Surgical Techniques

Is the extensive dissection of the Pfannenstiel incision necessary in cesarean delivery? Is bladder dissection essential? Must the visceral and parietal peritoneum be closed?

The success of our minimally invasive cesarean technique suggests the answer is “no.”

The approach described here features a short operative time; minimal instrumentation; reduced surgical dissection; decreased postoperative pain; and reduced risk of blood loss, infection, and wound complications. It is easily learned and cost-effective, with a brief postoperative recovery period.

Among the updates made from the technique’s initial publication in the mid-1990s^1,2:

• addition of routine perioperative oxygen (80%), to reduce the risk of surgical wound infection (see “Perioperative considerations”)
• regular use of forced warm air covers applied to the anterior skin surface, to help patients maintain normothermia
• addition of a soft, self-retaining abdominal retractor—which creates an atraumatic circle of exposure up to a calculated 177 cm² for a 15-cm incision (versus 113 cm² calculated for traditional retraction)
• vertical, rather than lateral, digital extension of the initial transverse uterine incision
• identification of a subgroup in whom peritoneal closure is strongly recommended
• new data on the procedure’s effectiveness.³

Modified abdominal incision reduces dissection

Make a straight low transverse incision with a scalpel, at a point approximately 3 to 4 cm above the symphysis pubis (FIGURE 1A).

The length of the incision is individualized (13 to 15 cm), though difficult fetal extraction is more likely if the abdominal incision is less than 15 cm.^4,5

Divide the subcutaneous tissue transversely with an electrocautery knife. In a cutting and coagulation blend mode, the knife divides the fat while achieving hemostasis. To improve hemostasis, coagulate the blood vessels that cross the subcutaneous fat layer in a brushing manner before dividing them. To prevent unnecessary dead space, avoid filleting the fat and separating adherent subcutaneous fat from the anterior rectus fascia beyond what is needed to expose the fascia.

Open the fascia transversely with the electrocautery knife to the same length as the skin incision. Coagulate the blood vessels that cross the fascia before dividing them. Identify the median raphe by pulling up the superior edge of the abdominal incision.

Separate the rectus muscles in the midline by vertical blunt finger dissection (FIGURE 1B). If digital dissection is inefficient due to a dense, thick, or scarred median raphe, use an electrocautery knife, a scalpel, or scissors.

Open the peritoneum. This is facilitated by upward traction and elevation of the superior edge of the abdominal incision that lifts the peritoneum, allowing easy digital perforation using the index or middle finger (FIGURE 1C).

If this maneuver is not feasible, open the peritoneum in the traditional fashion.

Stretch the full thickness of the abdominal wall to full size of the skin incision, using 1 or 2 fingers of each hand (FIGURE 1D). Incorporate the skin, subcutaneous tissue, fascia layer, rectus muscles, and peritoneum. An assistant’s hands may be required. When needed, extend the peritoneal opening transversely on either side, to the midline and away from the bladder.

Digitally stretching the full-thickness abdominal incision is easily achieved due to the mechanical stretching of the anterior abdominal wall, edema, and increased vascularization that occur during pregnancy.

FIGURE 1A Create a modified abdominal incision

FIGURE 1B Create a modified abdominal incision

FIGURE 1C Create a modified abdominal incision

FIGURE 1D Create a modified abdominal incision

Retractor facilitates exposure

Our positive experience with the soft, self-retaining abdominal retractor for minilaparotomy and laparotomy^6-8 compelled us to incorporate its use for cesarean 3 years ago.

The device consists of a flexible plastic inner ring and a firmer outer ring connected by a soft plastic sleeve. We use the large size of either of the 2 models currently available: the Mobius (Apple Medical Corporation, Marlboro, Miss) and the Protractor (Weck Closure Systems, Research Triangle Park, NC).

Introduce a hand through the laparotomy incision and evaluate the pelvis to ensure that no significant adhesions are present that may interfere with swift placement of the inner ring. If significant adhesions are found, use traditional metal retractors instead.

Squeeze the inner ring and insert it into the abdominal cavity toward the patient’s head, allowing the device to spring open against the parietal peritoneum (FIGURE 2A). Apply upper traction and elevate the superior edge of the abdominal incision to facilitate placement. Perform a digital check to ensure no tissue is trapped between the inner ring and the abdominal wall.

Hold up the outer ring, then roll the plastic sleeve until the ring completely inverts (FIGURE 2B). Repeat the process until the top ring is snug against the patient’s skin.

Advantages of the soft, self-retaining abdominal retractor include atraumatic retraction; incision protection; and adjustable height, making it ideal for obese patients.

FIGURE 2A Place the abdominal retractor

FIGURE 2B Place the abdominal retractor

Transverse hysterotomy in lower uterine segment

Make a transverse 2-cm uterine incision with a scalpel, approximately 1 cm above the vesicouterine peritoneal fold (identify this using gentle digital pressure to elevate the uterus) (FIGURE 3A).

Traditional bladder dissection is eliminated. We have found that when an adequate transverse hysterotomy is performed, a bladder flap is not required.^1-3 In a recent randomized trial, Hohlagschwandtner et al⁹ confirmed our findings that bladder-flap omission was associated with reduced operative time and incision-delivery interval, decreased blood loss, and less need for postoperative analgesics.

An additional advantage of this omission: We can avoid making the uterine incision too low—especially when the cervix is fully dilated. Further, making the hysterotomy (uterine serosa and myometrium together) slightly above the vesicouterine peritoneal fold without bladder flap dissection frees the loose connective tissue between the uterus and the urinary bladder, allowing the spontaneous descent of the bladder.

Digitally extend the transverse uterine incision. We extend the initial incision not laterally but, instead, vertically (FIGURE 3B). The vertical digital traction on the initial transverse uterine incision creates a transverse dissociation of the horizontal myometrium fibers; this results in a transverse extension of the original incision.

This modification prevents unintended and uncontrolled lateral extensions of the incision that may lacerate the uterine vessels.¹⁰ It also prevents the uterine incision from becoming an inverted “U” and the undesirable accumulation of myometrium fibers at the ends of the incision. Such incisions usually do not reapproximate well during hysterotomy closure and may lead to sacculation-type defects.¹¹

FIGURE 3A Use a standard hysterotomy in the lower uterine segment

FIGURE 3B Use a standard hysterotomy in the lower uterine segment

Delivering the fetus

For vertex presentations, place your hand into the uterine cavity between the lower edge of the hysterotomy and fetal head. While applying transabdominal fundal pressure, lift the head with your fingers and deliver it through the incision (FIGURE 4A).

The self-retaining retractor facilitates delivery of the fetal head by creating a rigid border around the abdominal incision. The back of the surgeon’s hand that is in the uterine cavity achieves better leverage, as it now rests on a rigid plane on the inferior part of the incision rather than on the back hand and the softer and pliable wound edge of the standard abdominal incision.

Vacuum-assistance. When delivery of the fetal head proves difficult, we use the soft vacuum cup, which avoids unnecessary intrauterine manipulation that may result in fetal or maternal trauma (FIGURE 4B).¹²

Breech extraction or transverse lie delivery is performed using standard extraction maneuvers (FIGURE 4C).¹³ We have found no need to perform T or J vertical extensions of the low transverse uterine incision, even in cases of a poorly developed lower uterine segment, abnormal presentation, or prematurity.

FIGURE 4A Deliver the fetal head

FIGURE 4B Deliver the fetal head

FIGURE 4C Deliver the fetal head

Uterine incision: 1-layer, in situ close

Remove the placenta only after it separates spontaneously—this greatly reduces blood loss compared with immediate manual placental delivery or umbilical-cord traction. Manually deliver the placenta only if it has not separated spontaneously after 5 minutes. Avoid routine manual clean-out of the uterine cavity if the placenta is completely delivered.^1-3,14

Dilate the cervix to facilitate lochial discharge, when necessary.

Decrease uterine bleeding by massaging the uterus and administering diluted oxytocin.

Close the uterine incision in situ. Disadvantages of routine uterine exteriorization include discomfort and vomiting resulting from traction, exposure of the fallopian tubes to unnecessary trauma, increased risk of infection, possible rupture of the uteroovarian veins, and pulmonary embolism.

Exteriorization may also increase the risk of adhesion formation by exposing the uterine serosa to the abrasive effects of drying or microscopic abrasion if sponges are used to hold the uterus in place.^1,14-17

Use a single-layer closure with a running suture of polyglycolic acid to close the uterine incision (FIGURE 5A). If needed, use atraumatic clamps to grasp the edges of the hysterotomy to facilitate visualization and closure.

Begin suturing at a point just beyond one end of the incision, continuing to the opposite side. Be sure to penetrate the full thickness of the myometrium and avoid incorporating the decidua in the suture line. After the uterine closure, use individual figure-of-8 sutures to control areas of persistent bleeding.

Compared with 2-layer closures, single-layer closure of a low transverse incision is associated with reduced operating time, improved hemostasis, and less tissue disruption; introduces less foreign material into the surgical site; reduces the need for postoperative analgesia; and potentially reduces infectious morbidity. A trial of labor after a cesarean section with 1-layer closure appears safe.^18-22

We do not close the vesicouterine fold and parietal peritoneum (FIGURE 5B) or reapproximate the rectus muscles. It has been shown that a new peritoneal layer is formed within days of the original incision closure.

Leaving the peritoneum open leads to no increased postoperative complications, nor obvious differences in wound healing, wound dehiscence, or incidence of postoperative adhesions. Compared to women without peritoneal closure, those with peritoneal closure require a longer operative time, greater amounts of post-operative narcotics for postoperative pain, a greater need for bowel stimulants, and a longer postoperative hospitalization.²³

In 1995, we performed laparoscopy for gynecologic conditions in 23 patients and repeat cesarean in 10 patients who had undergone our technique (with visceral and parietal peritoneum left open).² We found no adhesions and a normal peritoneal lining in all cases.

In 1 subgroup, peritoneal closure is strongly recommended: cases in which 1 or both rectus muscles have been transected to increase surgical exposure. Extremely thick fibromuscular adhesions between the low anterior surface of the uterus and the under-surface of the rectus musculature may develop if the parietal peritoneum is not closed.

FIGURE 5A Close the incisions

FIGURE 5B Close the incisions

Abdominal closure

Close the rectus fascia with a continuous nonlocking 0 suture after the rectus muscles fall into place. Place entry and exit sites at 1-cm intervals, 1.5 cm beyond the wound edges—this minimizes the risk of sutures pulling through fascia. Interrupted sutures offer no greater tensile strength than continuous suturing.²⁴ Tight, continuous suturing can lead to tissue ischemia, which may weaken the sutured fascia, and thus should be avoided.

The subcutaneous layer is not closed separately. One exception is obese patients with at least 2 cm of thick subcutaneous tissue. Thickness of subcutaneous tissue appears to be a significant risk factor for wound infection after cesarean section.²⁵

In patients with thick subcutaneous tissue, you can reduce tension on the skin edges and the risk of subcutaneous infection, seroma formation, and wound disruption by placing interrupted 3-0 absorbable synthetic sutures to eliminate dead space.^26-28 We have found no need to place Penrose drains or closed drainage systems in the subcutaneous layer.^29-31

Close the skin using a subcuticular continuous absorbable 4-0 suture or, alternatively, metal staples, which are removed 4 days after surgery (FIGURE 5C).

FIGURE 5C Close the incisions

Prompt postoperative recovery

The patient may drink fluids in the recovery room, can resume a regular solid food diet within 4 hours after surgery, and may resume mobility as soon as anesthesia wears off.

Early breast-feeding is also allowed in the recovery room. In our experience, this has not been associated with complications, has been highly appreciated by the patients, and has led to earlier hospital discharge.

Control pain with meperidine (50–75 mg) or morphine (10 mg) parenterally every 3 to 4 hours. Other options include oxycodone and acetaminophen, oxycodone and aspirin, and ibuprofen.

Patients are usually discharged 48 to 72 hours following surgery.

Our experience: The numbers

Using this updated system, we have successfully completed 300 consecutive cesarean sections (210 primary, 90 repeat).

The average operating time was 19 minutes; average blood loss, 405 mL.

There was no postoperative febrile morbidity, wound infection, wound disruption, or wound hematoma.Only 3 patients developed superficial wound seromas, which were easily resolved. There were no intraoperative or postoperative complications.

We attribute the absence of wound infection to routine prophylactic antibiotics; supplemental perioperative oxygen; maintenance of normothermia; use of an electrocautery knife to create rapid hemostatic division of subcutaneous fat and anterior rectus fascia; a simplified abdominal wall opening; and placement of a self-retaining atraumatic retractor.^10,32-36

Additional surgical procedures (tubal sterilization, myomectomy, appendectomy, and adhesiolysis) did not alter the recovery period, and all patients were able to get out of bed, shower, breast-feed, and care for their infants within 8 hours of surgery.

No infant complications related to the cesarean procedure occurred.

Patients were discharged from the hospital within 72 hours.

A prospective comparison study demonstrated that the original Pelosi-type of cesarean delivery was faster to perform, more cost-effective, and resulted in less maternal morbidity than the traditional cesarean technique.³

Dr. Pelosi II is a consultant for Apple Medical Corporation. Dr. Pelosi III reports no financial relationships relevant to this article.

Is the extensive dissection of the Pfannenstiel incision necessary in cesarean delivery? Is bladder dissection essential? Must the visceral and parietal peritoneum be closed?

The success of our minimally invasive cesarean technique suggests the answer is “no.”

The approach described here features a short operative time; minimal instrumentation; reduced surgical dissection; decreased postoperative pain; and reduced risk of blood loss, infection, and wound complications. It is easily learned and cost-effective, with a brief postoperative recovery period.

