Laparoscopic Paravaginal Repair,

A New Technique Using Mesh and Staples

John L. Washington, MD, FACOG

The history of laparoscopic surgery is made up of examples of surgeons applying minimally invasive techniques to standard procedures. First the standard laparotomy technique is used, adapted as little as possible to the constraints of laparoscopy. Then effort and ingenuity are applied to finding ways to make the procedure easier and more accessible, frequently by using innovative instrumentation or equipment.

White¹ first described the paravaginal repair as an anatomically correct procedure to repair cystocele caused by detachment of the vesicovaginal fascia from the arcus tendineus. The procedure has been described being done by laparotomy, by a vaginal approach² and laparoscopically³. The standard procedure involves placing sutures from the lateral margins of the vagina to the ipsilateral arcus tendineus. Usually three to six sutures are placed on each side. The procedure is frequently awkward or technically difficult because of the angles involved in placing sutures into the depths of the space of Retzius. Laparoscopically, the procedure is difficult but has been mastered by capable laparoscopic surgeons. Five years ago we began doing bladder neck suspensions using a laparoscopic mesh and staple method described by Ou⁴ . Our technique and results are published elsewhere⁵. We considered that we could use a similar technique for the paravaginal repair. Eleven patients who were scheduled for laparoscopic bladder neck suspension on the basis of physical exam and cystometrogram were found to have first degree cystocele or worse. Pelvic Organ Prolapse Qantitation examination was done⁶. Point AA(the relationship of the point 3cm from the urethral meatus to the hymeneal ring while straining) was at -2 or below in all patients. Based on their examinations none of these patients had central defects. Informed consent was obtained and the patients had paravaginal repairs done at the same time as their bladder neck suspensions.

Technique: See figure 1. The laparoscope is placed through the umbilicus in a 10mm Optivue (Ethicon Endosurgery, Cincinnatti, OH) sheath. A second 10 mm Optivue sheath is placed in the left lateral position and a 5 mm Step expanding sheath (Autosuture Step, Tyco Healthcare Norwalk, CT) is used in the in the right lateral position. Dissection is done with disposable laparoscopic scissors and harmonic scalpel (Ultracision Ethicon Endosurgery, Cincinnatti, OH). Bipolar cautery is employed for hemostasis. After the hysterectomy and any cul de sac repairs are completed, the space of Retzius is entered by making a transverse incision about two inches above the pubic symphisis. The incision extends from one obliterated umbilical artery to the other and is placed cephalad to the dome of the bladder. The space is dissected bluntly to just below the white line bilaterally. The obturator fossa with its neuro-vascular bundle is carefully identified. The bladder neck repair is accomplished using rectangles of Prolene mesh 2x4cms stapled on either side of the bladder neck and suspended to Coopers ligament. We use a helical hernia tacker to fasten the mesh. After the bladder neck is suspended we begin the paravaginal repair. We use two pieces of Prolene hernia mesh, cut in a semi-trapezoidal shape with the apex 1cm across and the base 5 cms. The front edge of each piece of mesh is vertical and the rear edge angles down to the base. The lateral vagina is supported by the fingers of the operator’s left hand, while the wide edge of the mesh is stapled to the vaginal margin with the helical tacker. The upper edge is tacked to Cooper’s ligament next to the bladder neck repair. The vertical height of the mesh is about 4 cms so that this leaves a suspension gap and avoids over-elevating the vagina. After the repair is successfully completed cystoscopy is performed with intravenous indigo carmine. The procedure requires only a small amount of extra time, approximately 15 minutes. No additional blood loss was encountered. The peritoneum is reaproximated either with the stapler or with a continuous suture of Vicryl. The cystoscopies showed no staples perforating from the repair and there was no instance of ureteral compromise.

Results: We have done 12 of these repairs over the last three years with good short-term results, which are below in Table 1. Results were evaluated by structured interview and examination. Subjective success was defined as a positive answer to the question "Is your bladder well supported?" Objective success is defined by the number D BA, the distance from the preoperative BA(the lowest point of decensus on the anterior vaginal wall to the hymeneal ring, in centimeters) and postoperative BA⁶. Adverse effects were defined as a positive answer to the question "Do you have Urge incontinence, dyspareunia, bladder or vaginal pain?" Results are tabulated below in Table 1. One patient who had preoperative deep dyspareunia, continued to have pain with intercourse. One patient had failure of the repair on one side. She had the feeling that her bladder was dropping but did not have SUI. One patient was lost to follow-up. There was no additional morbidity in the immediate postoperative period. No increase in blood loss was encountered and the increase in operating time was estimated at 15 minutes. All patients were discharged within 48 hours. There was no urinary retention beyond 48 hours.

Conclusion: We feel that this technique may provide a good alternative to the standard laparoscopic suture paravaginal repair and is technically easier to perform. Using staples and mesh for both the bladder neck suspension and paravaginal repair makes placement of the support to the bladder neck and vagina easier to accomplish laparoscopically and we feel that it makes for a more secure and reliable repair. We hypothesize that the mesh provides a framework for reparative fibrosis to reinforce the repair so that it will become sturdier as time passes, although this is yet to be proven. Use of sutures requires greater time and dexterity for adequate placement of support and, we feel, is more likely to be inconsistent, less reproducible and less reliable. Mechanical placement of the staples offers more consistency and easier placement. The risk of bladder perforation and the possibility of hemorrhage should be no greater for the staple technique than for the standard technique. So far, in our hands, the operation shows minimal morbidity and appears to be safe and effective in our small series with short follow-up. Our short term results have been promising, though it is obvious that longer term follow up and a larger series will be required before the procedure can become part of the mainstream surgical armamentarium. We hope that, in the future a larger series, with sufficient numbers, controls and randomization will be undertaken.

Table 1.

Figure 1.

Legend: Space of Retzius showing the placement of mesh and staples relative to the bladder neck and paravaginal defects.