Double-Layered Correction of Severe Anterior Vaginal-Wall Prolapse Utilizing a Suspended Demucosalized In Situ Vaginal Flap

Abstract

The objective was to evaluate a new surgical technique utilizing a double-layered repair that included a demucosalized in situ anterior vaginal wall flap (DIVF) for the management of large (grade III and IV) cystoceles and to analyze technical modifications for the correction of simultaneous stress urinary incontinence (SUI) and/or vaginal vault descent (VVD) as well as surgical complications. Twenty-five (25) females between the ages of 47 and 79 years (mean, 69) underwent surgical correction of stage III-IV anterior vaginal wall prolapse. Lateral and midline support defects were not differentiated because the reported technique corrects both. Sixteen (16) patients (64%) presented with simultaneous SUI and 12 (48%) also had stage III-IV VVD. All patients had had a prior hysterectomy. Twenty-one (21) had undergone previous anterior vaginal wall repair. Our surgical technique includes the isolation of a 6 × 4-cm anterior vaginal wall flap that is carefully demucosalized with electrocautery in an attempt to minimize the risk for inclusion cysts. The rest of the anterior vaginal wall as well as the vaginal vault are carefully dissected from the bladder neck and residual cardinal-uterosacral ligament complex. The flap is suspended with four sutures placed at the angles that will be brought up suprapubically. The posterior sutures are modified by incorporation of the cardinal-uterosacral ligament complex for VVD correction, while the anterior ones are utilized for bladder neck support when necessary. A second supportive layer was created with the mobilized anterior (lateral to the DIVF) vaginal wall that is sutured underneath the suspended DIVF. Two of the patients with stage III or IV vaginal vault prolapse required concomitant enterocele closure and high McCall's culdoplasty. Patients have been followed for 7 to 97 months (mean, 31.1). Four patients also underwent posterior colporrhaphy. Anterior vaginal wall prolapse was corrected compared to the preoperative condition in 23 of 25 (92%). SUI was improved or eliminated in 14 of 16 (86.8%). VVD was corrected in 10 of 12 (84%). Complications included voiding dysfunction (3), polypropylene suture erosion (2), and one each with a suprapubic wound infection and inguinal neuropathy. The creation of a double-layer support including a buried DIVF allows satisfactory anterior vaginal suspension with minimal risk for the development of inclusion cysts. The technique was efficacious even though in the majority of patients prior anterior colporrhaphy had been unsuccessful. This technique can be modified to treat SUI and VVD satisfactorily. The paucity of complications makes this technique an excellent alternative to synthetics to treat large anterior wall prolapse.