Among the updates made from the technique’s initial publication in the mid-1990s^1,2:

• addition of routine perioperative oxygen (80%), to reduce the risk of surgical wound infection (see “Perioperative considerations”)
• regular use of forced warm air covers applied to the anterior skin surface, to help patients maintain normothermia
• addition of a soft, self-retaining abdominal retractor—which creates an atraumatic circle of exposure up to a calculated 177 cm² for a 15-cm incision (versus 113 cm² calculated for traditional retraction)
• vertical, rather than lateral, digital extension of the initial transverse uterine incision
• identification of a subgroup in whom peritoneal closure is strongly recommended
• new data on the procedure’s effectiveness.³

Modified abdominal incision reduces dissection

Make a straight low transverse incision with a scalpel, at a point approximately 3 to 4 cm above the symphysis pubis (FIGURE 1A).

The length of the incision is individualized (13 to 15 cm), though difficult fetal extraction is more likely if the abdominal incision is less than 15 cm.^4,5

Divide the subcutaneous tissue transversely with an electrocautery knife. In a cutting and coagulation blend mode, the knife divides the fat while achieving hemostasis. To improve hemostasis, coagulate the blood vessels that cross the subcutaneous fat layer in a brushing manner before dividing them. To prevent unnecessary dead space, avoid filleting the fat and separating adherent subcutaneous fat from the anterior rectus fascia beyond what is needed to expose the fascia.

Open the fascia transversely with the electrocautery knife to the same length as the skin incision. Coagulate the blood vessels that cross the fascia before dividing them. Identify the median raphe by pulling up the superior edge of the abdominal incision.

Separate the rectus muscles in the midline by vertical blunt finger dissection (FIGURE 1B). If digital dissection is inefficient due to a dense, thick, or scarred median raphe, use an electrocautery knife, a scalpel, or scissors.

Open the peritoneum. This is facilitated by upward traction and elevation of the superior edge of the abdominal incision that lifts the peritoneum, allowing easy digital perforation using the index or middle finger (FIGURE 1C).

If this maneuver is not feasible, open the peritoneum in the traditional fashion.

Stretch the full thickness of the abdominal wall to full size of the skin incision, using 1 or 2 fingers of each hand (FIGURE 1D). Incorporate the skin, subcutaneous tissue, fascia layer, rectus muscles, and peritoneum. An assistant’s hands may be required. When needed, extend the peritoneal opening transversely on either side, to the midline and away from the bladder.

Digitally stretching the full-thickness abdominal incision is easily achieved due to the mechanical stretching of the anterior abdominal wall, edema, and increased vascularization that occur during pregnancy.

FIGURE 1A Create a modified abdominal incision

FIGURE 1B Create a modified abdominal incision

FIGURE 1C Create a modified abdominal incision

FIGURE 1D Create a modified abdominal incision

Retractor facilitates exposure

Our positive experience with the soft, self-retaining abdominal retractor for minilaparotomy and laparotomy^6-8 compelled us to incorporate its use for cesarean 3 years ago.

The device consists of a flexible plastic inner ring and a firmer outer ring connected by a soft plastic sleeve. We use the large size of either of the 2 models currently available: the Mobius (Apple Medical Corporation, Marlboro, Miss) and the Protractor (Weck Closure Systems, Research Triangle Park, NC).

Introduce a hand through the laparotomy incision and evaluate the pelvis to ensure that no significant adhesions are present that may interfere with swift placement of the inner ring. If significant adhesions are found, use traditional metal retractors instead.

Squeeze the inner ring and insert it into the abdominal cavity toward the patient’s head, allowing the device to spring open against the parietal peritoneum (FIGURE 2A). Apply upper traction and elevate the superior edge of the abdominal incision to facilitate placement. Perform a digital check to ensure no tissue is trapped between the inner ring and the abdominal wall.

Hold up the outer ring, then roll the plastic sleeve until the ring completely inverts (FIGURE 2B). Repeat the process until the top ring is snug against the patient’s skin.

Advantages of the soft, self-retaining abdominal retractor include atraumatic retraction; incision protection; and adjustable height, making it ideal for obese patients.

FIGURE 2A Place the abdominal retractor

FIGURE 2B Place the abdominal retractor

Transverse hysterotomy in lower uterine segment

Make a transverse 2-cm uterine incision with a scalpel, approximately 1 cm above the vesicouterine peritoneal fold (identify this using gentle digital pressure to elevate the uterus) (FIGURE 3A).

Traditional bladder dissection is eliminated. We have found that when an adequate transverse hysterotomy is performed, a bladder flap is not required.^1-3 In a recent randomized trial, Hohlagschwandtner et al⁹ confirmed our findings that bladder-flap omission was associated with reduced operative time and incision-delivery interval, decreased blood loss, and less need for postoperative analgesics.

An additional advantage of this omission: We can avoid making the uterine incision too low—especially when the cervix is fully dilated. Further, making the hysterotomy (uterine serosa and myometrium together) slightly above the vesicouterine peritoneal fold without bladder flap dissection frees the loose connective tissue between the uterus and the urinary bladder, allowing the spontaneous descent of the bladder.

Digitally extend the transverse uterine incision. We extend the initial incision not laterally but, instead, vertically (FIGURE 3B). The vertical digital traction on the initial transverse uterine incision creates a transverse dissociation of the horizontal myometrium fibers; this results in a transverse extension of the original incision.

This modification prevents unintended and uncontrolled lateral extensions of the incision that may lacerate the uterine vessels.¹⁰ It also prevents the uterine incision from becoming an inverted “U” and the undesirable accumulation of myometrium fibers at the ends of the incision. Such incisions usually do not reapproximate well during hysterotomy closure and may lead to sacculation-type defects.¹¹

FIGURE 3A Use a standard hysterotomy in the lower uterine segment

FIGURE 3B Use a standard hysterotomy in the lower uterine segment

Delivering the fetus

For vertex presentations, place your hand into the uterine cavity between the lower edge of the hysterotomy and fetal head. While applying transabdominal fundal pressure, lift the head with your fingers and deliver it through the incision (FIGURE 4A).

The self-retaining retractor facilitates delivery of the fetal head by creating a rigid border around the abdominal incision. The back of the surgeon’s hand that is in the uterine cavity achieves better leverage, as it now rests on a rigid plane on the inferior part of the incision rather than on the back hand and the softer and pliable wound edge of the standard abdominal incision.

Vacuum-assistance. When delivery of the fetal head proves difficult, we use the soft vacuum cup, which avoids unnecessary intrauterine manipulation that may result in fetal or maternal trauma (FIGURE 4B).¹²

Breech extraction or transverse lie delivery is performed using standard extraction maneuvers (FIGURE 4C).¹³ We have found no need to perform T or J vertical extensions of the low transverse uterine incision, even in cases of a poorly developed lower uterine segment, abnormal presentation, or prematurity.

FIGURE 4A Deliver the fetal head

FIGURE 4B Deliver the fetal head

FIGURE 4C Deliver the fetal head

Uterine incision: 1-layer, in situ close

Remove the placenta only after it separates spontaneously—this greatly reduces blood loss compared with immediate manual placental delivery or umbilical-cord traction. Manually deliver the placenta only if it has not separated spontaneously after 5 minutes. Avoid routine manual clean-out of the uterine cavity if the placenta is completely delivered.^1-3,14

Dilate the cervix to facilitate lochial discharge, when necessary.

Decrease uterine bleeding by massaging the uterus and administering diluted oxytocin.

Close the uterine incision in situ. Disadvantages of routine uterine exteriorization include discomfort and vomiting resulting from traction, exposure of the fallopian tubes to unnecessary trauma, increased risk of infection, possible rupture of the uteroovarian veins, and pulmonary embolism.

Exteriorization may also increase the risk of adhesion formation by exposing the uterine serosa to the abrasive effects of drying or microscopic abrasion if sponges are used to hold the uterus in place.^1,14-17

Use a single-layer closure with a running suture of polyglycolic acid to close the uterine incision (FIGURE 5A). If needed, use atraumatic clamps to grasp the edges of the hysterotomy to facilitate visualization and closure.

Begin suturing at a point just beyond one end of the incision, continuing to the opposite side. Be sure to penetrate the full thickness of the myometrium and avoid incorporating the decidua in the suture line. After the uterine closure, use individual figure-of-8 sutures to control areas of persistent bleeding.

Compared with 2-layer closures, single-layer closure of a low transverse incision is associated with reduced operating time, improved hemostasis, and less tissue disruption; introduces less foreign material into the surgical site; reduces the need for postoperative analgesia; and potentially reduces infectious morbidity. A trial of labor after a cesarean section with 1-layer closure appears safe.^18-22

We do not close the vesicouterine fold and parietal peritoneum (FIGURE 5B) or reapproximate the rectus muscles. It has been shown that a new peritoneal layer is formed within days of the original incision closure.

Leaving the peritoneum open leads to no increased postoperative complications, nor obvious differences in wound healing, wound dehiscence, or incidence of postoperative adhesions. Compared to women without peritoneal closure, those with peritoneal closure require a longer operative time, greater amounts of post-operative narcotics for postoperative pain, a greater need for bowel stimulants, and a longer postoperative hospitalization.²³

In 1995, we performed laparoscopy for gynecologic conditions in 23 patients and repeat cesarean in 10 patients who had undergone our technique (with visceral and parietal peritoneum left open).² We found no adhesions and a normal peritoneal lining in all cases.

In 1 subgroup, peritoneal closure is strongly recommended: cases in which 1 or both rectus muscles have been transected to increase surgical exposure. Extremely thick fibromuscular adhesions between the low anterior surface of the uterus and the under-surface of the rectus musculature may develop if the parietal peritoneum is not closed.

FIGURE 5A Close the incisions

FIGURE 5B Close the incisions

Abdominal closure

Close the rectus fascia with a continuous nonlocking 0 suture after the rectus muscles fall into place. Place entry and exit sites at 1-cm intervals, 1.5 cm beyond the wound edges—this minimizes the risk of sutures pulling through fascia. Interrupted sutures offer no greater tensile strength than continuous suturing.²⁴ Tight, continuous suturing can lead to tissue ischemia, which may weaken the sutured fascia, and thus should be avoided.

The subcutaneous layer is not closed separately. One exception is obese patients with at least 2 cm of thick subcutaneous tissue. Thickness of subcutaneous tissue appears to be a significant risk factor for wound infection after cesarean section.²⁵

In patients with thick subcutaneous tissue, you can reduce tension on the skin edges and the risk of subcutaneous infection, seroma formation, and wound disruption by placing interrupted 3-0 absorbable synthetic sutures to eliminate dead space.^26-28 We have found no need to place Penrose drains or closed drainage systems in the subcutaneous layer.^29-31

Close the skin using a subcuticular continuous absorbable 4-0 suture or, alternatively, metal staples, which are removed 4 days after surgery (FIGURE 5C).

FIGURE 5C Close the incisions

Prompt postoperative recovery

The patient may drink fluids in the recovery room, can resume a regular solid food diet within 4 hours after surgery, and may resume mobility as soon as anesthesia wears off.

Early breast-feeding is also allowed in the recovery room. In our experience, this has not been associated with complications, has been highly appreciated by the patients, and has led to earlier hospital discharge.

Control pain with meperidine (50–75 mg) or morphine (10 mg) parenterally every 3 to 4 hours. Other options include oxycodone and acetaminophen, oxycodone and aspirin, and ibuprofen.

Patients are usually discharged 48 to 72 hours following surgery.

Our experience: The numbers

Using this updated system, we have successfully completed 300 consecutive cesarean sections (210 primary, 90 repeat).

The average operating time was 19 minutes; average blood loss, 405 mL.

There was no postoperative febrile morbidity, wound infection, wound disruption, or wound hematoma.Only 3 patients developed superficial wound seromas, which were easily resolved. There were no intraoperative or postoperative complications.

We attribute the absence of wound infection to routine prophylactic antibiotics; supplemental perioperative oxygen; maintenance of normothermia; use of an electrocautery knife to create rapid hemostatic division of subcutaneous fat and anterior rectus fascia; a simplified abdominal wall opening; and placement of a self-retaining atraumatic retractor.^10,32-36

Additional surgical procedures (tubal sterilization, myomectomy, appendectomy, and adhesiolysis) did not alter the recovery period, and all patients were able to get out of bed, shower, breast-feed, and care for their infants within 8 hours of surgery.

No infant complications related to the cesarean procedure occurred.

Patients were discharged from the hospital within 72 hours.

A prospective comparison study demonstrated that the original Pelosi-type of cesarean delivery was faster to perform, more cost-effective, and resulted in less maternal morbidity than the traditional cesarean technique.³

Dr. Pelosi II is a consultant for Apple Medical Corporation. Dr. Pelosi III reports no financial relationships relevant to this article.

Is the extensive dissection of the Pfannenstiel incision necessary in cesarean delivery? Is bladder dissection essential? Must the visceral and parietal peritoneum be closed?

The success of our minimally invasive cesarean technique suggests the answer is “no.”

The approach described here features a short operative time; minimal instrumentation; reduced surgical dissection; decreased postoperative pain; and reduced risk of blood loss, infection, and wound complications. It is easily learned and cost-effective, with a brief postoperative recovery period.

Among the updates made from the technique’s initial publication in the mid-1990s^1,2:

• addition of routine perioperative oxygen (80%), to reduce the risk of surgical wound infection (see “Perioperative considerations”)
• regular use of forced warm air covers applied to the anterior skin surface, to help patients maintain normothermia
• addition of a soft, self-retaining abdominal retractor—which creates an atraumatic circle of exposure up to a calculated 177 cm² for a 15-cm incision (versus 113 cm² calculated for traditional retraction)
• vertical, rather than lateral, digital extension of the initial transverse uterine incision
• identification of a subgroup in whom peritoneal closure is strongly recommended
• new data on the procedure’s effectiveness.³

Modified abdominal incision reduces dissection

Make a straight low transverse incision with a scalpel, at a point approximately 3 to 4 cm above the symphysis pubis (FIGURE 1A).

