Int Urogynecol J (1999) 10:223–229 ß 1999 Springer-Verlag London Ltd

International Urogynecology Journal

Original Article Laparoscopic Surgery for Enterocele, Vaginal Apex Prolapse and Rectocele M. F. R. Paraiso1, T. Falcone2 and M. D. Walters2 1 Truman Medical Center/University of Missouri-Kansas City, Kansas City, Missouri; 2The Cleveland Clinic Foundation, Cleveland, Ohio, USA

Abstract: Laparoscopy has been applied to all aspects of gynecologic surgery, but few investigators have reported the repair of vaginal apex prolapse, enterocele and rectocele via the laparoscopic route. This article reviews the indications, anatomy, operative technique, clinical results and complications of laparoscopic culdeplasty, enterocele repair, posterior repair, sacral colpopexy and vaginal vault–uterosacral ligament suspension. Keywords: Culdeplasty; Enterocele repair; Laparoscopy; Pelvic organ prolapse; Rectocele repair; Sacral colpopexy

Introduction The adoption of laparoscopic treatment for vaginal apex and posterior wall support defects has been less rapid than the adoption of laparoscopic colposuspension, probably because many gynecologic surgeons prefer the vaginal route and because of the technical difficulty of laparoscopic suturing. Since Nezhat et al. [1] reported a small series of laparoscopic sacral colpopexies in 1994, there have been few subsequent case series on surgical procedures for pelvic organ prolapse. The advantages of laparoscopic surgery are the improved visualization of the anatomy of the peritoneal cavity, presacral space and rectovaginal space thanks to laparoscopic magnification, insufflation effects and Correspondence and offprint requests to: Dr Marie Fidela R. Paraiso, Associate Staff, Department of Gynecology and Obstetrics, Section of Urogynecology and Reconstructive Pelvic Surgery, Desk A-81, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.

improved hemostasis; shortened hospitalization; decreased postoperative pain, rapid recovery and return to work; and the cosmetic appearance of smaller incisions. Disadvantages include the technical difficulty of acquiring suturing skills; increased operating time early in the surgeon’s experience, especially if concomitant procedures are performed laparoscopically; and increased hospital costs secondary to increased operating room time and the use of disposable surgical instruments. When performing laparoscopic procedures for the repair of pelvic support defects the operation must be identical to conventional pelvic reconstructive procedures. The goals of the surgery – i.e. to restore anatomy, relieve symptoms, and restore or maintain urinary, bowel and sexual function – are the same, and should not be compromised when operating by laparoscopic route.

Indications The indications for laparoscopic enterocele, vaginal apex prolapse and rectocele repair are identical to those for vaginal and abdominal routes. Surgeon and patient preference and the laparoscopic skill of the surgeon determine the choice of laparoscopic route. Additional factors that should be considered include a history of previous pelvic or anti-incontinence surgery, previous failed sacrospinous or iliococcygeus fascia suspensions, a small or foreshortened vagina, severe abdominopelvic adhesions, patient age and weight, the need for concomitant pelvic surgery, and patient ability to undergo general anesthesia.

