure most commonly used for cystocele repair is anterior colporrhaphy, which involves plication of the pubocervical fascia in the midline, thus reducing the cystocele. This approach theoretically corrects only the central defect and uses the patient's inherently weak tissue. Recurrence rates with this approach have been reported at up to 50%.

Correction of the cystocele defect with graft material allows for correction of both the central and lateral cystocele defects simultaneously without vaginal narrowing and obviates the need to use the patient's weak native tissues. Currently, many graft materials are being used to repair cystocele defects, and there are no good data to support the use of one material over another.

We review our results for cystocele repair with non-frozen cadaveric fascia lata in patients with recurrent symptomatic cystoceles after previous failed anterior colporrhaphy with or without prior hysterectomy.

Preoperative evaluation

Office evaluation of the patient with pelvic prolapse consists of a complete medical history, including emphasis on urinary, bowel, and sexual functions. With regard to urinary function, it is important to note any symptoms of urinary obstruction from the prolapse, which can include frequency, urgency with or without urge incontinence, weak stream, hesitancy, recurrent urinary tract infections, a sensation of incomplete bladder emptying, or the need to manually reduce the bladder in order to void to completion. It is also important to note whether the patient has a history of stress incontinence and, if so, the severity of the incontinence.

A complete surgical history is needed, with special focus on whether a hysterectomy has been performed. If the patient still has a uterus and has a history of uterine bleeding, an abnormal Pap smear, or uterine diseases, gynecology consultation should be obtained preoperatively.

The patient's reproductive and hormonal status should also be noted. It is also important to ask the patient if she is sexually active and if her sexual function is normal. Bowel function also should be assessed. Validated questionnaires focusing on quality of life can also be used to quantitate symptoms.

A complete physical exam should be performed. The exam should first focus on a patient's functional and cognitive status. The neurologic exam is an essential part of the evaluation, and should focus on perineal and lower extremity sensation as well as lower extremity motor function. An abdominal exam should be performed. Examination of the vaginal vault should be performed systematically. The first focus of the exam is the external genitalia and vaginal wall, which are evaluated for abnormalities in the thickness and integrity of the vaginal wall, in particular.