The length of the incision is individualized (13 to 15 cm), though difficult fetal extraction is more likely if the abdominal incision is less than 15 cm.^4,5

Divide the subcutaneous tissue transversely with an electrocautery knife. In a cutting and coagulation blend mode, the knife divides the fat while achieving hemostasis. To improve hemostasis, coagulate the blood vessels that cross the subcutaneous fat layer in a brushing manner before dividing them. To prevent unnecessary dead space, avoid filleting the fat and separating adherent subcutaneous fat from the anterior rectus fascia beyond what is needed to expose the fascia.

Open the fascia transversely with the electrocautery knife to the same length as the skin incision. Coagulate the blood vessels that cross the fascia before dividing them. Identify the median raphe by pulling up the superior edge of the abdominal incision.

Separate the rectus muscles in the midline by vertical blunt finger dissection (FIGURE 1B). If digital dissection is inefficient due to a dense, thick, or scarred median raphe, use an electrocautery knife, a scalpel, or scissors.

Open the peritoneum. This is facilitated by upward traction and elevation of the superior edge of the abdominal incision that lifts the peritoneum, allowing easy digital perforation using the index or middle finger (FIGURE 1C).

If this maneuver is not feasible, open the peritoneum in the traditional fashion.

Stretch the full thickness of the abdominal wall to full size of the skin incision, using 1 or 2 fingers of each hand (FIGURE 1D). Incorporate the skin, subcutaneous tissue, fascia layer, rectus muscles, and peritoneum. An assistant’s hands may be required. When needed, extend the peritoneal opening transversely on either side, to the midline and away from the bladder.

Digitally stretching the full-thickness abdominal incision is easily achieved due to the mechanical stretching of the anterior abdominal wall, edema, and increased vascularization that occur during pregnancy.

FIGURE 1A Create a modified abdominal incision

FIGURE 1B Create a modified abdominal incision

FIGURE 1C Create a modified abdominal incision

FIGURE 1D Create a modified abdominal incision

Retractor facilitates exposure

Our positive experience with the soft, self-retaining abdominal retractor for minilaparotomy and laparotomy^6-8 compelled us to incorporate its use for cesarean 3 years ago.

The device consists of a flexible plastic inner ring and a firmer outer ring connected by a soft plastic sleeve. We use the large size of either of the 2 models currently available: the Mobius (Apple Medical Corporation, Marlboro, Miss) and the Protractor (Weck Closure Systems, Research Triangle Park, NC).

Introduce a hand through the laparotomy incision and evaluate the pelvis to ensure that no significant adhesions are present that may interfere with swift placement of the inner ring. If significant adhesions are found, use traditional metal retractors instead.

Squeeze the inner ring and insert it into the abdominal cavity toward the patient’s head, allowing the device to spring open against the parietal peritoneum (FIGURE 2A). Apply upper traction and elevate the superior edge of the abdominal incision to facilitate placement. Perform a digital check to ensure no tissue is trapped between the inner ring and the abdominal wall.

Hold up the outer ring, then roll the plastic sleeve until the ring completely inverts (FIGURE 2B). Repeat the process until the top ring is snug against the patient’s skin.

Advantages of the soft, self-retaining abdominal retractor include atraumatic retraction; incision protection; and adjustable height, making it ideal for obese patients.

FIGURE 2A Place the abdominal retractor

FIGURE 2B Place the abdominal retractor

Transverse hysterotomy in lower uterine segment

Make a transverse 2-cm uterine incision with a scalpel, approximately 1 cm above the vesicouterine peritoneal fold (identify this using gentle digital pressure to elevate the uterus) (FIGURE 3A).

Traditional bladder dissection is eliminated. We have found that when an adequate transverse hysterotomy is performed, a bladder flap is not required.^1-3 In a recent randomized trial, Hohlagschwandtner et al⁹ confirmed our findings that bladder-flap omission was associated with reduced operative time and incision-delivery interval, decreased blood loss, and less need for postoperative analgesics.

An additional advantage of this omission: We can avoid making the uterine incision too low—especially when the cervix is fully dilated. Further, making the hysterotomy (uterine serosa and myometrium together) slightly above the vesicouterine peritoneal fold without bladder flap dissection frees the loose connective tissue between the uterus and the urinary bladder, allowing the spontaneous descent of the bladder.

Digitally extend the transverse uterine incision. We extend the initial incision not laterally but, instead, vertically (FIGURE 3B). The vertical digital traction on the initial transverse uterine incision creates a transverse dissociation of the horizontal myometrium fibers; this results in a transverse extension of the original incision.

This modification prevents unintended and uncontrolled lateral extensions of the incision that may lacerate the uterine vessels.¹⁰ It also prevents the uterine incision from becoming an inverted “U” and the undesirable accumulation of myometrium fibers at the ends of the incision. Such incisions usually do not reapproximate well during hysterotomy closure and may lead to sacculation-type defects.¹¹

FIGURE 3A Use a standard hysterotomy in the lower uterine segment

FIGURE 3B Use a standard hysterotomy in the lower uterine segment

Delivering the fetus

For vertex presentations, place your hand into the uterine cavity between the lower edge of the hysterotomy and fetal head. While applying transabdominal fundal pressure, lift the head with your fingers and deliver it through the incision (FIGURE 4A).

The self-retaining retractor facilitates delivery of the fetal head by creating a rigid border around the abdominal incision. The back of the surgeon’s hand that is in the uterine cavity achieves better leverage, as it now rests on a rigid plane on the inferior part of the incision rather than on the back hand and the softer and pliable wound edge of the standard abdominal incision.

Vacuum-assistance. When delivery of the fetal head proves difficult, we use the soft vacuum cup, which avoids unnecessary intrauterine manipulation that may result in fetal or maternal trauma (FIGURE 4B).¹²

Breech extraction or transverse lie delivery is performed using standard extraction maneuvers (FIGURE 4C).¹³ We have found no need to perform T or J vertical extensions of the low transverse uterine incision, even in cases of a poorly developed lower uterine segment, abnormal presentation, or prematurity.

FIGURE 4A Deliver the fetal head

FIGURE 4B Deliver the fetal head

FIGURE 4C Deliver the fetal head

Uterine incision: 1-layer, in situ close

Remove the placenta only after it separates spontaneously—this greatly reduces blood loss compared with immediate manual placental delivery or umbilical-cord traction. Manually deliver the placenta only if it has not separated spontaneously after 5 minutes. Avoid routine manual clean-out of the uterine cavity if the placenta is completely delivered.^1-3,14

Dilate the cervix to facilitate lochial discharge, when necessary.

Decrease uterine bleeding by massaging the uterus and administering diluted oxytocin.

Close the uterine incision in situ. Disadvantages of routine uterine exteriorization include discomfort and vomiting resulting from traction, exposure of the fallopian tubes to unnecessary trauma, increased risk of infection, possible rupture of the uteroovarian veins, and pulmonary embolism.

Exteriorization may also increase the risk of adhesion formation by exposing the uterine serosa to the abrasive effects of drying or microscopic abrasion if sponges are used to hold the uterus in place.^1,14-17

Use a single-layer closure with a running suture of polyglycolic acid to close the uterine incision (FIGURE 5A). If needed, use atraumatic clamps to grasp the edges of the hysterotomy to facilitate visualization and closure.

Begin suturing at a point just beyond one end of the incision, continuing to the opposite side. Be sure to penetrate the full thickness of the myometrium and avoid incorporating the decidua in the suture line. After the uterine closure, use individual figure-of-8 sutures to control areas of persistent bleeding.

Compared with 2-layer closures, single-layer closure of a low transverse incision is associated with reduced operating time, improved hemostasis, and less tissue disruption; introduces less foreign material into the surgical site; reduces the need for postoperative analgesia; and potentially reduces infectious morbidity. A trial of labor after a cesarean section with 1-layer closure appears safe.^18-22

We do not close the vesicouterine fold and parietal peritoneum (FIGURE 5B) or reapproximate the rectus muscles. It has been shown that a new peritoneal layer is formed within days of the original incision closure.

Leaving the peritoneum open leads to no increased postoperative complications, nor obvious differences in wound healing, wound dehiscence, or incidence of postoperative adhesions. Compared to women without peritoneal closure, those with peritoneal closure require a longer operative time, greater amounts of post-operative narcotics for postoperative pain, a greater need for bowel stimulants, and a longer postoperative hospitalization.²³

In 1995, we performed laparoscopy for gynecologic conditions in 23 patients and repeat cesarean in 10 patients who had undergone our technique (with visceral and parietal peritoneum left open).² We found no adhesions and a normal peritoneal lining in all cases.

In 1 subgroup, peritoneal closure is strongly recommended: cases in which 1 or both rectus muscles have been transected to increase surgical exposure. Extremely thick fibromuscular adhesions between the low anterior surface of the uterus and the under-surface of the rectus musculature may develop if the parietal peritoneum is not closed.

FIGURE 5A Close the incisions

FIGURE 5B Close the incisions

Abdominal closure

Close the rectus fascia with a continuous nonlocking 0 suture after the rectus muscles fall into place. Place entry and exit sites at 1-cm intervals, 1.5 cm beyond the wound edges—this minimizes the risk of sutures pulling through fascia. Interrupted sutures offer no greater tensile strength than continuous suturing.²⁴ Tight, continuous suturing can lead to tissue ischemia, which may weaken the sutured fascia, and thus should be avoided.

The subcutaneous layer is not closed separately. One exception is obese patients with at least 2 cm of thick subcutaneous tissue. Thickness of subcutaneous tissue appears to be a significant risk factor for wound infection after cesarean section.²⁵

In patients with thick subcutaneous tissue, you can reduce tension on the skin edges and the risk of subcutaneous infection, seroma formation, and wound disruption by placing interrupted 3-0 absorbable synthetic sutures to eliminate dead space.^26-28 We have found no need to place Penrose drains or closed drainage systems in the subcutaneous layer.^29-31

Close the skin using a subcuticular continuous absorbable 4-0 suture or, alternatively, metal staples, which are removed 4 days after surgery (FIGURE 5C).

FIGURE 5C Close the incisions

Prompt postoperative recovery

The patient may drink fluids in the recovery room, can resume a regular solid food diet within 4 hours after surgery, and may resume mobility as soon as anesthesia wears off.

Early breast-feeding is also allowed in the recovery room. In our experience, this has not been associated with complications, has been highly appreciated by the patients, and has led to earlier hospital discharge.

Control pain with meperidine (50–75 mg) or morphine (10 mg) parenterally every 3 to 4 hours. Other options include oxycodone and acetaminophen, oxycodone and aspirin, and ibuprofen.

Patients are usually discharged 48 to 72 hours following surgery.

Our experience: The numbers

Using this updated system, we have successfully completed 300 consecutive cesarean sections (210 primary, 90 repeat).

The average operating time was 19 minutes; average blood loss, 405 mL.

There was no postoperative febrile morbidity, wound infection, wound disruption, or wound hematoma.Only 3 patients developed superficial wound seromas, which were easily resolved. There were no intraoperative or postoperative complications.

We attribute the absence of wound infection to routine prophylactic antibiotics; supplemental perioperative oxygen; maintenance of normothermia; use of an electrocautery knife to create rapid hemostatic division of subcutaneous fat and anterior rectus fascia; a simplified abdominal wall opening; and placement of a self-retaining atraumatic retractor.^10,32-36

Additional surgical procedures (tubal sterilization, myomectomy, appendectomy, and adhesiolysis) did not alter the recovery period, and all patients were able to get out of bed, shower, breast-feed, and care for their infants within 8 hours of surgery.

No infant complications related to the cesarean procedure occurred.

Patients were discharged from the hospital within 72 hours.

A prospective comparison study demonstrated that the original Pelosi-type of cesarean delivery was faster to perform, more cost-effective, and resulted in less maternal morbidity than the traditional cesarean technique.³

Dr. Pelosi II is a consultant for Apple Medical Corporation. Dr. Pelosi III reports no financial relationships relevant to this article.

Ask a pelvic reconstructive surgeon to name the most difficult challenge, and the answer is likely to be anterior vaginal wall prolapse. The reason: The anterior wall usually is the leading edge of prolapse and the most common site of relaxation or failure following reconstructive surgery. This appears to hold true regardless of surgical route or technique.

Short-term success rates of anterior wall repairs appear promising, but long-term outcomes are not as encouraging. Success usually is claimed as long as the anterior wall is kept above the hymen, since the patient rarely reports symptoms in these cases.

Another challenge involves the use of allografts or xenografts, which have not undergone sufficient study to determine their long-term benefit or risks in comparison with traditional repairs.

This article reviews anatomy of the anterior vaginal wall and its supports, as well as surgical technique and outcomes.

Why the anterior wall is more susceptible to prolapse

One theory is that, in comparison with the posterior compartment, the anterior wall is not as well supported by the levator plate, which counters the effects of gravity and abdominal pressure. Normally, the anterior wall rests horizontally on the posterior wall, which in turn rests on the levator plate. When the levator muscles weaken, the anterior wall is the first to fall as increasing force is placed on the connective tissue supports.

Other possibilities: The anterior compartment’s attachments to the pelvic sidewall or apex may be weaker, the anterior wall may be more elastic or less dense than the posterior wall, and the anterior wall may be more susceptible to damage during childbirth or to the effects of age and loss of estrogen.

If only some defects are addressed at surgery, failure may be more likely. Some experts believe pelvic surgeons have focused too much attention on the urethrovesical junction in patients with concomitant urinary incontinence and not enough attention on suspending the anterior wall at the apex.

For most women, it is probably a combination of many of these factors that renders the anterior compartment so vulnerable.