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Anatomy When considering the anatomy of the repair of pelvic organ support, the surgeon needs to bear in mind the three levels of support of the vagina described by DeLancey in 1992 [2]. The upper quarter of the vagina (level I) is suspended by the cardinal/uterosacral complex; the middle half (level II) is attached laterally to the arcus tendineus fasciae pelvis and the medial aspects of the levator ani muscles; and the lower quarter (level III) is fused to the perineal body. The endopelvic fascia (referred to as the pubocervical fascia anteriorly) contributes to the integrity of the anterior wall of the vagina. The rectovaginal fascia contributes to the support of the posterior wall. All pelvic support defects, whether anterior, apical or posterior, represent a break in the continuity of the endopelvic fascia and/or a loss of its suspension, attachment or fusion to adjacent structures. The goals of pelvic reconstructive surgery are to correct all defects, thus re-establishing vaginal support at all three levels, and to maintain and/or restore normal visceral and sexual function. The anatomic landmarks during laparoscopic enterocele repair are the pubocervical fascia, the rectovaginal fascia, the uterosacral ligaments and the ureter, which courses along the pelvic side wall and is approximately 1–1.5 cm lateral to the uterosacral ligament as it passes underneath the uterine artery. If a uterosacral ligamentvaginal vault suspension is performed the portion of the uterosacral ligament proximal to its break from previous attachment to the vagina is delineated. Richardson [3,4] describes breaks in the endopelvic fascia and uterosacral/ cardinal ligaments rather than attenuation and stretching of tissue as the cause of vaginal apex prolapse. He defines enterocele as a condition in which there is peritoneum in contact with vaginal mucosa, with no intervening fascia. When performing a uterosacral ligament–vaginal vault suspension and enterocele repair or an ‘apical vault repair’, the ‘pericervical ring’ of endopelvic fascia – the utereosacral/cardinal ligament complex, pubocervical fascia and rectovaginal fascia – must be re-established. The key anatomic aspects of sacral colpopexy are the middle sacral artery and vein; the sacral promontory with anterior longitudinal ligament; the aortic bifurcation and the vena cava, which are at the L4–5 level; the right common iliac vessels and right ureter, which are at the right margin of the presacral space; and the sigmoid colon, which is at the left margin. The left common iliac vein is medial to the left common iliac artery and can be damaged during dissection or retraction. The anatomic landmarks of laparoscopic rectocele repair are the rectovaginal septum, comprised of Denonvilliers’ fascia, and its lateral attachment to the medial aspect of the levator ani muscles. Denonvilliers’ fascia is the endopelvic fascia which is attached to the uterosacral cardinal ligament complex superiorly, the superior fascia of the levator ani muscles laterally, and the perineal body inferiorly. The rectovaginal septum is the posterior point of attachment of the sacral colpopexy

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mesh. Rectovaginal fascia, rectovaginal septum and Denonvilliers’ fascia are synonymous terms. The pubocervical fascia is the anterior point of mesh attachment during sacral colpopexy.

Operative Technique Laparoscopic Moschcowitz and Halban Procedures The Moschcowitz procedure is performed laparoscopically exactly as during laparotomy. A no. 0 nonabsorbable 36-inch suture is stitched in the peritoneum around the cul-de-sac in a pursestring fashion and subsequently tied extracorporeally. Additionally sutures are placed as needed. The ureters should be carefully examined during and after the Moschcowitz procedure. The peritoneum medial to the ureters may be incised in order to prevent ureteral kinking. The Halban procedure is performed with no. 0 nonabsorbable suture, starting at the posterior vagina and proceeding longitudinally over the cul-de-sac peritoneum and then over the inferior sigmoid serosa. These sutures are tied as they are placed and should be approximately 1 cm apart. There is little risk of ureteral compromise with this procedure; however, it is important to visualize the ureters after all sutures are tied.

Laparoscopic Enterocele Repair The enterocele sac is dissected laparoscopically or vaginally so that the endopelvic fascial defects are identified and the ‘pubocervical fascia’ and rectovaginal fascia (Denonvilliers’ fascia) are delineated. If the enterocele is large, the surgeon excises redundant peritoneum and vagina by the vaginal route, taking care not to foreshorten or narrow the vaginal apex. A vaginal obturator, spongestick or equivalent vaginal manipulator (EEA sizer by US Surgical Corp., Norwalk, CT, or the CDH by Ethicon Endo-Surgery Inc., Cincinnati, OH) may be used for delineation of the vaginal apex and/or rectum when performing the dissection laparoscopically. The ‘pubocervical’ and rectovaginal fascial edges are reapproximated with no. 0 non-absorbable suture in interrupted stitches until the fascial defect is closed. Extracorporeal knot-tying is performed after each stitch is placed. This is often performed concomitantly with a uterosacral ligament– vault vault suspension, so that level I suspension is reestablished.

