Endoscopic Cystocele Surgery: Lateral Repair with Combined Suture/Mesh Technique *

Introduction

T he dislocation of the anterior part of the vagina is considered as one form of a genital descensus. The adjacent bladder is, in general, involved and becomes symptomatic as a cystocele. The classic form of a cystocele is originated from a midline defect of the cysto-vaginal fascia. A reduction of the vaginal rugae is a clinical sign for this type of cystocele.

In 1909 White ¹ described another type of cystocele with sustained rugae. This defect is found more lateral, leads to elapsed sulci, and is called “lateral” or “paravaginal” defect. The anatomic correlate is a rupture of the arcus tendineus and the adjacent fascia. The paravaginal defects have been described isolated or combined with other defects. ^2,3 The right side is more often affected, but mostly a bilateral manifestation is found.

Meanwhile, various open and vaginal approaches have been reported. ^4,5 The vaginal approach is sophisticated and requires a dilatable vagina. The open approach is associated with a scar and a higher degree of morbidity. The laparoscopic approach came into focus during the last decade. In the few reported laparoscopic approaches, success rates of about 90% have been reported. ^{6 –8}

Meshes have been used successfully for different defects of the pelvic floor. ⁸ Most authors emphasize the advantages of monofilament meshes, as the risk of mesh erosion is reduced. ⁸ Meshes provide a matrix and boost the invasion of fibrocytes. This induces a more stable connective tissue. The use of meshes for the lateral repair has been reported only by Rivoire et al ⁸ and Dubuisson et al. ⁹ Both studies reported on good intermediate-term outcome of patients.

We here describe our modified laparoscopic lateral repair with a mesh inlay. With our modifications the lateral repair can be performed within 50 minutes. We intend to present an easy and reproducible method of laparoscopic lateral repair.

Technique

Operative procedure

The patient is placed in a dorsal lithotomy position with both arms tucked to her side. A 16F catheter with a 10-mL balloon tip is inserted into the bladder and attached to a continuous drainage. Operation is done under general anesthesia.

We routinely perform an incision of the inferior margin of umbilicus and insert a 12-mm access port to introduce the laparoscope. The abdomen is insufflated with CO₂ up to 12-mm-Hg intraabdominal pressure. Two additional 5-mm access ports are placed 2 to 4 cm medial and inferior to the anterior superior iliacal spine at both sides. One further 12-mm access port is placed 2 to 3 cm superior to the symphysis (Fig. 1).

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FIG. 1.

Space of Retzius. A 12-mm access port (a) and laparoscope (b) are placed at the space of Retzius (c). The arrow indicates the retrograde penetration of peritoneum with the laparoscope.

Step one: intraperitoneal survey and preparation of retrograde transperitoneal access to the space of Retzius

After insufflation and intraabdominal survey the suprapubic 12-mm port is retracted and sited outside of the peritoneum. The remaining peritoneal orifice is enlarged to 15 mm and used later as an entrance for the laparoscope (Figs. 1 and 2a).

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FIG. 2.

Intraoperative situation. (a) The peritoneal orifice (arrow) is enlarged to 15 mm and used later as an entrance for the laparoscope (compare Fig. 1). (b) Space of Retzius, prepared layers, and defects of white line (star). (c–e) Suture and mesh inlay on the right side. (f) Final situation after repair on both sides.

The 12-mm port is used to detect the pubic ramus. The retropubic place is developed by separating the layers. Insufflation with CO₂ via the 12-mm port and blunt dissection with the port itself helps to prepare the retropubic space. Both lateral ports are placed under visual control into the space of Retzius.

Step two: preparation of the iliopectineal ligament and the defects of white line

The pubic symphysis and bladder neck are identified in the midline (Fig. 2b). The bladder is dissected from the fatty tissue. The iliopectineal ligament is prepared to its complete length up to the oblique muscle. The lateral margin of the pubocervical fascia is detached from the pelvic sidewall and the white line with the lateral defect(s) is observed bilaterally along the pelvic sidewall using a blunt instrument and a bipolar clamp (Fig. 2b, c).