Anatomy of the pelvic floor

The anterior vaginal wall resembles a trapezoidal plane due to ventral and more medial attachments near the pubic symphysis, and dorsal and more lateral attachments near the ischial spine (FIGURE 1).¹ This helps explain the many appearances of the cystocele. The type of cystocele is defined by the location of the break in the fascial attachments.

Paravaginal defects. The trapezoidal anterior wall is suspended on both sides from the parietal fascia overlying the levator ani muscles at the arcus tendineus fascia pelvis (ATFP). Prolapse can occur when there is loss of attachment to the pelvic sidewall at any point between the pubis and ischial spine.

First described by White² and characterized later by Richardson et al,³ this loss of lateral attachment is called a paravaginal defect or displacement cystocele (FIGURE 2). The goal of paravaginal repair is to reattach the lateral vaginal walls to the ATFP, either abdominally, laparoscopically, or vaginally.

Central defects, the rarest type of anterior wall prolapse, involve a loss of support near the pubis and tend to be smaller. The most common manifestation is urethral hypermobility.

Transverse defects occur when the top of the pubocervical fascia detaches from the cervix or vaginal apex, both of which are suspended from the uterosacral-cardinal ligament complex. A transverse cystocele is evidenced by loss of the anterior fornix. The anterior wall appears to be attenuated in the midline, and the vaginal mucosa is pale, thin, and smooth (FIGURE 3).

Goals of traditional repair. The traditional anterior colporrhaphy aims to excise or reinforce the attenuated transverse defect with plication of the “endopelvic fascia” in the midline of the anterior vaginal wall. The endopelvic fascia is not true fascia but the muscularis of the vaginal wall. It is comprised of smooth muscle and elastin along with the collagenous adventitia layer.⁴

The importance of restoring apical wall support becomes apparent when one considers the trapezoidal anatomy. The most common sites of defects or detachments of the anterior wall are near the ischial spines laterally. In an operative case series of paravaginal defects, DeLancey¹ found the site of defect to be near the ischial spine in 96% of cases. The reattachment of the apex near the level of the spine becomes the highest point of support for the anterior vaginal wall.

This cephalad apical attachment can be accomplished in a variety of ways, by suspending the vaginal apex from the uterosacral ligaments, from the sacrospinous ligament, or via abdominal sacrocolpopexy.

FIGURE 1 Anatomy of the anterior wall

The anterior vaginal wall resembles a trapezoidal plane, with ventral and more medial attachments near the pubic symphysis, and dorsal and more lateral attachments to the ischial spine. Detachment from the pelvic sidewall and ischial spine results in anterior wall prolapse (right).

FIGURE 2 Paravaginal defect

FIGURE 3 Transverse defect

A transverse defect with loss of the anterior fornix. The loss of cephalad apical attachment at the level of the ischial spine leads to anterior wall prolapse. Suspending the upper vagina from shortened cardinal/uterosacral ligaments, the sacrospinous ligament, or via abdominal sacrocolpopexy is as important as plication.

Symptoms of anterior wall prolapse

As with other forms of pelvic organ prolapse, many patients complain of a bulge or feeling of pelvic pressure when the anterior vaginal wall has come through the introitus. However, some symptoms of anterior wall prolapse are unique.

Incontinence is not universal. A common misperception is that most patients with cystocele also experience stress urinary incontinence (SUI), which can develop when there is loss of urethral support and descent of the lower vaginal wall along with urethral hypermobility. However, there is no defining degree of hypermobility that links anterior wall prolapse with SUI. That is because the continence mechanism relies not only on urethral position and lateral attachments, but also on the neuromuscular function of the pelvis and lower urinary tract.

In fact, descent of the midvagina under the bladder base may actually reduce the chance of SUI. The reason: As a woman strains, the increased abdominal pressure pushes the cystocele farther and farther out. As the cystocele enlarges, it creates a functional outlet obstruction by kinking the urethra shut. When this is the case, patients may complain of prolonged voiding, an intermittent urine stream, and/or urinary retention. The woman may have to elevate the vaginal wall to empty her bladder. Patients with chronic urinary retention are at risk of developing recurrent urinary tract infections.

Bladder outlet obstruction and detrusor dysfunction. Women with grade 3 or 4 cystoceles often have evidence of bladder outlet obstruction on urodynamic testing, according to a study that found such evidence in 57% of subjects.⁵ After reduction of the prolapse with a pessary, obstructed flow reverted to normal in 94% of these women.

A large proportion (52%) of women with cystoceles also have detrusor instability, as well as evidence of impaired detrusor contractility. Many complain of urinary frequency and urgency and difficulty emptying the bladder.⁵

Again, this phenomenon is complex, related not only to anatomy but to altered neuromuscular function of the lower urinary tract. Incomplete emptying, frequency, and urgency may arise from stretching of the bladder base as it prolapses through the vaginal introitus, resulting in urinary retention. These symptoms often are less pronounced at night when the patient is supine.

We reviewed 35 cases of anterior wall prolapse greater than 1 cm outside the hymen, with elevated postvoid residuals exceeding 100 cc on 2 separate occasions.⁶ Thirty-one (89%) had normal postvoid residuals following reconstructive surgery and correction of their anterior wall prolapse.

Preoperative assessment

A careful physical exam is a prerequisite for all surgical repairs of pelvic organ prolapse. During this exam, identify the sites of defects and detachments.

Maximize the defect. Have the patient perform the Valsalva maneuver, cough, and/or strain while sitting upright or standing. As she is performing these maneuvers, ask her if this feels like her maximum prolapse. A split speculum often aids in visualizing the anterior and posterior compartments without pressure from the opposite vaginal wall.

Assess the apex. Place a large swab in the vagina, hold it gently against the apex, and ask the patient to strain. If the swab is pushed out, the apex needs suspension.

This technique can help identify apical relaxation that may be masked by a large anterior or posterior wall defect. A standardized staging system, such as the Pelvic Organ Prolapse Quantitative Examination (POP-Q) or Baden-Walker, aids in communicating and documenting the prolapse. In addition, it allows the surgeon to track anatomical outcomes after surgery.

Look for paravaginal defects by supporting the lateral anterior walls with a ring forceps at the level of the ATFP. Barber et al⁷ found this maneuver to be highly sensitive (90–94%): If no paravaginal defect was suspected clinically, none was found intraoperatively. However, the positive predictive value was poor (57%), in that defects suspected preoperatively were confirmed during surgery in less than two thirds of patients.

These findings point to the importance of careful intraoperative assessment, both before and during the repair procedure.

Limited utility of imaging studies. The use of radiologic studies such as defecography or dynamic magnetic resonance imaging of the pelvis may aid in the evaluation of defecatory disorders or suspected sigmoidocele or rectal prolapse, but have not been studied sufficiently to determine the impact on surgical outcome.

Unmasking SUI

As mentioned above, women with anterior wall prolapse do not always complain of stress incontinence. However, correction of the cystocele can relieve their obstructive voiding and unmask “occult” SUI. Various techniques have been described to elevate the anterior wall with pessaries, swabs, etc, during urodynamic testing to predict which women should have an incontinence procedure performed at the time of reconstructive surgery.

Conflicting rates of occult SUI have been reported, with estimates ranging from 36% to 80%.⁸ Although preoperative urodynamic testing indicates a high rate of occult stress incontinence, a study by Borstad et al⁹ suggests that the rate of de novo incontinence may be lower and that preoperative urodynamic findings are not predictive of postoperative continence status. In that study, 16 of 73 women (22%) developed stress incontinence following surgery for prolapse when no incontinence procedure was performed. Advanced age increased the risk of incontinence after surgery.

Contrast these findings with those of Chaikin and colleagues,¹⁰ who prospectively followed 24 patients with grade 3 or 4 cystoceles. Preoperative urodynamics showed a 58% rate of occult stress incontinence. All these patients were also defined as having intrinsic sphincter deficiency with leak point pressures below 60 cm water. The incontinent group underwent anterior colporrhaphy and concomitant pubovaginal sling, compared with anterior colporrhaphy alone for those without incontinence. Postoperatively, 2 patients who had the pubovaginal sling procedure reported continued stress incontinence (14%). No new symptoms of incontinence were reported in the patients without leakage on preoperative urodynamics. Thus, preoperative urodynamics were 100% accurate in determining which women did not need additional surgery for SUI.

Implications of a negative stress test. Our experience has shown that, despite our best attempts, a negative stress test with the prolapse reduced prior to surgery is less than 100% predictive. Occasionally, new SUI occurs after reconstructive surgery. It is unclear whether this incontinence is caused by straightening the urethra and reducing the bulge or secondary to the dissection of surgery.

Tips on technique

Anterior colporrhaphy traditionally is performed with plication of the “endopelvic fascia” or fibromuscular layer at the bladder neck with a Kelly plication stitch. Using “3-point” traction aids in dissecting the muscularis (FIGURE 4). Repair the remainder of the cystocele using vertical mattress stitches (1 or 2 layers) from the bladder neck to the apex.

Avoid creating weak areas. Using this technique, the repair frequently stops short of the apex, leaving a “gap” or weak area. One way to avoid this is to begin plication at the apex instead of the bladder neck (FIGURE 5).

Next, excise the excess vaginal tissue and close with interrupted fine absorbable sutures (FIGURE 6).

Recreate apical support. Another problem with traditional repairs is that they do not reestablish apical support. In many patients with anterior wall prolapse, reattachment of the apex reduces the cystocele. Therefore, it often is necessary to combine anterior colporrhaphy with an apical repair procedure such as uterosacral ligament suspension or sacrospinous ligament suspension.

Sutures for the apical repair should be placed and held prior to initiating the anterior colporrhaphy. At the end of the anterior repair, incorporate the apical sutures into the vaginal cuff.

Careful attention to the integrity and strength of the tissue is crucial. Regardless of the type of transvaginal suspension, we advocate bringing 1 arm of the suspension suture through the anterior wall of the cuff. Then place the other suture arm through the posterior cuff so that, when tied, anterior and posterior walls are brought together and suspended.

Using prolonged-delayed absorbable suture allows for a full-thickness bite, ensuring scarring to the suspensory ligament. If permanent suture is used for the uterosacral suspension, place the stitches along the inside surface of the anterior wall with a strong, broad bite that incorporates the muscularis or “endopelvic fascia.”

The occasional enterocele. When a transverse cystocele occurs following hysterectomy, the surgeon should be on the lookout for an enterocele, which sometimes accompanies anterior wall prolapse. The enterocele should be corrected at the time of surgery by closing the defect and suspending the cuff.

FIGURE 4 Three-point traction

Three-point traction using Allis clamps. The assistant retracts with DeBackey forceps to allow dissection of the muscularis. An index finger placed firmly against the vaginal mucosa enables the surgeon to judge depth of dissection.

FIGURE 5 Begin plication at the apex

Plication begins at the apex with vertical mattress stitches. Use 3-0 prolonged delayed absorbable or permanent suture in the anterior wall.

FIGURE 6 The reduced cystocele

The cystocele reduced following midline plication of the vaginal muscularis. The excess vagina is then trimmed and closed with interrupted 3-0 absorbable suture.

Functional surgical outcomes

Because of the long association between anterior wall prolapse and SUI, most surgeons evaluate patients preoperatively to determine the need for concomitant incontinence procedures. As a result, the literature reporting surgical cystocele repair via anterior colporrhaphy frequently uses continence of urine as the functional outcome. This is not surprising considering that anterior repair and Kelly plication, as reported by Howard Kelly more than 75 years ago, have been the gold standard for surgical correction of anterior wall prolapse and SUI.

In a series of 194 SUI patients who underwent anterior colporrhaphy, Beck¹¹ found that adding a modified Kelly plication, including a vaginal retropubic urethropexy, increased the cure rate for SUI from 75% to 94%. Unfortunately, he did not report the anatomic success of the anterior colporrhaphy.

Kohli et al¹² also retrospectively examined patients who had undergone anterior colporrhaphy with and without needle bladder-neck suspension. Although the cure rate for SUI was not reported, patients who underwent concomitant needle suspension had a higher rate of recurrent cystocele: 33% (n = 40) versus 7% (n = 27). Investigators theorized that retropubic dissection at the time of transvaginal needle suspension resulted in an iatrogenic paravaginal defect and denervation of the anterior vaginal wall.

The risks of needle suspension. A randomized controlled trial by Bump et al⁸ also suggests that needle suspension should be avoided. In that trial, 29 patients with stage 3 and 4 prolapse were randomized to needle colposuspension or endopelvic fascia plication. They, too, found that needle colposuspension carried a higher rate of recurrent anterior prolapse. Further, it did not reduce the rates of SUI compared with fascia plication.

Although incontinence surgery performed at the time of cystocele repair will reduce the rates of de novo incontinence, the higher rates of cystocele recurrence associated with some procedures warrants judicious preoperative planning. Clearly, needle suspension should not be performed as an incontinence procedure or repair of anterior wall prolapse. Whether other vaginal incontinence procedures, eg, midurethral slings, lead to recurrence of anterior wall prolapse deserves further investigation.

Anatomic outcomes

Midline colporrhaphy. Because anterior colporrhaphy is rarely performed alone, few series describe patients having undergone simply an anterior repair. Stanton et al¹³ followed 54 women for up to 2 years after they underwent traditional midline plication with vaginal hysterectomy for prolapse. Eight (15%) of the women had recurrent anterior wall prolapse.

Colombo et al¹⁴ randomized 71 women with clinical SUI and stage 2 or 3 prolapse to Burch colposuspension or anterior colporrhaphy with Kelly plication. All women were followed for at least 8 years. The cure rate for SUI was 86% for the Burch procedure, compared with 52% for anterior repair and Kelly plication. However, 12 (34%) women treated with Burch colposuspension and 1 (3%) treated with anterior colporrhaphy had recurrent cystocele of grade 2 or 3 with or without prolapse at other vaginal sites.