Laparoscopic Uterosacral Ligament–Vaginal Vault Suspension In order to suspend the vaginal apex to the uterosacral ligament, the surgeon must dissect and delineate the

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The ‘apical vault repair’ described by Ross [5] reestablishes the lateral and posterior ‘pericervical rings’ of endopelvic fascia by bringing the rectovaginal septum and cardinal–uterosacral ligaments together. After the peritoneum is dissected off the vaginal apex, the rectovaginal septum and the pubocervical fascia are identified. No. 0 non-absorbable suture is used to incorporate the left and right uterosacral and cardinal ligaments, the rectovaginal septum and posterior vaginal wall in pursestring stitches, thus plicating the uterosacral ligaments. The first stitch is placed in the uterosacral ligament approximately 3–4 cm proximal to the vaginal apex. Three or more successive stitches are placed until the vaginal apex is reached. The final suture incorporates the pubocervical fascia into the repair. This repair differs from the uterosacral ligament–vaginal vault suspension by the placement of pursestring sutures, resulting in uterosacral ligament plication. Fig. 1. Dissection of the pubocervical and rectovaginal fasciae. Manipulators have been placed in the vagina and rectum.

Laparoscopic Sacral Colpopexy In addition to the intraumbilical port, one 10/12 mm trocar should be placed in each lower quadrant bilaterally for suture introduction. One 5 mm port is placed at the level of the umbilicus, lateral to the rectus muscle for retraction (Fig. 3) [6]. After the ancillary ports are placed the peritoneum is dissected off the vaginal apex in order to delineate the rectovaginal fascia. Anterior dissection, taking care to avoid damage to the bladder, is performed if a T-shaped mesh is stitched to the pubocervical fascia anteriorly, or if enterocele repair is needed. A vaginal obturator, spongestick or equivalent vaginal manipulator is used to delineate the vaginal apex and/or rectum.

Fig. 2. Uterosacral ligament–vaginal vault suspension.

‘pubocervical’ and rectovaginal fasciae (Fig. 1). The surgeon sutures the full thickness of the uterosacral ligament at the proximal portion of its break with no. 0 non-absorbable suture and reattaches it to the vaginal apex with a full-thickness stitch incorporating the uterosacral–cardinal ligament complex and rectovaginal fascia, excluding the vaginal epithelium. This stitch is tied extracorporeally and the opposite uterosacral ligament is reattached in the same fashion. Two or three additional stitches are taken more proximally in the uterosacral ligaments on each side in order to reattach them to the rectovaginal fascia (Fig. 2). Plication of the uterosacral ligaments is not necessary. If concomitant enterocele repair is performed, the uterosacral ligaments may be tagged prior to dissection of the posterior vagina and rectovaginal septum so that they are easily identified for subsequent suspension. In order to protect the ureters, peritoneal incisions may be made lateral to the uterosacral ligaments.

Fig. 3. Anatomy of the anterior abdominal wall, with designated sites for port placement (from Paraiso MFR and Falcone T [6], with permission).

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If exposure of the sacral promontory and presacral space is not adequate, the patient should be tilted to her left and/or a fan retractor (Origin Medsystems, Menlo Park, CA and US Surgical Corp., Norwalk, CT) placed through an ancillary port. The peritoneum overlying the sacral promontory is incised longitudinally and extended to the cul-de-sac. A laparoscopic dissector or hydrodissection is used to expose the periosteum of sacral promontory (Fig. 4). If blood vessels are encountered during the dissection, coagulation or clip placement is used to achieve hemostasis. A Halban procedure or other culdeplasty is usually performed. When a concomitant enterocele repair is performed, this is completed prior to mesh placement. A 10 6 2.5 cm autologous fascia lata, freeze-dried non-radiated cadaveric fascia lata, polypropylene or