Step three: suture

A 2-0 nonabsorbable suture of 50-cm length with attached needle is inserted through the 12-mm port. The suture is started on the right side. The first stitch is placed in the iliopectineal ligament as lateral as possible (Fig. 2c). A polypropylene mesh of 6 × 4 cm is inserted and placed to cover the defect (Fig. 2d). The surgeons' left hand is now inserted into the vagina and elevates the anterior vaginal wall with the adjacent pubocervical fascia to the physiological position. The assistant supports the observation of the pubocervical fascia laparoscopically from the space of Retzius and additionally bluntly protects the bladder. The pubovesical fascia is first attached on the level of the cervix. Iliopectineal ligament and pubovesical fascia are then sutured consecutively along the paravaginal defect starting laterally and ending toward the urethrovesical junction (Fig. 2e). To avoid a displacement of the mesh a fixation with one or more stitches is useful.

In general, four to six stitches at the ligament and at the fascia, respectively, are used for a stable tissue approximation. The physiological position of the lateral vagina should be reconstituted with a moderate degree of tension. For this purpose a fine adjustment of the consecutive suture is possible. Suture is completed by the use of an intracorporal knot-tying technique.

For the left side the suture procedure is repeated basically, but, in general, we start medially at the urethrovesical junction and end laterally (Fig. 2f).

Step four

Needles are removed via the 12-mm port. There is no need for a suture of the peritoneal incision. Ports and CO₂ are removed from the space of Retzius after a careful hemostasis.

Equipment

Access ports: 2 × 5 mm and 2 × 12 mm

Instruments: 1 Metzenbaum scissors, 2x universal (blunt) grasping forceps, 1 bipolar forceps, and 1 needle holder

Full HD Camera 0°

Polypropylene mesh 6 × 4 cm

2 sutures (2-0 nonabsorbable suture of 50 cm length with attached needle)

Role in Urologic Practice

Our method differs from conventional lateral repair concerning the following aspects:

We use a very small peritoneal incision for the retrograde laparoscopic access to the space of Retzius. A suture is not necessary. Operation time is reduced.

The lack of reproducible and standardized operation methods is reflected in the rare use of laparoscopic lateral repair operation. ^{6 –8} Our method simplifies the laparoscopic approach, resulting in a reduced operation time and good reproducibility. It offers advantages concerning postoperative comfort, recovery time, scars, postoperative pain, and duration of hospitalization (Table 1). Complication rate of our method is acceptable and seems to be better than after vaginal approach (Table 1). ^6,8,10,12,13 In accordance to other authors ^8,9,14 we used monofilament polypropylene meshes to induce a stable connective tissue. In the follow-up no mesh erosion or other mesh-associated complications were found. Postoperative results were good (Table 1). In a further study, we investigated sexual impairment after endoscopic sacropexy using two validated sexual questionnaires (International Consultation on Incontinence Modular Questionnaire [ICIQ]-vaginal symptoms, sexual part and ICIQ-sex). ¹⁵ Eighteen patients underwent simultaneous lateral repair. Fifteen patients reported sexual activity before operation. All sexually active patients reported of an improved sexuality after operation (ICIQ-vaginal symptoms: preoperative sexual score 28.5; postoperative sexual score 10.5; p = 0.001; ICIQ-sex: preoperative score 3.6; postoperative score 1.9, p not significant, two-sided paired t-test). Single-item analysis revealed a maximum benefit concerning pain during intercourse, urinary incontinence during intercourse, interference of sex life because of worries, and affected partnership.

We consider our laparoscopic lateral repair with a combination of suture and mesh inlay as a good instrument for a durable repair. Although our modifications make the laparoscopic lateral repair easier and more secure, the surgeon should be experienced in the anatomical characteristics of the bladder region and in intracorporal laparoscopic suture and knotting techniques. Further studies will show whether the use of meshes elevates the long-term stability of repair.