Abdominal paravaginal repair. Shull¹⁵ followed 149 women for 6 months to 4 years after they underwent abdominal paravaginal repair with the urethrovesical stitch brought through Cooper’s ligament for treatment of SUI and paravaginal cystocele. He reported a 5% recurrence of anterior wall prolapse.

In another series, Shull¹⁶ reported on 62 women who were followed for a mean of 18 months after abdominal paravaginal repair. Four of 57 (7%) had recurrent vaginal prolapse to the hymen.

Vaginal paravaginal repair. Mallipeddi et al¹⁷ reported on 45 patients undergoing vaginal paravaginal repair over 2 years, with 35 women followed for a mean of 1.6 years. Incontinent patients had a Kelly plication performed at the time of vaginal paravaginal repair. Recurrence rates were 3% for cystocele, 14% for rectocele, and 20% for enterocele.

Young et al¹⁸ followed 100 women for as long as 36 months after bilateral paravaginal repair using 1 to 6 expanded polytetrafluoroethylene (Gore-Tex) CV-0 sutures and midline colporrhaphy. Two patients had grade 1 or 2 failure at the lateral fixation points, but 21 patients had recurrent midline defects, all but 1 inside the hymen. Several patients had bloody discharge from the permanent sutures.

Sacrocolpopexy. Brubaker¹⁹ retrospectively reviewed 65 women who underwent sacrocolpopexy for apical prolapse. Three months postoperatively 19 patients (29%) had persistent anterior wall defects.

Uterosacral suspension. Shull et al²⁰ also found the anterior segment to have the most recurrent defects. In that study, which had an average follow-up of a little over a year, 289 patients underwent vaginal uterosacral ligament repair of the apex, and 264 had an anterior wall defect preoperatively. At the time of furthest follow-up, 26 patients (9%) had failure at this site. This study confirmed that the anterior compartment is the most likely site to fail, and also that it fails the quickest.

Sacrospinous ligament suspension (SSLS). Morley and DeLancey²¹ found a 22% cystocele recurrence rate in 71 women 1 year after SSLS, with most of them asymptomatic. Shull²² reported a 30% incidence of cystoceles after SSLS. Paraiso and colleagues²³ reported on 243 women undergoing SSLS and pelvic reconstructive surgery. Of these, 217 patients underwent concomitant anterior colporrhaphy. Follow-up at 74 months found 37% with symptomatic recurrence at the anterior wall, 13% at the posterior wall, and 8% at the apex.

Vaginal versus abdominal repair

Few studies have compared vaginal and abdominal repair of pelvic organ prolapse, including anterior wall prolapse.

In a trial by Benson et al,²⁴ women with prolapse to or beyond the hymen were randomized to bilateral sacrospinous vault suspension and vaginal paravaginal repair (n = 48) or abdominal sacrocolpopexy with abdominal paravaginal repair (n = 40). One third of patients in each group also underwent anterior colporrhaphy. After a mean follow-up of 2.5 years, 16 of 20 women required reoperation for recurrent cystocele—12 (29%) from the vaginal group and 4 (10.5%) from the abdominal group. Vaginal vault eversion recurred in 5 women from the vaginal group and 1 from the abdominal group.

Investigators concluded that the anterior wall was the most likely site of failure because of the posterior placement of the vaginal apex with SSLS, predisposing the anterior wall to greater pressures and to neuropathy caused by lateral dissection of the anterior wall. Earlier studies have demonstrated that neuropathy may occur after extensive dissection of the vaginal wall and may affect the strength and integrity of the muscular support tissues.^25,26

Allografts and xenografts

The difficulty of repairing anterior wall prolapse has led some pelvic surgeons to use mesh for cystocele repair. When Julian²⁷ randomized 24 patients with recurrent cystocele to transvaginal repair with and without polypropylene (Marlex) mesh, 4 patients in the control group and no patients in the mesh group had recurrences (P <.05). However, 3 patients (25%) had mesh-related complications.

Weber et al²⁸ randomized patients to standard midline plication, plication of the paravaginal tissue more laterally, or standard plication plus polyglactin 910 (Vicryl) mesh. Among 83 patients who returned for follow-up, there were no differences in anatomic outcome. Weber and colleagues concluded that there is little benefit to using mesh to correct cystoceles.

Still, although the overall cure rate was low (30–46%), most patients had cystocele to the hymen and not beyond, with significant improvement of symptoms. Although this cannot be defined as an anatomic cure, it is encouraging that the majority of patients appear to have benefited from surgery.

Sand et al²⁹ randomized 161 women with the anterior wall to or beyond the hymen to traditional anterior colporrhaphy with or without Vicryl. The 2-inch square mesh was not placed over the repair as described above, but was folded into the anterior colporrhaphy stitches. At 1 year, 16 (22%) of 73 women with mesh and 28 (40%) of the 88 women without mesh had recurrent central cystoceles beyond the midvagina (P = .02). No women had cystoceles beyond the hymen or vaginal erosions.

Difficulty of interpreting the evidence

Because of the broad range of study designs, small number of patients per series, variety of concomitant procedures, and wide range of variables used to describe recurrence and success, it is difficult to draw conclusions from the literature. The evidence does suggest that the risks of wide vaginal dissection required for vaginal paravaginal repair outweigh the benefits. As a result, we have abandoned this technique. As mentioned above, it remains unclear whether graft materials will prove to be of long-term benefit for either midline plication or paravaginal repair.

The gold standard, for now

Prolapse of the anterior vaginal wall remains a challenge for the gynecologic surgeon. Careful preoperative and intraoperative evaluation and identification of support defects should guide repairs.

Randomized, controlled trials of midline versus paravaginal repair, as well as use of various graft materials, are greatly needed. These studies should not only address recurrence of prolapse symptoms, but the impact of surgery on sexual and lower urinary tract function.

At this time, the traditional anterior colporrhaphy with attention to apical suspension remains the gold standard.

The authors report no financial relationships relevant to this article.

Ask a pelvic reconstructive surgeon to name the most difficult challenge, and the answer is likely to be anterior vaginal wall prolapse. The reason: The anterior wall usually is the leading edge of prolapse and the most common site of relaxation or failure following reconstructive surgery. This appears to hold true regardless of surgical route or technique.

Short-term success rates of anterior wall repairs appear promising, but long-term outcomes are not as encouraging. Success usually is claimed as long as the anterior wall is kept above the hymen, since the patient rarely reports symptoms in these cases.

Another challenge involves the use of allografts or xenografts, which have not undergone sufficient study to determine their long-term benefit or risks in comparison with traditional repairs.

This article reviews anatomy of the anterior vaginal wall and its supports, as well as surgical technique and outcomes.

Why the anterior wall is more susceptible to prolapse

One theory is that, in comparison with the posterior compartment, the anterior wall is not as well supported by the levator plate, which counters the effects of gravity and abdominal pressure. Normally, the anterior wall rests horizontally on the posterior wall, which in turn rests on the levator plate. When the levator muscles weaken, the anterior wall is the first to fall as increasing force is placed on the connective tissue supports.

Other possibilities: The anterior compartment’s attachments to the pelvic sidewall or apex may be weaker, the anterior wall may be more elastic or less dense than the posterior wall, and the anterior wall may be more susceptible to damage during childbirth or to the effects of age and loss of estrogen.

If only some defects are addressed at surgery, failure may be more likely. Some experts believe pelvic surgeons have focused too much attention on the urethrovesical junction in patients with concomitant urinary incontinence and not enough attention on suspending the anterior wall at the apex.

For most women, it is probably a combination of many of these factors that renders the anterior compartment so vulnerable.

Anatomy of the pelvic floor

The anterior vaginal wall resembles a trapezoidal plane due to ventral and more medial attachments near the pubic symphysis, and dorsal and more lateral attachments near the ischial spine (FIGURE 1).¹ This helps explain the many appearances of the cystocele. The type of cystocele is defined by the location of the break in the fascial attachments.

Paravaginal defects. The trapezoidal anterior wall is suspended on both sides from the parietal fascia overlying the levator ani muscles at the arcus tendineus fascia pelvis (ATFP). Prolapse can occur when there is loss of attachment to the pelvic sidewall at any point between the pubis and ischial spine.

First described by White² and characterized later by Richardson et al,³ this loss of lateral attachment is called a paravaginal defect or displacement cystocele (FIGURE 2). The goal of paravaginal repair is to reattach the lateral vaginal walls to the ATFP, either abdominally, laparoscopically, or vaginally.

Central defects, the rarest type of anterior wall prolapse, involve a loss of support near the pubis and tend to be smaller. The most common manifestation is urethral hypermobility.

Transverse defects occur when the top of the pubocervical fascia detaches from the cervix or vaginal apex, both of which are suspended from the uterosacral-cardinal ligament complex. A transverse cystocele is evidenced by loss of the anterior fornix. The anterior wall appears to be attenuated in the midline, and the vaginal mucosa is pale, thin, and smooth (FIGURE 3).

Goals of traditional repair. The traditional anterior colporrhaphy aims to excise or reinforce the attenuated transverse defect with plication of the “endopelvic fascia” in the midline of the anterior vaginal wall. The endopelvic fascia is not true fascia but the muscularis of the vaginal wall. It is comprised of smooth muscle and elastin along with the collagenous adventitia layer.⁴

The importance of restoring apical wall support becomes apparent when one considers the trapezoidal anatomy. The most common sites of defects or detachments of the anterior wall are near the ischial spines laterally. In an operative case series of paravaginal defects, DeLancey¹ found the site of defect to be near the ischial spine in 96% of cases. The reattachment of the apex near the level of the spine becomes the highest point of support for the anterior vaginal wall.

This cephalad apical attachment can be accomplished in a variety of ways, by suspending the vaginal apex from the uterosacral ligaments, from the sacrospinous ligament, or via abdominal sacrocolpopexy.

FIGURE 1 Anatomy of the anterior wall

The anterior vaginal wall resembles a trapezoidal plane, with ventral and more medial attachments near the pubic symphysis, and dorsal and more lateral attachments to the ischial spine. Detachment from the pelvic sidewall and ischial spine results in anterior wall prolapse (right).

FIGURE 2 Paravaginal defect

FIGURE 3 Transverse defect

A transverse defect with loss of the anterior fornix. The loss of cephalad apical attachment at the level of the ischial spine leads to anterior wall prolapse. Suspending the upper vagina from shortened cardinal/uterosacral ligaments, the sacrospinous ligament, or via abdominal sacrocolpopexy is as important as plication.

Symptoms of anterior wall prolapse

As with other forms of pelvic organ prolapse, many patients complain of a bulge or feeling of pelvic pressure when the anterior vaginal wall has come through the introitus. However, some symptoms of anterior wall prolapse are unique.

Incontinence is not universal. A common misperception is that most patients with cystocele also experience stress urinary incontinence (SUI), which can develop when there is loss of urethral support and descent of the lower vaginal wall along with urethral hypermobility. However, there is no defining degree of hypermobility that links anterior wall prolapse with SUI. That is because the continence mechanism relies not only on urethral position and lateral attachments, but also on the neuromuscular function of the pelvis and lower urinary tract.

In fact, descent of the midvagina under the bladder base may actually reduce the chance of SUI. The reason: As a woman strains, the increased abdominal pressure pushes the cystocele farther and farther out. As the cystocele enlarges, it creates a functional outlet obstruction by kinking the urethra shut. When this is the case, patients may complain of prolonged voiding, an intermittent urine stream, and/or urinary retention. The woman may have to elevate the vaginal wall to empty her bladder. Patients with chronic urinary retention are at risk of developing recurrent urinary tract infections.

Bladder outlet obstruction and detrusor dysfunction. Women with grade 3 or 4 cystoceles often have evidence of bladder outlet obstruction on urodynamic testing, according to a study that found such evidence in 57% of subjects.⁵ After reduction of the prolapse with a pessary, obstructed flow reverted to normal in 94% of these women.

A large proportion (52%) of women with cystoceles also have detrusor instability, as well as evidence of impaired detrusor contractility. Many complain of urinary frequency and urgency and difficulty emptying the bladder.⁵

Again, this phenomenon is complex, related not only to anatomy but to altered neuromuscular function of the lower urinary tract. Incomplete emptying, frequency, and urgency may arise from stretching of the bladder base as it prolapses through the vaginal introitus, resulting in urinary retention. These symptoms often are less pronounced at night when the patient is supine.

We reviewed 35 cases of anterior wall prolapse greater than 1 cm outside the hymen, with elevated postvoid residuals exceeding 100 cc on 2 separate occasions.⁶ Thirty-one (89%) had normal postvoid residuals following reconstructive surgery and correction of their anterior wall prolapse.

Preoperative assessment

A careful physical exam is a prerequisite for all surgical repairs of pelvic organ prolapse. During this exam, identify the sites of defects and detachments.

Maximize the defect. Have the patient perform the Valsalva maneuver, cough, and/or strain while sitting upright or standing. As she is performing these maneuvers, ask her if this feels like her maximum prolapse. A split speculum often aids in visualizing the anterior and posterior compartments without pressure from the opposite vaginal wall.

Assess the apex. Place a large swab in the vagina, hold it gently against the apex, and ask the patient to strain. If the swab is pushed out, the apex needs suspension.

This technique can help identify apical relaxation that may be masked by a large anterior or posterior wall defect. A standardized staging system, such as the Pelvic Organ Prolapse Quantitative Examination (POP-Q) or Baden-Walker, aids in communicating and documenting the prolapse. In addition, it allows the surgeon to track anatomical outcomes after surgery.

Look for paravaginal defects by supporting the lateral anterior walls with a ring forceps at the level of the ATFP. Barber et al⁷ found this maneuver to be highly sensitive (90–94%): If no paravaginal defect was suspected clinically, none was found intraoperatively. However, the positive predictive value was poor (57%), in that defects suspected preoperatively were confirmed during surgery in less than two thirds of patients.