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dacron mesh is introduced through the 10/12 mm port. When a T-shaped mesh is used, a 4 6 2.5 cm mesh is sutured to the larger piece of mesh with no. 0 nonabsorbable suture. The mesh is sutured to the vaginal apex anteriorly with two pairs of no. 0 non-absorbable sutures, and into the posterior vaginal apex and rectovaginal septum with three similar rows of suture (Fig. 5). When using a T-shaped mesh it is easier to suture the anterior portion first, so that the cephalad portion may be retracted anteriorly while the posterior rows of sutures are being placed. The sutures are tied extracorporeally as they are placed. Another technique used to incorporate a T-shaped mesh includes suturing two pieces of mesh separately. The larger piece is sutured to the anterior wall; we then sew both pieces together into the vaginal apex, and trim the excess

Fig. 4. Technique of laparoscopic sacral colpopexy with incision of the peritoneum and dissection of the presacral and rectovaginal spaces. Spongesticks have been placed in the vagina and rectum and a grasper points to the rectovaginal space.

Fig. 5. Technique of laparoscopic sacral colpopexy where T-shaped Prolene mesh has been sutured to the anterior vagina. The cephalad portion of the graft is retracted laterally so that the posterior portion of the graft is visualized.

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Fig. 6. Technique of laparoscopic sacral colpopexy with the Prolene mesh attached to the longitudinal ligament with coils and suture (from Paraiso MFR and Falcone T [6], with permission).

Fig. 7. Technique of laparoscopic sacral colpopexy with closure of the peritoneum and the use of sigmoid epiploic fat to cover the graft caudally.

anterior mesh. Care is taken to place the stitches through the entire thickness of the vaginal wall, excluding the epithelium. The mesh is stitched to the longitudinal ligament of the sacrum in two rows of two no. 0 nonabsorbable suture, without undue tension. Titanium tacks or hernia staples may also be used to attach the mesh to the longitudinal ligament (Fig. 6). The redundant portion of the mesh is excised and the peritoneum reapproximated over the mesh with no. 2-0 polyglactin suture. If the mesh remains exposed, sigmoid epiploic fat may be sutured over it (Fig. 7). A concomitant laparoscopic colposuspension is performed if the patient has genuine stress incontinence, otherwise a paravaginal defect repair is performed, if needed, to treat compensatory anterior defects. If rectal prolapse is present, a rectopexy may be performed laparoscopically. We perform these combined cases with our colorectal surgery colleagues.

Laparoscopic Rectocele Repair The rectovaginal septum is opened using electrocautery, harmonic scalpel or laser. Blunt dissection with blunt- or dolphin-tipped dissectors, or hydrodissection and/or sharp dissection may be used to open the rectovaginal space down to the perineal body. This dissection should follow surgical planes and be relatively bloodless. The perineal body is sutured to the rectovaginal septum and the rectovaginal fascial defects are closed with no. 0 non-absorbable suture. If the rectovaginal fascia is detached from the iliococcygeus fascia, it is reattached with no. 0 non-absorbable suture. The medial aspects of the levator ani muscles may also be plicated, but care should be taken to avoid a posterior vaginal ridge. Lyons and Winer [7] have reported the use of polyglactin mesh in extensive laparoscopic rectocele repairs.

