Severe vaginal vault prolapse affects more than 3 million women in the United States, and 11% of women will require prolapse or incontinence surgeries in their lifetime. This article discusses the range of evolving surgical options for repairing rectocele, cystocele, and enterocele, with an emphasis on techniques using synthetic mesh.
Epidemiology of prolapse
To fully understand vaginal vault prolapse correction, one has to become familiar with the three levels of support. Level 1 is the most proximal and comprises the upper third of the vagina or the apex, consisting of the cardinal and uterosacral ligaments. Level 2 support is the mid-third of the vagina, and typically includes the pubocervical fascia and the rectovaginal septum. Level 3 support is the most distal and comprises the perineal membrane and perineal body.
The goal of pelvic organ prolapse repair is to correct level 2 support for rectoceles and cystoceles and level 1 support for apical laxity. There are three main approaches to correcting prolapse: vaginal repairs using autologous tissue, vaginal repairs using synthetic or biologic material, and repairs using an abdominal approach, either laparoscopically or through an abdominal incision.
Historically, plication techniques were performed to correct cystocele and rectocele defects. Plication involved re-approximating the tissues in the midline over the prolapsed organ. Results of the plication techniques varied, but many had high recurrence rates.5 It was soon realized that with cystocele defects, plication corrected only the central portion of the defect, but not the lateral aspects. At least where the bladder was concerned, attempts were then made to correct the lateral defects.
This consideration resulted in vaginal paravaginal repairs and abdominal paravaginal repairs. However, these procedures often had high recurrence rates and unsatisfied patients. In a study on the laparoscopic paravaginal repair, Behnia-Willison et al showed cure rates of 76%, with 78% of the failures resulting in re-operation.6