These findings point to the importance of careful intraoperative assessment, both before and during the repair procedure.

Limited utility of imaging studies. The use of radiologic studies such as defecography or dynamic magnetic resonance imaging of the pelvis may aid in the evaluation of defecatory disorders or suspected sigmoidocele or rectal prolapse, but have not been studied sufficiently to determine the impact on surgical outcome.

Unmasking SUI

As mentioned above, women with anterior wall prolapse do not always complain of stress incontinence. However, correction of the cystocele can relieve their obstructive voiding and unmask “occult” SUI. Various techniques have been described to elevate the anterior wall with pessaries, swabs, etc, during urodynamic testing to predict which women should have an incontinence procedure performed at the time of reconstructive surgery.

Conflicting rates of occult SUI have been reported, with estimates ranging from 36% to 80%.⁸ Although preoperative urodynamic testing indicates a high rate of occult stress incontinence, a study by Borstad et al⁹ suggests that the rate of de novo incontinence may be lower and that preoperative urodynamic findings are not predictive of postoperative continence status. In that study, 16 of 73 women (22%) developed stress incontinence following surgery for prolapse when no incontinence procedure was performed. Advanced age increased the risk of incontinence after surgery.

Contrast these findings with those of Chaikin and colleagues,¹⁰ who prospectively followed 24 patients with grade 3 or 4 cystoceles. Preoperative urodynamics showed a 58% rate of occult stress incontinence. All these patients were also defined as having intrinsic sphincter deficiency with leak point pressures below 60 cm water. The incontinent group underwent anterior colporrhaphy and concomitant pubovaginal sling, compared with anterior colporrhaphy alone for those without incontinence. Postoperatively, 2 patients who had the pubovaginal sling procedure reported continued stress incontinence (14%). No new symptoms of incontinence were reported in the patients without leakage on preoperative urodynamics. Thus, preoperative urodynamics were 100% accurate in determining which women did not need additional surgery for SUI.

Implications of a negative stress test. Our experience has shown that, despite our best attempts, a negative stress test with the prolapse reduced prior to surgery is less than 100% predictive. Occasionally, new SUI occurs after reconstructive surgery. It is unclear whether this incontinence is caused by straightening the urethra and reducing the bulge or secondary to the dissection of surgery.

Tips on technique

Anterior colporrhaphy traditionally is performed with plication of the “endopelvic fascia” or fibromuscular layer at the bladder neck with a Kelly plication stitch. Using “3-point” traction aids in dissecting the muscularis (FIGURE 4). Repair the remainder of the cystocele using vertical mattress stitches (1 or 2 layers) from the bladder neck to the apex.

Avoid creating weak areas. Using this technique, the repair frequently stops short of the apex, leaving a “gap” or weak area. One way to avoid this is to begin plication at the apex instead of the bladder neck (FIGURE 5).

Next, excise the excess vaginal tissue and close with interrupted fine absorbable sutures (FIGURE 6).

Recreate apical support. Another problem with traditional repairs is that they do not reestablish apical support. In many patients with anterior wall prolapse, reattachment of the apex reduces the cystocele. Therefore, it often is necessary to combine anterior colporrhaphy with an apical repair procedure such as uterosacral ligament suspension or sacrospinous ligament suspension.

Sutures for the apical repair should be placed and held prior to initiating the anterior colporrhaphy. At the end of the anterior repair, incorporate the apical sutures into the vaginal cuff.

Careful attention to the integrity and strength of the tissue is crucial. Regardless of the type of transvaginal suspension, we advocate bringing 1 arm of the suspension suture through the anterior wall of the cuff. Then place the other suture arm through the posterior cuff so that, when tied, anterior and posterior walls are brought together and suspended.

Using prolonged-delayed absorbable suture allows for a full-thickness bite, ensuring scarring to the suspensory ligament. If permanent suture is used for the uterosacral suspension, place the stitches along the inside surface of the anterior wall with a strong, broad bite that incorporates the muscularis or “endopelvic fascia.”

The occasional enterocele. When a transverse cystocele occurs following hysterectomy, the surgeon should be on the lookout for an enterocele, which sometimes accompanies anterior wall prolapse. The enterocele should be corrected at the time of surgery by closing the defect and suspending the cuff.

FIGURE 4 Three-point traction

Three-point traction using Allis clamps. The assistant retracts with DeBackey forceps to allow dissection of the muscularis. An index finger placed firmly against the vaginal mucosa enables the surgeon to judge depth of dissection.

FIGURE 5 Begin plication at the apex

Plication begins at the apex with vertical mattress stitches. Use 3-0 prolonged delayed absorbable or permanent suture in the anterior wall.

FIGURE 6 The reduced cystocele

The cystocele reduced following midline plication of the vaginal muscularis. The excess vagina is then trimmed and closed with interrupted 3-0 absorbable suture.

Functional surgical outcomes

Because of the long association between anterior wall prolapse and SUI, most surgeons evaluate patients preoperatively to determine the need for concomitant incontinence procedures. As a result, the literature reporting surgical cystocele repair via anterior colporrhaphy frequently uses continence of urine as the functional outcome. This is not surprising considering that anterior repair and Kelly plication, as reported by Howard Kelly more than 75 years ago, have been the gold standard for surgical correction of anterior wall prolapse and SUI.

In a series of 194 SUI patients who underwent anterior colporrhaphy, Beck¹¹ found that adding a modified Kelly plication, including a vaginal retropubic urethropexy, increased the cure rate for SUI from 75% to 94%. Unfortunately, he did not report the anatomic success of the anterior colporrhaphy.

Kohli et al¹² also retrospectively examined patients who had undergone anterior colporrhaphy with and without needle bladder-neck suspension. Although the cure rate for SUI was not reported, patients who underwent concomitant needle suspension had a higher rate of recurrent cystocele: 33% (n = 40) versus 7% (n = 27). Investigators theorized that retropubic dissection at the time of transvaginal needle suspension resulted in an iatrogenic paravaginal defect and denervation of the anterior vaginal wall.

The risks of needle suspension. A randomized controlled trial by Bump et al⁸ also suggests that needle suspension should be avoided. In that trial, 29 patients with stage 3 and 4 prolapse were randomized to needle colposuspension or endopelvic fascia plication. They, too, found that needle colposuspension carried a higher rate of recurrent anterior prolapse. Further, it did not reduce the rates of SUI compared with fascia plication.

Although incontinence surgery performed at the time of cystocele repair will reduce the rates of de novo incontinence, the higher rates of cystocele recurrence associated with some procedures warrants judicious preoperative planning. Clearly, needle suspension should not be performed as an incontinence procedure or repair of anterior wall prolapse. Whether other vaginal incontinence procedures, eg, midurethral slings, lead to recurrence of anterior wall prolapse deserves further investigation.

Anatomic outcomes

Midline colporrhaphy. Because anterior colporrhaphy is rarely performed alone, few series describe patients having undergone simply an anterior repair. Stanton et al¹³ followed 54 women for up to 2 years after they underwent traditional midline plication with vaginal hysterectomy for prolapse. Eight (15%) of the women had recurrent anterior wall prolapse.

Colombo et al¹⁴ randomized 71 women with clinical SUI and stage 2 or 3 prolapse to Burch colposuspension or anterior colporrhaphy with Kelly plication. All women were followed for at least 8 years. The cure rate for SUI was 86% for the Burch procedure, compared with 52% for anterior repair and Kelly plication. However, 12 (34%) women treated with Burch colposuspension and 1 (3%) treated with anterior colporrhaphy had recurrent cystocele of grade 2 or 3 with or without prolapse at other vaginal sites.

Abdominal paravaginal repair. Shull¹⁵ followed 149 women for 6 months to 4 years after they underwent abdominal paravaginal repair with the urethrovesical stitch brought through Cooper’s ligament for treatment of SUI and paravaginal cystocele. He reported a 5% recurrence of anterior wall prolapse.

In another series, Shull¹⁶ reported on 62 women who were followed for a mean of 18 months after abdominal paravaginal repair. Four of 57 (7%) had recurrent vaginal prolapse to the hymen.

Vaginal paravaginal repair. Mallipeddi et al¹⁷ reported on 45 patients undergoing vaginal paravaginal repair over 2 years, with 35 women followed for a mean of 1.6 years. Incontinent patients had a Kelly plication performed at the time of vaginal paravaginal repair. Recurrence rates were 3% for cystocele, 14% for rectocele, and 20% for enterocele.

Young et al¹⁸ followed 100 women for as long as 36 months after bilateral paravaginal repair using 1 to 6 expanded polytetrafluoroethylene (Gore-Tex) CV-0 sutures and midline colporrhaphy. Two patients had grade 1 or 2 failure at the lateral fixation points, but 21 patients had recurrent midline defects, all but 1 inside the hymen. Several patients had bloody discharge from the permanent sutures.

Sacrocolpopexy. Brubaker¹⁹ retrospectively reviewed 65 women who underwent sacrocolpopexy for apical prolapse. Three months postoperatively 19 patients (29%) had persistent anterior wall defects.

Uterosacral suspension. Shull et al²⁰ also found the anterior segment to have the most recurrent defects. In that study, which had an average follow-up of a little over a year, 289 patients underwent vaginal uterosacral ligament repair of the apex, and 264 had an anterior wall defect preoperatively. At the time of furthest follow-up, 26 patients (9%) had failure at this site. This study confirmed that the anterior compartment is the most likely site to fail, and also that it fails the quickest.

Sacrospinous ligament suspension (SSLS). Morley and DeLancey²¹ found a 22% cystocele recurrence rate in 71 women 1 year after SSLS, with most of them asymptomatic. Shull²² reported a 30% incidence of cystoceles after SSLS. Paraiso and colleagues²³ reported on 243 women undergoing SSLS and pelvic reconstructive surgery. Of these, 217 patients underwent concomitant anterior colporrhaphy. Follow-up at 74 months found 37% with symptomatic recurrence at the anterior wall, 13% at the posterior wall, and 8% at the apex.

Vaginal versus abdominal repair

Few studies have compared vaginal and abdominal repair of pelvic organ prolapse, including anterior wall prolapse.

In a trial by Benson et al,²⁴ women with prolapse to or beyond the hymen were randomized to bilateral sacrospinous vault suspension and vaginal paravaginal repair (n = 48) or abdominal sacrocolpopexy with abdominal paravaginal repair (n = 40). One third of patients in each group also underwent anterior colporrhaphy. After a mean follow-up of 2.5 years, 16 of 20 women required reoperation for recurrent cystocele—12 (29%) from the vaginal group and 4 (10.5%) from the abdominal group. Vaginal vault eversion recurred in 5 women from the vaginal group and 1 from the abdominal group.

Investigators concluded that the anterior wall was the most likely site of failure because of the posterior placement of the vaginal apex with SSLS, predisposing the anterior wall to greater pressures and to neuropathy caused by lateral dissection of the anterior wall. Earlier studies have demonstrated that neuropathy may occur after extensive dissection of the vaginal wall and may affect the strength and integrity of the muscular support tissues.^25,26

Allografts and xenografts

The difficulty of repairing anterior wall prolapse has led some pelvic surgeons to use mesh for cystocele repair. When Julian²⁷ randomized 24 patients with recurrent cystocele to transvaginal repair with and without polypropylene (Marlex) mesh, 4 patients in the control group and no patients in the mesh group had recurrences (P <.05). However, 3 patients (25%) had mesh-related complications.

Weber et al²⁸ randomized patients to standard midline plication, plication of the paravaginal tissue more laterally, or standard plication plus polyglactin 910 (Vicryl) mesh. Among 83 patients who returned for follow-up, there were no differences in anatomic outcome. Weber and colleagues concluded that there is little benefit to using mesh to correct cystoceles.

Still, although the overall cure rate was low (30–46%), most patients had cystocele to the hymen and not beyond, with significant improvement of symptoms. Although this cannot be defined as an anatomic cure, it is encouraging that the majority of patients appear to have benefited from surgery.

Sand et al²⁹ randomized 161 women with the anterior wall to or beyond the hymen to traditional anterior colporrhaphy with or without Vicryl. The 2-inch square mesh was not placed over the repair as described above, but was folded into the anterior colporrhaphy stitches. At 1 year, 16 (22%) of 73 women with mesh and 28 (40%) of the 88 women without mesh had recurrent central cystoceles beyond the midvagina (P = .02). No women had cystoceles beyond the hymen or vaginal erosions.

Difficulty of interpreting the evidence

Because of the broad range of study designs, small number of patients per series, variety of concomitant procedures, and wide range of variables used to describe recurrence and success, it is difficult to draw conclusions from the literature. The evidence does suggest that the risks of wide vaginal dissection required for vaginal paravaginal repair outweigh the benefits. As a result, we have abandoned this technique. As mentioned above, it remains unclear whether graft materials will prove to be of long-term benefit for either midline plication or paravaginal repair.

The gold standard, for now

Prolapse of the anterior vaginal wall remains a challenge for the gynecologic surgeon. Careful preoperative and intraoperative evaluation and identification of support defects should guide repairs.

Randomized, controlled trials of midline versus paravaginal repair, as well as use of various graft materials, are greatly needed. These studies should not only address recurrence of prolapse symptoms, but the impact of surgery on sexual and lower urinary tract function.

At this time, the traditional anterior colporrhaphy with attention to apical suspension remains the gold standard.

The authors report no financial relationships relevant to this article.

Ask a pelvic reconstructive surgeon to name the most difficult challenge, and the answer is likely to be anterior vaginal wall prolapse. The reason: The anterior wall usually is the leading edge of prolapse and the most common site of relaxation or failure following reconstructive surgery. This appears to hold true regardless of surgical route or technique.

