Here, we present a retrospective study of patients who received modified paravaginal repair for anterior vaginal prolapse and cystocele at Beijing Hospital during the period from June 2014 to May 2018. The study was approved by the Ethics Advisory Group at Beijing Hospital. As this was a retrospective study, the Ethics Advisory Group waived the need for informed consent. All participants received a complete clinical examination, with particular emphasis on pelvic examinations and the assessment of prolapse. Pelvic evaluations were performed using Pelvic Organ Prolapse Quantification (POP-Q). We also performed a pelvic examination to rule out bulging. Urinary incontinence was evaluated by asking patients to perform the cough test. They also completed a short version of the pelvic floor quality of life questionnaire, which included POP-Q, as well as subscale scores for the Pelvic Floor Distress Inventory-20 (PFDI-20), the Pelvic Floor Impact Questionnaire-7 (PFIQ-7), and the Pelvic Organ Prolapse Urinary Incontinence Sexual Questionnaire 12 (PISQ-12) [9]. Participants who reported urinary symptoms, or who had urinary leakage during the prolapse examination, underwent urodynamic testing.
Patients were followed at 1, 3, 6, 12, and 24 months after surgery. Objective success was defined as no prolapse beyond the hymen, as evaluated by the POP-Q examination (i.e., Ba, C, and Bp measurements ≤0) and no subsequent treatment for prolapse. We assessed subjective outcomes using the short version of the pelvic floor quality of life questionnaires (PFDI-20, PFIQ-7, PISQ-12). Subjective success was defined as the absence of bothersome bulging symptoms, as measured by question 5 on the PFDI.
Surgical technique
Our modified technique featured 7 key steps, as follows.
(1) Bladder lithotomy was performed for patients who required hysterectomy, and for those in which the vaginal fragment was not closed after vaginal hysterectomy using the traditional method.
(2) Bridge formation was performed. After bladder emptying, the anterior vaginal wall mucosa was incised 1–2 cm below the external urethral orifice. This incision was used to form a trapezoid in the vaginal mucosa; the top edge was 1–2 cm in length, 1–2 cm below the external urethral orifice. The bottom edge, 3–4 cm in length, lay at the margin of the vaginal incision. Secretory function was destroyed by cautery with a Unipolar Electrotome (Hongsheng Co., Jining, China) (Fig. 1, Panel A), thus creating a bridge (Fig. 1, Panel B).
(3) To expose the pelvic fascia tendinous arch (denoted as a white line), we separated the bladder and the vaginal mucosa to the retro-pubic space (Fig. 1, Panel C).
(4) To close paravaginal defects, we sutured along the white line with No. 4 silk thread, on one side (Fig. 1, Panel D), at the level of the urethral bladder groove. We sutured on the edge of the anterior pelvic fascia tear (Fig. 1, Panel E) and then sutured the bridge with the same silk thread (Fig. 1, Panel F). This process was repeated on the other side (Fig. 1, Panel G and H). The four threads were then crossed and knotted (Fig. 1, Panel I and J). The same style of suturing was performed 1–1.5 cm below the level of the urethral bladder groove, and then 1–1.5 cm below the second level; this created a parallel network formed by 3–4 silk threads (Fig. 1, Panel K and L).
(5) Additional pelvic floor repairs were carried out if necessary.
(6) The mucosa of the anterior vaginal wall was then sutured, and the denuded trapezoid was buried by suturing the lateral vagina along the midline (Fig. 1, Panel M).
(7) Finally, the vaginal stump was sutured (Fig. 1, Panel N).
We also performed middle pelvic cavity repair (sacral ligament suspension or sacrospinous ligament fixation), old perineal laceration repair, or paraurethral fascia reinforcement, as required by the patient's condition.
We recorded intraoperative bleeding volume, operation time, and any postoperative complications.