Figure 27.6 Vaginograms from the same patient at rest (A) and during Valsalva maneuver (B). Illustrates posterior vaginal deﬂection maintained by apical cardinal/uterosacral posterior suspension and the anterior sling effect of the puborectalis muscle and more distal perineal structures. (From Nichols DH, Randall CL. Vaginal surgery. 4th ed. Baltimore, MD: Williams & Wilkins, 1996:4–5, with permission.) attached to the upper anterior rectum at its sigmoid junction and forms the inferior border of the cul-de-sac of Douglas. The cardinal and uterosacral ligaments are condensations of areolar connective tissue and they contribute level I support for the vagina. Their origin is at the lateral borders of sacral vertebra 2 to 4, and they travel retroperitoneally to their insertion at the upper vagina and cervix (Fig. 27.1). They serve as the anterior and lateral borders of the cul-de-sac and cross at or just anterior to the ischial spines. The ureter is closest to the uterosacral ligament at or just posterior to its insertion on the posterior lateral cervix. If anterior cephalad traction is placed on the ureter or cervix, frequently the cardinal uterosacral ligaments will stand out as ridges lateral to the cul-de-sac; however, peritoneal folds may have similar appearance. Therefore, placement of sutures in such structures based on visual appearance may not be reliable.
Defects in apical support include: 1.
The loss of cardinal/uterosacral support with resultant cervical/uterine or vaginal cuff descent 2.
The detachment of the fibromuscular vagina from the anterior rectum with resultant enterocele or, at times, sigmoidocele into the rectovaginal space 3.
Tears or attenuation of the upper fibromuscular tissue, usually after hysterectomy, leading to a central apical descent that frequently presents as a ballooning defect
Often, these defects occur concurrently. Defects in cardinal/uterosacral attachment are at sites close to their insertion into the cervix and upper vagina where breaks or tears occur; in those with apical descent, condensations of cardinal/uterosacral tissue can be found adjacent to the peritoneum just cephalad to the ischial spines (13).
Anterior Compartment The anterior vaginal compartment includes the anterior vaginal wall, its attachments, the urethra, and the bladder. The support structure for the bladder is the rhomboid-shaped anterior vaginal wall (specifically its fibromuscular layer), which is attached laterally to the arcus tendineus fascia (Fig. 27.7). Inferiorly, the fibromuscular layer blends in with the connective tissue, which spans the two bands of puborectalis and pubococcygeus muscles
Figure 27.7 View of the pelvic cavity with bladder, upper vagina, and sigmoid colon removed. The fibromuscular wall of the anterior vagina is attached to the arcus tendineus fascia pelvis by endopelvic connective tissue and supports the bladder. The pararectal fascia (Denonvillier’s fascia) includes the fibromuscular tissue of the posterior vagina and its lateral attachment to the fascia levator ani.
and the pubic rami. The urethra appears to be preferentially supported by these connective tissues as well as by the pubourethral ligaments. In the apical area, the vaginal fibromuscular layer blends in with the precervical fascia and the connective tissue of the cardinal ligament complex. In the upright position, the rhomboid-shaped anterior vaginal wall is oriented approximately 30 degrees from the horizon (from pubis to ischial spines). There is some downward bulge of the central area of the rhomboid plate, which should be minimized by the back-stop effect of the posterior vagina and rectum if the pelvic ﬂoor anatomy and function are normal.