Short-term success rates of anterior wall repairs appear promising, but long-term outcomes are not as encouraging. Success usually is claimed as long as the anterior wall is kept above the hymen, since the patient rarely reports symptoms in these cases.

Another challenge involves the use of allografts or xenografts, which have not undergone sufficient study to determine their long-term benefit or risks in comparison with traditional repairs.

This article reviews anatomy of the anterior vaginal wall and its supports, as well as surgical technique and outcomes.

Why the anterior wall is more susceptible to prolapse

One theory is that, in comparison with the posterior compartment, the anterior wall is not as well supported by the levator plate, which counters the effects of gravity and abdominal pressure. Normally, the anterior wall rests horizontally on the posterior wall, which in turn rests on the levator plate. When the levator muscles weaken, the anterior wall is the first to fall as increasing force is placed on the connective tissue supports.

Other possibilities: The anterior compartment’s attachments to the pelvic sidewall or apex may be weaker, the anterior wall may be more elastic or less dense than the posterior wall, and the anterior wall may be more susceptible to damage during childbirth or to the effects of age and loss of estrogen.

If only some defects are addressed at surgery, failure may be more likely. Some experts believe pelvic surgeons have focused too much attention on the urethrovesical junction in patients with concomitant urinary incontinence and not enough attention on suspending the anterior wall at the apex.

For most women, it is probably a combination of many of these factors that renders the anterior compartment so vulnerable.

Anatomy of the pelvic floor

The anterior vaginal wall resembles a trapezoidal plane due to ventral and more medial attachments near the pubic symphysis, and dorsal and more lateral attachments near the ischial spine (FIGURE 1).¹ This helps explain the many appearances of the cystocele. The type of cystocele is defined by the location of the break in the fascial attachments.

Paravaginal defects. The trapezoidal anterior wall is suspended on both sides from the parietal fascia overlying the levator ani muscles at the arcus tendineus fascia pelvis (ATFP). Prolapse can occur when there is loss of attachment to the pelvic sidewall at any point between the pubis and ischial spine.

First described by White² and characterized later by Richardson et al,³ this loss of lateral attachment is called a paravaginal defect or displacement cystocele (FIGURE 2). The goal of paravaginal repair is to reattach the lateral vaginal walls to the ATFP, either abdominally, laparoscopically, or vaginally.

Central defects, the rarest type of anterior wall prolapse, involve a loss of support near the pubis and tend to be smaller. The most common manifestation is urethral hypermobility.

Transverse defects occur when the top of the pubocervical fascia detaches from the cervix or vaginal apex, both of which are suspended from the uterosacral-cardinal ligament complex. A transverse cystocele is evidenced by loss of the anterior fornix. The anterior wall appears to be attenuated in the midline, and the vaginal mucosa is pale, thin, and smooth (FIGURE 3).

Goals of traditional repair. The traditional anterior colporrhaphy aims to excise or reinforce the attenuated transverse defect with plication of the “endopelvic fascia” in the midline of the anterior vaginal wall. The endopelvic fascia is not true fascia but the muscularis of the vaginal wall. It is comprised of smooth muscle and elastin along with the collagenous adventitia layer.⁴

The importance of restoring apical wall support becomes apparent when one considers the trapezoidal anatomy. The most common sites of defects or detachments of the anterior wall are near the ischial spines laterally. In an operative case series of paravaginal defects, DeLancey¹ found the site of defect to be near the ischial spine in 96% of cases. The reattachment of the apex near the level of the spine becomes the highest point of support for the anterior vaginal wall.

This cephalad apical attachment can be accomplished in a variety of ways, by suspending the vaginal apex from the uterosacral ligaments, from the sacrospinous ligament, or via abdominal sacrocolpopexy.

FIGURE 1 Anatomy of the anterior wall

The anterior vaginal wall resembles a trapezoidal plane, with ventral and more medial attachments near the pubic symphysis, and dorsal and more lateral attachments to the ischial spine. Detachment from the pelvic sidewall and ischial spine results in anterior wall prolapse (right).

FIGURE 2 Paravaginal defect

FIGURE 3 Transverse defect

A transverse defect with loss of the anterior fornix. The loss of cephalad apical attachment at the level of the ischial spine leads to anterior wall prolapse. Suspending the upper vagina from shortened cardinal/uterosacral ligaments, the sacrospinous ligament, or via abdominal sacrocolpopexy is as important as plication.

Symptoms of anterior wall prolapse

As with other forms of pelvic organ prolapse, many patients complain of a bulge or feeling of pelvic pressure when the anterior vaginal wall has come through the introitus. However, some symptoms of anterior wall prolapse are unique.

Incontinence is not universal. A common misperception is that most patients with cystocele also experience stress urinary incontinence (SUI), which can develop when there is loss of urethral support and descent of the lower vaginal wall along with urethral hypermobility. However, there is no defining degree of hypermobility that links anterior wall prolapse with SUI. That is because the continence mechanism relies not only on urethral position and lateral attachments, but also on the neuromuscular function of the pelvis and lower urinary tract.

In fact, descent of the midvagina under the bladder base may actually reduce the chance of SUI. The reason: As a woman strains, the increased abdominal pressure pushes the cystocele farther and farther out. As the cystocele enlarges, it creates a functional outlet obstruction by kinking the urethra shut. When this is the case, patients may complain of prolonged voiding, an intermittent urine stream, and/or urinary retention. The woman may have to elevate the vaginal wall to empty her bladder. Patients with chronic urinary retention are at risk of developing recurrent urinary tract infections.

Bladder outlet obstruction and detrusor dysfunction. Women with grade 3 or 4 cystoceles often have evidence of bladder outlet obstruction on urodynamic testing, according to a study that found such evidence in 57% of subjects.⁵ After reduction of the prolapse with a pessary, obstructed flow reverted to normal in 94% of these women.

A large proportion (52%) of women with cystoceles also have detrusor instability, as well as evidence of impaired detrusor contractility. Many complain of urinary frequency and urgency and difficulty emptying the bladder.⁵

Again, this phenomenon is complex, related not only to anatomy but to altered neuromuscular function of the lower urinary tract. Incomplete emptying, frequency, and urgency may arise from stretching of the bladder base as it prolapses through the vaginal introitus, resulting in urinary retention. These symptoms often are less pronounced at night when the patient is supine.

We reviewed 35 cases of anterior wall prolapse greater than 1 cm outside the hymen, with elevated postvoid residuals exceeding 100 cc on 2 separate occasions.⁶ Thirty-one (89%) had normal postvoid residuals following reconstructive surgery and correction of their anterior wall prolapse.

Preoperative assessment

A careful physical exam is a prerequisite for all surgical repairs of pelvic organ prolapse. During this exam, identify the sites of defects and detachments.

Maximize the defect. Have the patient perform the Valsalva maneuver, cough, and/or strain while sitting upright or standing. As she is performing these maneuvers, ask her if this feels like her maximum prolapse. A split speculum often aids in visualizing the anterior and posterior compartments without pressure from the opposite vaginal wall.

Assess the apex. Place a large swab in the vagina, hold it gently against the apex, and ask the patient to strain. If the swab is pushed out, the apex needs suspension.

This technique can help identify apical relaxation that may be masked by a large anterior or posterior wall defect. A standardized staging system, such as the Pelvic Organ Prolapse Quantitative Examination (POP-Q) or Baden-Walker, aids in communicating and documenting the prolapse. In addition, it allows the surgeon to track anatomical outcomes after surgery.

Look for paravaginal defects by supporting the lateral anterior walls with a ring forceps at the level of the ATFP. Barber et al⁷ found this maneuver to be highly sensitive (90–94%): If no paravaginal defect was suspected clinically, none was found intraoperatively. However, the positive predictive value was poor (57%), in that defects suspected preoperatively were confirmed during surgery in less than two thirds of patients.

These findings point to the importance of careful intraoperative assessment, both before and during the repair procedure.

Limited utility of imaging studies. The use of radiologic studies such as defecography or dynamic magnetic resonance imaging of the pelvis may aid in the evaluation of defecatory disorders or suspected sigmoidocele or rectal prolapse, but have not been studied sufficiently to determine the impact on surgical outcome.

Unmasking SUI

As mentioned above, women with anterior wall prolapse do not always complain of stress incontinence. However, correction of the cystocele can relieve their obstructive voiding and unmask “occult” SUI. Various techniques have been described to elevate the anterior wall with pessaries, swabs, etc, during urodynamic testing to predict which women should have an incontinence procedure performed at the time of reconstructive surgery.

Conflicting rates of occult SUI have been reported, with estimates ranging from 36% to 80%.⁸ Although preoperative urodynamic testing indicates a high rate of occult stress incontinence, a study by Borstad et al⁹ suggests that the rate of de novo incontinence may be lower and that preoperative urodynamic findings are not predictive of postoperative continence status. In that study, 16 of 73 women (22%) developed stress incontinence following surgery for prolapse when no incontinence procedure was performed. Advanced age increased the risk of incontinence after surgery.

Contrast these findings with those of Chaikin and colleagues,¹⁰ who prospectively followed 24 patients with grade 3 or 4 cystoceles. Preoperative urodynamics showed a 58% rate of occult stress incontinence. All these patients were also defined as having intrinsic sphincter deficiency with leak point pressures below 60 cm water. The incontinent group underwent anterior colporrhaphy and concomitant pubovaginal sling, compared with anterior colporrhaphy alone for those without incontinence. Postoperatively, 2 patients who had the pubovaginal sling procedure reported continued stress incontinence (14%). No new symptoms of incontinence were reported in the patients without leakage on preoperative urodynamics. Thus, preoperative urodynamics were 100% accurate in determining which women did not need additional surgery for SUI.

Implications of a negative stress test. Our experience has shown that, despite our best attempts, a negative stress test with the prolapse reduced prior to surgery is less than 100% predictive. Occasionally, new SUI occurs after reconstructive surgery. It is unclear whether this incontinence is caused by straightening the urethra and reducing the bulge or secondary to the dissection of surgery.

Tips on technique

Anterior colporrhaphy traditionally is performed with plication of the “endopelvic fascia” or fibromuscular layer at the bladder neck with a Kelly plication stitch. Using “3-point” traction aids in dissecting the muscularis (FIGURE 4). Repair the remainder of the cystocele using vertical mattress stitches (1 or 2 layers) from the bladder neck to the apex.

Avoid creating weak areas. Using this technique, the repair frequently stops short of the apex, leaving a “gap” or weak area. One way to avoid this is to begin plication at the apex instead of the bladder neck (FIGURE 5).

Next, excise the excess vaginal tissue and close with interrupted fine absorbable sutures (FIGURE 6).

Recreate apical support. Another problem with traditional repairs is that they do not reestablish apical support. In many patients with anterior wall prolapse, reattachment of the apex reduces the cystocele. Therefore, it often is necessary to combine anterior colporrhaphy with an apical repair procedure such as uterosacral ligament suspension or sacrospinous ligament suspension.

Sutures for the apical repair should be placed and held prior to initiating the anterior colporrhaphy. At the end of the anterior repair, incorporate the apical sutures into the vaginal cuff.

Careful attention to the integrity and strength of the tissue is crucial. Regardless of the type of transvaginal suspension, we advocate bringing 1 arm of the suspension suture through the anterior wall of the cuff. Then place the other suture arm through the posterior cuff so that, when tied, anterior and posterior walls are brought together and suspended.

Using prolonged-delayed absorbable suture allows for a full-thickness bite, ensuring scarring to the suspensory ligament. If permanent suture is used for the uterosacral suspension, place the stitches along the inside surface of the anterior wall with a strong, broad bite that incorporates the muscularis or “endopelvic fascia.”

The occasional enterocele. When a transverse cystocele occurs following hysterectomy, the surgeon should be on the lookout for an enterocele, which sometimes accompanies anterior wall prolapse. The enterocele should be corrected at the time of surgery by closing the defect and suspending the cuff.

FIGURE 4 Three-point traction

Three-point traction using Allis clamps. The assistant retracts with DeBackey forceps to allow dissection of the muscularis. An index finger placed firmly against the vaginal mucosa enables the surgeon to judge depth of dissection.

FIGURE 5 Begin plication at the apex

Plication begins at the apex with vertical mattress stitches. Use 3-0 prolonged delayed absorbable or permanent suture in the anterior wall.

FIGURE 6 The reduced cystocele

The cystocele reduced following midline plication of the vaginal muscularis. The excess vagina is then trimmed and closed with interrupted 3-0 absorbable suture.

Functional surgical outcomes

Because of the long association between anterior wall prolapse and SUI, most surgeons evaluate patients preoperatively to determine the need for concomitant incontinence procedures. As a result, the literature reporting surgical cystocele repair via anterior colporrhaphy frequently uses continence of urine as the functional outcome. This is not surprising considering that anterior repair and Kelly plication, as reported by Howard Kelly more than 75 years ago, have been the gold standard for surgical correction of anterior wall prolapse and SUI.

In a series of 194 SUI patients who underwent anterior colporrhaphy, Beck¹¹ found that adding a modified Kelly plication, including a vaginal retropubic urethropexy, increased the cure rate for SUI from 75% to 94%. Unfortunately, he did not report the anatomic success of the anterior colporrhaphy.

Kohli et al¹² also retrospectively examined patients who had undergone anterior colporrhaphy with and without needle bladder-neck suspension. Although the cure rate for SUI was not reported, patients who underwent concomitant needle suspension had a higher rate of recurrent cystocele: 33% (n = 40) versus 7% (n = 27). Investigators theorized that retropubic dissection at the time of transvaginal needle suspension resulted in an iatrogenic paravaginal defect and denervation of the anterior vaginal wall.

The risks of needle suspension. A randomized controlled trial by Bump et al⁸ also suggests that needle suspension should be avoided. In that trial, 29 patients with stage 3 and 4 prolapse were randomized to needle colposuspension or endopelvic fascia plication. They, too, found that needle colposuspension carried a higher rate of recurrent anterior prolapse. Further, it did not reduce the rates of SUI compared with fascia plication.

