Vaginal paravaginal repair: one-year outcomes.

OBJECTIVE: This study was carried out to determine the efficacy and safety of the vaginal approach to paravaginal repair of symptomatic paravaginal defect cystocele.

METHODS: This study is an observational case series of 100 consecutive women, referred from December 1996 to August 2000, with symptomatic grade II to IV paravaginal defect cystocele. Preoperative and postoperative pelvic evaluations were performed with the Baden-Walker halfway system. The same surgeon performed all repairs. Fourteen patients had prior anterior repairs, and 530 concomitant procedures were performed. The vaginal approach consisted of a thorough entry from the vesicovaginal space under the inferior pubic ramus into the retropubic space, widely exposing the area of the arcus tendineus. A repair was done bilaterally in 95 patients and unilaterally in 5. Between 1 and 6 Gore-tex CV-0 sutures (W. L. Gore and Associates, Inc, Elkton, Md) were placed widely around the arcus tendineus on either side and fixed to appropriate locations on the bladder fascia and anterior vaginal walls. Tying these sutures resulted in dramatic elevation of the lateral superior sulci. Patients were followed up for 1 to 36 months, with a mean of 10.6 months. Criteria for objective cure were defined as the lateral sulci of the anterior vaginal walls being at grade 0 and firmly apposed to the lateral pelvic sidewalls.

RESULTS: Of the 100 patients, 34 had grade II, 54 had grade III, and 12 had grade IV paravaginal defect cystocele. Patients were followed up postoperatively for 1 to 36 months: 84 for more than 6 weeks and 55 for 1 year or longer. Our objective cure rate was 98%. Two asymptomatic patients had a unilateral grade I or a bilateral grade II paravaginal defect cystocele. A recurrent midline cystocele occurred in 22 patients between 3 and 11 months after the operation. Twenty-one patients were asymptomatic and one was symptomatic. Twenty-one patients had grade I-II cystocele and one had grade III cystocele. There were 3 major intraoperative hemorrhagic complications; one of the operations was converted to an anterior colporrhaphy. There were a total of 21 major and 14 minor inpatient complications. Twenty-five subsequent complications included various urinary symptoms in 14 patients, long-term lower extremity neuropathy in 2, bloody discharge from intravaginal sutures in 3, absent coital sensation in 1, and recurrent pelvic organ prolapse in 5, all of which included grade III enterocele between 3 and 25 months.

CONCLUSIONS: The vaginal approach to the correction of paravaginal defect cystocele is highly effective in our population at a mean of 11 months after the operation. Frequent complications do occur but are largely manageable.