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Clinical Results and Complications The current gynecologic literature for laparoscopic pelvic reconstruction is sparse and consists of descriptive studies with short-term follow-up. There are several reports of laparoscopic rectopexy in the colorectal surgery literature, which is beyond the scope of this paper. There are no large case series that evaluate cure rates for uterosacral shortening of culdeplasty, although these techniques have been described by a few authors. Lyons and Winer [8] reported 276 enterocele repairs or prophylaxis with Halban or Moschcowitz procedures, and noted no complications other than trocar site infections. Long-term follow-up was not reported. Cadeddu [9] et al. describe a modified Moschcowitz approximating the posterior vaginal fascia with the anterior wall of the rectum. Koninckx et al. [10] used the carbon dioxide laser to vaporize the enterocele sac, followed by uterosacral shortening and suspension of the posterior vaginal wall. Lyons and Winer [7] evaluated prospectively at 3month intervals for 1 year, 20 patients who underwent laparoscopic rectocele repair with polyglactin mesh and concomitant reparative procedures. An objective telephone interviewer asked a series of questions with regard to bowel and sexual function. The mean operative time for rectocele repair was 35 minutes (range 20–48). Estimated blood loss was minimal and hospital stay less than 24 hours; 80% of patients had symptomatic relief of digital defecation and prolapse at 1 year. There are a small number of reports of laparoscopic repair of vaginal apex prolapse. There are a few case reports and small case series that describe the surgical technique and results of various ventral suspensions of the uterus and/or vaginal apex. We did not include these procedures because they are not considered conventional surgical treatment for uterovaginal prolapse. Nezhat et al. [1] reported a series of 15 patients who underwent laparoscopic sacral colpopexy, in whom the mean operative time was 170 minutes (range 105–320) and mean blood loss 226 ml (range 50–800). The mean hospital stay was 2.3 days, excluding the case converted to laparotomy for presacral hemorrhage. The cure rate for apical prolapse was 100% at 3–40 months. Lyons [11] reported four laparoscopic sacrospinous fixations and 10 laparoscopic sacral colpopexies, with operative times comparable to vaginal and abdominal approaches. He reported less intra- and postoperative morbidity with the laparoscopic route; this was attributed to a superior anatomic approach and visualization of anatomic structures. Nezhat et al. [1] and Lyons [11] used mesh and suture, and at times they stapled the mesh into the longitudinal ligament of the anterior sacrum rather than suturing it. Ross [12] prospectively evaluated 19 patients with posthysterectomy vaginal apex prolapse with extensive preoperative and postoperative testing, including multichannel urodynamics and transperineal ultrasound. All patients underwent sacral colpopexy, Burch colposuspension and modified culdeplasty. Paravaginal defect

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repair and posterior colporrhaphy were added as indicated. The author reported seven complications: 3 cystotomies, 2 urinary tract infections, 1 seroma and 1 inferior epigastric vessel laceration. Five patients had recurrent defects which were all less than grade 2 (2 paravaginal defects and 3 rectoceles). Vaginal length ranged from 10.8 to 12.1 cm, and all sexually active patients reported no sexual dysfunction. All but 4 patients voided spontaneously, and no-one required more than 4 days of catheterization. All were discharged within 24 hours. The cure rate at 1 year was 100% for vaginal apex prolapse and 93% for genuine stress incontinence, although 2 patients were lost to follow-up. Ostrzenski [13] described a ‘modified translaparoscopic colpopexy’ for the repair of total vaginal prolapse, which included vaginal vault suspension to the uterosacral– cardinal ligament complex–paravesical fascia in 16 patients (Group 1) compared to a group of 11 patients (Group 2) who underwent similar vaginal vault suspension with a paravaginal defect repair. The author reported minimal blood loss, an average operative time of 222 minutes (range 187–365) in Group 1 and 200 minutes (range 170–310) in Group 2, and a cure rate of 69% at 36 months in Group 1 and 91% at 42 months in Group 2. One patient in the first group reported vaginal stenosis.

Conclusion The principles of laparoscopic reparative procedures for enterocele, rectocele and vaginal apex prolapse are not new: it is the route by which they are performed that is different. Adequate laparoscopic suturing skills are essential when performing these procedures. The increase in operative time may elevate the cost of the procedure, especially early in a surgeon’s experience. Prospective clinical trials and long-term follow-up are warranted from experienced laparoscopic surgeons prior to the universal application of laparoscopy for the repair of pelvic organ prolapse.

