Anterior Vaginal Anatomic correction of an anterior defect or cystocele will generally relieve symptoms Colporrhaphy of protrusion and pressure and usually will improve micturition function when abnormal micturition is associated temporally with the defect and if there is no associated neuropathy. If a single, well-defined midline defect is recognized, excision of the weak vaginal wall and an imbricating closure of the defect may be performed. Most central anterior defects require a more extensive dissection of the vesicovaginal space. Following this dissection, many surgeons then separate the vaginal mucosa and submucosal layers from the fibromuscular layer out to a point lateral to the defect, followed by midline plication of this tissue, then excision of excess epithelium, and closure (72–78). It appears important to maintain the continuum of repaired fibromuscular tissue to a well-supported vaginal apex. If the repair is being performed simultaneously with a vaginal apical suspension, the anterior colporrhaphy is typically performed after the apical support sutures have been placed and prior to tying them down. The dissection is carried out starting from the everted vaginal cuff edge and dissecting toward the bladder neck. A high central defect may also be corrected via a transabdominal approach by dissecting between the base of the bladder and the upper one-third of the anterior vaginal wall. The defective tissue may then be wedged out and the defect closed with running or interrupted sutures. This approach may be of use when performing transabdominal procedures for apical suspension.
If the patient has significant stress incontinence (based on report or the presence of occult or potential incontinence), an appropriate bladder neck suspension may be performed simultaneously with the anterior repair. When performing midurethral sling procedures, it may be preferable not to extend the repair procedure below the urethra, but instead to make a separate incision for the sling. Maintaining some degree of the urethrovesical angle may improve the results of any incontinence procedure. If the patient has voiding dysfunction (reports of incomplete emptying and a high residual urine) and stress incontinence, appropriate urodynamic evaluation should be performed before a procedure is selected, and the patient should be made aware of the potential for continued problems after surgery (78).
Recurrence rates of traditional “fibromuscular plication” anterior repairs vary from 3% to 92%; however, studies define recurrence in numerous ways, from minimal prolapse to stage III descent (63,73–81). The clinical significance of recurrent mild cystoceles (stage I) that are asymptomatic is debatable because many of these defects do not progress to larger ones. When traditional anterior repairs are performed in patients with POP-Q stage II or greater cystoceles (frequently concurrently with other procedures), a 20% recurrence rate of stage II or greater prolapse is not uncommon, although overall recurrence rates as low as 3% have been reported (76). Many studies do not define how the participants were evaluated postoperatively and vary with respect to patient populations, type and severity of defects, presence of concurrent defects, surgical technique, and follow-up time and length. Some studies have suggested higher recurrence rates when these repairs are performed concurrently with sacrospinous suspensions and hypothesize that this type of apical suspension may predispose the repaired anterior wall to greater pressure transmission (63,64). These studies may show higher failure rates because patients having such concurrent repairs may be more likely to have more complicated forms of prolapse or more extensive pelvic ﬂoor defects than other patients.