Paravaginal Repair: What Is It and When Is It Necessary?
A person’s body is not held together by skin. The human body depends on supporting tissues called Fascia. Fascia is in the back, in the abdominal wall, between the organs, and supporting tissues are interconnected. Fascia is the scaffolding that holds you together. Fascia works together with skeleton, muscles, ligaments. For example, an abdominal wall hernia forms when there is a defect in the fascia.
There is an interconnecting system of Pelvic Supports. Pelvic Support Defects are when supports are broken and tissues start to fall down, called Pelvic Prolapse. With prolapse the bladder, rectum, cervix-uterus, and/or upper vagina can drop down. All areas can be effected, or only specific areas can be effected, referred to as Site-Specific Defects.
There is a shelf of supporting tissue, from side to side, between the bladder and vagina, from pubis to cervix. This is the Pubocervical Fascia, and this holds the urethra, bladder, and anterior vaginal wall in place. There is a shelf of supporting tissue, from side to side, between the rectum and vagina, from perineum to cervix. This is the Rectovaginal Septum, and this holds the rectum and posterior vaginal wall in place. There are other supporting tissues that hold the vaginal apex up and in place.
When the bladder drops, this is called a Cystocele (“cysto” means bladder, “cele” refers to sac or hernia).
- Cystocele could be due to central defect with stretching of the supporting tissues. This is a central Cystocele. Traditionally, central defects are corrected by making a vertical incision in the vaginal epithelium, dissecting the wall wall off the underlying fascial supporting tissues, and bring together with absorbable sutures the fascia in the midline and thereby building up the shelf holding up the bladder.
- Cystocele could be due to lateral defect with fascial supports tearing away from the lateral pelvic wall. This is a lateral Cystocele secondary to a Paravaginal Defect. Although the paravaginal space can be approach vaginally, the paravaginal defects are generally approached abdominally, usually by laparoscopy (“lapar” means abdomen”, “scopy” is a tube with a light). The space between the bladder and the pubic bone is developed, the surgeon goes down both sides to the paravaginal defects where the pubocervical fascia has torn away from the fascial layer of the lateral pelvic wall (on the medial aspect of the Obturator Internus muscle). Individual permanent sutures are placed to bring back together the pubocervical fascia to the fascia overlying the Obturator Internus muscle laterally. Pictures of this procedure are on the website.
It is been found that up to 80% of Cystoceles are caused by Lateral Defects where the fascia has torn away from the lateral pelvic wall.
Plicating the fascia in the midline only pulls the fascia further away from the sidewalls were the fascia is supposed to be attached. Cystoceles are really hernias, and General Surgeons would never repair hernias with absorbable sutures. Due to swelling under the urethra, a catheter has to stay in the bladder for a few days. On the other hand, vaginal cystocele repairs have been done for many years, results are good at least in the short-term, and vaginal approach avoids going into the abdomen.
Paravaginal Repairs reattach the Pubocervical Fascia to the fascia on the Obturator Internus muscle on the lateral pelvic wall, and this is a more anatomically correct repair. Permanent sutures add to the security of the repair, but any repair can fail over time, and even permanent sutures may not hold if the tissues are intrinsically weak. With the laparoscopic Paravaginal Repair, no dissection is done under the urethra, so there is less risk of hurting the blood supply to the urethra. With no vaginal incision and no swelling under the urethra, the catheter comes out the morning after surgery, which is done Outpatient overnight.