References 1. Nezhat CH, Nezhat F, Nezhat C. Laparoscopic sacral colpopexy for vaginal vault prolapse. Obstet Gynecol 1994;84:885–888 2. DeLancey JO. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol 1992;166:1717–1728 3. Richardson AC. The rectovaginal septum revisited: its relationship to rectocele and its importance in rectocele repair. Clin Obstet Gynecol 1993;36:976–983 4. Richardson AC. The anatomic defects in rectocele and entercele. J Pelv Surg 1995;1:214–221 5. Ross JW. Apical vault repair, the cornerstone of pelvic vault reconstruction. Int Urogynecol J 1997;8:146–152 6. Paraiso MR, Falcone T. Laparoscopic surgery for genuine stress incontinence and pelvic organ prolapse. In: Walters MD, Karram MM, eds. Urogynecology and reconstructive pelvic surgery, 2nd edn. Mosby, Chicago: 1998 7. Lyons TL, Winer WK. Laparoscopic rectocele repair using polyglactin mesh. J Am Assoc Gynecol Laparosc 1997;4:381–384

Laparoscopic Surgery for Enterocele, Prolapse and Rectocele 8. Lyons TL. Minimally invasive treatment of urinary stress incontinence and laparoscopically directed repair of pelvic floor defects. Clin Obstet Gynecol 1995;38:380–391 9. Cadeddu JA, Micali S, Moore RG, Kavoussi LR. Laparoscopic repair of enterocele. J Endourol 1996;4:367–369 10. Koninckx PR, Poppe W, Deprest J. Carbon dioxide laser for laparoscopic enterocele repair. J Am Assoc Gynecol Laparosc 1995;2:181–185

229 11. Lyons TL, Winer WK. Vaginal vault suspension. Endosc Surg 1995;3:88–92 12. Ross JW. Techniques of laparoscopic repair of total vault eversion after hysterectomy. J Am Assoc Gynecol Laparosc 1997;4:173–183 13. Ostrzenski A. Laparoscopic colposuspension for total vaginal prolapse. Int J Gynecol Obstet 1996;55:147–152

Review of Current Literature Bladder Function in Patients with Lumbar Intervertebral Disc Protrusion Bartolin Z, Golja I, Bedalov G, Savic I Department of Urology, Clinical Hospital ‘Dubrava’ and Urological Institute, General Hospital, ‘Sv. Duh,’ Zagreb, Croatia J Urol 1998;159:969–971

not found in any case. Patients with detrusor areflexia had decreased proprioceptive sensation due to a lesion of the visceral sensory fibers of the cauda equina. Decreased bladder sensation appears to be the cause of detrusor areflexia, and the bladder becomes distended with resultant excessive stretching of the detrusor muscle.

Comment: Lumbar intervertebral disc protrusion frequently causes neurological problems and may result in bladder dysfunction due to pressure on the cauda equina. Seventy-seven men and 37 women with symptomatic lumbar disc protrusion causing pain on one or both sides were studied. Disc protrusions were noted at L3 (8), L4 (54), and L5 (52). No voiding disorder was present in 71 patients, but the remaining 43 had symptoms related to bladder evacuation or storage. Of these, 31 had difficulty voiding with straining, and 12 had frequency. Patients with central disc protrusion were excluded. Detrusor areflexia was found in 31 patients (27%). Median residual urine in 23 of these 31 patients was 45 ml. Patients with L3 protrusion had detrusor areflexia in 3/8 cases, L4 was 10/54, and L5 was 18/52. Twelve of the 83 patients with normal cystometric findings had urinary frequency. Detrusor hyperreflexia was

Detrusor areflexia occurs in patients with intervertebral disc protrusion at the L3–L5 level. The patients voided by straining, with remarkably low postvoid residual urine volumes. Cauda equina syndrome may occur after trauma, but more often after surgery to correct abnormalities, some of which are the result of trauma. Sensory changes are variable, but patients generally have problems with bladder emptying as well as bowel evacuation. There may be sexual dysfunction as well. The bladder problem is best managed by intermittent self-catheterization in the female, the frequency of which depends on the residual urine amounts. A good rule of thumb is to catheterize once daily if residual urine is over 100 ml, twice daily if over 200 ml, three times daily if over 300 ml, and four times daily for volumes over 400 ml.