Anterior vaginal prolapse: Review of anatomy and techniques of surgical repair

Abstract

To summarize the literature on anterior vaginal prolapse, focusing on vaginal anatomy, etiologic theories, and comparison of anterior colporrhaphy and paravaginal repair. We identified articles related to anterior vaginal prolapse through a MEDLINE search of English-language literature published from January 1966 through December 1995 and in bibliographies in gynecologic text-books. We reviewed 80 articles published in peer-reviewed journals or textbooks and related to anterior vaginal prolapse. In addition, ten articles on operative procedures for urinary incontinence were studied. We abstracted and synthesized information from 31 papers that contained descriptions of and opinions on vaginal anatomy and etiology of vaginal prolapse. The vagina has three layers—mucosa, muscularis, and adventitia; there is no vaginal “fascia.” Vaginal support is provided by the underlying levator ani muscles and by lateral connective-tissue attachments at the arcus tendineus fasciae pelvis or “white line.” Anterior vaginal prolapse results from direct or indirect damage to the pelvic muscles or connective tissue or both. Forty-nine articles described surgical techniques for the correction of anterior vaginal prolapse, and 24 of them reported postoperative outcomes. Reported failure rates ranged from 0–20% for anterior colporrhaphy and 3–14% for paravaginal repair. No controlled studies compared different procedures performed primarily for correction of anterior vaginal prolapse. Dissection during anterior colporrhaphy splits vaginal muscularis, and repair involves plication of the muscularis and adventitia (not vaginal “fascia”) in the midline, which may pull the lateral attachments further from the pelvic sidewall. Paravaginal repair restores the lateral attachments to the pelvic sidewall at the white line. Controlled studies that compare directly these two procedures for anterior vaginal prolapse repair are necessary to determine their relative effectiveness.