Although incontinence surgery performed at the time of cystocele repair will reduce the rates of de novo incontinence, the higher rates of cystocele recurrence associated with some procedures warrants judicious preoperative planning. Clearly, needle suspension should not be performed as an incontinence procedure or repair of anterior wall prolapse. Whether other vaginal incontinence procedures, eg, midurethral slings, lead to recurrence of anterior wall prolapse deserves further investigation.

Anatomic outcomes

Midline colporrhaphy. Because anterior colporrhaphy is rarely performed alone, few series describe patients having undergone simply an anterior repair. Stanton et al¹³ followed 54 women for up to 2 years after they underwent traditional midline plication with vaginal hysterectomy for prolapse. Eight (15%) of the women had recurrent anterior wall prolapse.

Colombo et al¹⁴ randomized 71 women with clinical SUI and stage 2 or 3 prolapse to Burch colposuspension or anterior colporrhaphy with Kelly plication. All women were followed for at least 8 years. The cure rate for SUI was 86% for the Burch procedure, compared with 52% for anterior repair and Kelly plication. However, 12 (34%) women treated with Burch colposuspension and 1 (3%) treated with anterior colporrhaphy had recurrent cystocele of grade 2 or 3 with or without prolapse at other vaginal sites.

Abdominal paravaginal repair. Shull¹⁵ followed 149 women for 6 months to 4 years after they underwent abdominal paravaginal repair with the urethrovesical stitch brought through Cooper’s ligament for treatment of SUI and paravaginal cystocele. He reported a 5% recurrence of anterior wall prolapse.

In another series, Shull¹⁶ reported on 62 women who were followed for a mean of 18 months after abdominal paravaginal repair. Four of 57 (7%) had recurrent vaginal prolapse to the hymen.

Vaginal paravaginal repair. Mallipeddi et al¹⁷ reported on 45 patients undergoing vaginal paravaginal repair over 2 years, with 35 women followed for a mean of 1.6 years. Incontinent patients had a Kelly plication performed at the time of vaginal paravaginal repair. Recurrence rates were 3% for cystocele, 14% for rectocele, and 20% for enterocele.

Young et al¹⁸ followed 100 women for as long as 36 months after bilateral paravaginal repair using 1 to 6 expanded polytetrafluoroethylene (Gore-Tex) CV-0 sutures and midline colporrhaphy. Two patients had grade 1 or 2 failure at the lateral fixation points, but 21 patients had recurrent midline defects, all but 1 inside the hymen. Several patients had bloody discharge from the permanent sutures.

Sacrocolpopexy. Brubaker¹⁹ retrospectively reviewed 65 women who underwent sacrocolpopexy for apical prolapse. Three months postoperatively 19 patients (29%) had persistent anterior wall defects.

Uterosacral suspension. Shull et al²⁰ also found the anterior segment to have the most recurrent defects. In that study, which had an average follow-up of a little over a year, 289 patients underwent vaginal uterosacral ligament repair of the apex, and 264 had an anterior wall defect preoperatively. At the time of furthest follow-up, 26 patients (9%) had failure at this site. This study confirmed that the anterior compartment is the most likely site to fail, and also that it fails the quickest.

Sacrospinous ligament suspension (SSLS). Morley and DeLancey²¹ found a 22% cystocele recurrence rate in 71 women 1 year after SSLS, with most of them asymptomatic. Shull²² reported a 30% incidence of cystoceles after SSLS. Paraiso and colleagues²³ reported on 243 women undergoing SSLS and pelvic reconstructive surgery. Of these, 217 patients underwent concomitant anterior colporrhaphy. Follow-up at 74 months found 37% with symptomatic recurrence at the anterior wall, 13% at the posterior wall, and 8% at the apex.

Vaginal versus abdominal repair

Few studies have compared vaginal and abdominal repair of pelvic organ prolapse, including anterior wall prolapse.

In a trial by Benson et al,²⁴ women with prolapse to or beyond the hymen were randomized to bilateral sacrospinous vault suspension and vaginal paravaginal repair (n = 48) or abdominal sacrocolpopexy with abdominal paravaginal repair (n = 40). One third of patients in each group also underwent anterior colporrhaphy. After a mean follow-up of 2.5 years, 16 of 20 women required reoperation for recurrent cystocele—12 (29%) from the vaginal group and 4 (10.5%) from the abdominal group. Vaginal vault eversion recurred in 5 women from the vaginal group and 1 from the abdominal group.

Investigators concluded that the anterior wall was the most likely site of failure because of the posterior placement of the vaginal apex with SSLS, predisposing the anterior wall to greater pressures and to neuropathy caused by lateral dissection of the anterior wall. Earlier studies have demonstrated that neuropathy may occur after extensive dissection of the vaginal wall and may affect the strength and integrity of the muscular support tissues.^25,26

Allografts and xenografts

The difficulty of repairing anterior wall prolapse has led some pelvic surgeons to use mesh for cystocele repair. When Julian²⁷ randomized 24 patients with recurrent cystocele to transvaginal repair with and without polypropylene (Marlex) mesh, 4 patients in the control group and no patients in the mesh group had recurrences (P <.05). However, 3 patients (25%) had mesh-related complications.

Weber et al²⁸ randomized patients to standard midline plication, plication of the paravaginal tissue more laterally, or standard plication plus polyglactin 910 (Vicryl) mesh. Among 83 patients who returned for follow-up, there were no differences in anatomic outcome. Weber and colleagues concluded that there is little benefit to using mesh to correct cystoceles.

Still, although the overall cure rate was low (30–46%), most patients had cystocele to the hymen and not beyond, with significant improvement of symptoms. Although this cannot be defined as an anatomic cure, it is encouraging that the majority of patients appear to have benefited from surgery.

Sand et al²⁹ randomized 161 women with the anterior wall to or beyond the hymen to traditional anterior colporrhaphy with or without Vicryl. The 2-inch square mesh was not placed over the repair as described above, but was folded into the anterior colporrhaphy stitches. At 1 year, 16 (22%) of 73 women with mesh and 28 (40%) of the 88 women without mesh had recurrent central cystoceles beyond the midvagina (P = .02). No women had cystoceles beyond the hymen or vaginal erosions.

Difficulty of interpreting the evidence

Because of the broad range of study designs, small number of patients per series, variety of concomitant procedures, and wide range of variables used to describe recurrence and success, it is difficult to draw conclusions from the literature. The evidence does suggest that the risks of wide vaginal dissection required for vaginal paravaginal repair outweigh the benefits. As a result, we have abandoned this technique. As mentioned above, it remains unclear whether graft materials will prove to be of long-term benefit for either midline plication or paravaginal repair.

The gold standard, for now

Prolapse of the anterior vaginal wall remains a challenge for the gynecologic surgeon. Careful preoperative and intraoperative evaluation and identification of support defects should guide repairs.

Randomized, controlled trials of midline versus paravaginal repair, as well as use of various graft materials, are greatly needed. These studies should not only address recurrence of prolapse symptoms, but the impact of surgery on sexual and lower urinary tract function.

At this time, the traditional anterior colporrhaphy with attention to apical suspension remains the gold standard.

The authors report no financial relationships relevant to this article.

When A.M. Liber encountered a family of 5 sisters and their mother with histologically confirmed papillary adenocarcinoma of the ovary, he recommended frequent gynecologic cancer screening for all family members and suggested prophylactic oophorectomy as an option.¹ The year was 1950.

Flash forward half a century or so, and prophylactic oophorectomy has gained wider acceptance for the prevention of hereditary ovarian and breast cancer, with the only prospective trial to date confirming its overall efficacy for women with BRCA1 and BRCA2 mutations. These mutations are related to the vast majority of inherited ovarian cancers.

Using the evidence published thus far, including the recently published prospective trial, we discuss surgical technique, post-oophorectomy estrogens, psychosocial impact, insurance reimbursement, and other issues.

Three hereditary syndromes

The single biggest risk factor for ovarian cancer is a family history, although only about 10% of cases are believed to be due to an inherited predisposition. Three syndromes are associated with such a predisposition:

• Hereditary breast-ovarian cancer syndrome, caused by mutations in BRCA1 and BRCA2, is thought to be responsible for more than 90% of inherited predisposition to ovarian cancer.
• Hereditary nonpolyposis colon cancer (HNPCC) syndrome is associated with mutations in the mismatch repair genes and a greatly increased risk of cancers of the colon, endometrium, ovaries, and urinary tract. HNPCC accounts for about 2% of inherited ovarian cancers.
• A syndrome of site-specific ovarian cancer also has been proposed, though we lack conclusive evidence that it exists as a separate entity at the genetic level.

How BRCA mutations lead to cancer

BRCA1 and BRCA2 are tumor suppressor genes that play a role in genomic stability and double-stranded DNA break repair. BRCA1 is located on chromosome 17; BRCA2 on chromosome 13. Both genes function as classic tumor suppressors, as described by Knudson.² Only a single working copy of each gene is needed for the genes to effectively suppress tumors.

In patients with no inherited mutation in these genes, carcinogenesis caused by dysfunction of this pathway can occur only if both working copies of the gene are lost. In contrast, women with an inherited mutation in BRCA1 or BRCA2 start out with only a single working copy of the gene. If any cell loses this single copy, DNA repair cannot occur via this pathway, and cancer can develop.

These repair pathways seem to be particularly important in dividing breast and ovarian cells. This explains why women with inherited mutations in these genes develop cancers more frequently and at an earlier age.

Quantifying the risk

Specific risks associated with BRCA1 and BRCA2 mutations include:

• a lifetime risk of breast cancer of up to 85%, with half of these cancers occurring prior to age 50
• a 15% to 45% lifetime risk of ovarian cancer^3,4

Mutations in these genes can be inherited from a mother or father. In the general population, between 1 in 385 and 1 in 800 individuals carry a deleterious mutation in either BRCA1 or BRCA2.

In certain populations, such as Icelandic, French Canadian, or Eastern European Jewish populations, founder effects can contribute to a greatly increased frequency of mutation. For example, the Eastern European Jewish population, from which approximately 90% of North American Jews are descended, has one of the highest known frequencies of BRCA1 and BRCA2 mutation: 1 in 40 individuals carries a deleterious mutation in 1 of these 2 genes.^5,6

Most evidence is historical or retrospective

Liber was not the first to suggest oophorectomy to impact the risk of breast or ovarian cancer: The procedure was initially proposed by Schinziner in 1889 as a treatment for breast cancer.⁷ However, the earliest evidence that oophorectomy was performed as adjuvant therapy did not appear until 7 years later, in 1896 (reviewed by Love and Philips).⁸

In 1968, Feinleib⁹ reported that premenopausal oophorectomy decreased the rate of subsequent breast cancer. Twenty years later, Brinton suggested that prophylactic oophorectomy might reduce breast cancer risk in women with a family history of the disease.¹⁰

In the sole prospective trial, salpingo-oophorectomy was associated with a 75% reduction in breast and gynecologic cancer.

Post-oophorectomy cancers identified. Possible limitations to the strategy became apparent in the early 1980s, when Tobacman and colleagues¹¹ reported adenocarcinoma histologically indistinguishable from ovarian cancer after oophorectomy in a series of women with a strong family history.

In 1993, Piver et al¹² reported a series of 6 cases of primary peritoneal cancer after prophylactic oophorectomy in 324 women from hereditary ovarian cancer families.

In 1997, the Cancer Genetics Studies Consortium reviewed all available data and concluded: “There is insufficient evidence to recommend for or against prophylactic oophorectomy as a measure for reducing ovarian cancer risk. Women with BRCA1 mutations should be counseled that this is an option available to them. Those considering prophylactic oophorectomy should be counseled that cancer has been documented to occur after the procedure.”¹³

Although the Cancer Genetics Studies Consortium did not specifically comment on prophylactic oophorectomy in carriers of BRCA2 mutations, most authorities interpreted these recommendations to apply to these women as well.

Predicting life expectancy. After these findings, several groups undertook decision analyses to evaluate the effect of prophylactic oophorectomy on life expectancy in women with BRCA mutations. Schrag et al¹⁴ reported that prophylactic oophorectomy in a 30-year-old with a BRCA mutation increased life expectancy by 0.3 to 1.7 years. This compares to 0.9 years for adjuvant chemotherapy in node-negative breast cancer.

A subsequent report by Grann and colleagues¹⁵ also suggested that prophylactic oophorectomy was associated with an increased life expectancy of 0.4 to 2.6 years. However, surgery was not cost-effective for quality-adjusted life-years saved.

Investigators cite need for prospective studies. In 1999, Rebbeck and colleagues¹⁶ conducted a retrospective case-control study of 43 women with BRCA1 mutations who underwent oophorectomy and 79 age-matched women with BRCA1 mutations who had ovaries in situ. In this series, oophorectomy was associated with a 47% decreased risk of subsequent breast cancer (hazard ratio 0.53). However, several investigators cited the need for prospective studies before incorporating oophorectomy into routine clinical practice for the prevention of cancer.¹⁷

The first prospective look at risk-reducing surgery

It was in this setting that our group launched a prospective trial to determine whether salpingo-oophorectomy offers any benefit over surveillance in preventing breast and gynecologic (ovarian, fallopian tube, and peritoneal) cancers in women with BRCA mutations.¹⁸

Proportional hazard analysis demonstrated that salpingo-oophorectomy was associated with a 75% reduction in subsequent breast and gynecologic cancer incidence in women with BRCA mutations (hazard ratio 0.25, 95% confidence interval 0.08 to 0.74). When the individual endpoints of breast and gynecologic cancer were observed, risk-reducing salpingo-oophorectomy (RRSO) was associated with an 85% reduction in subsequent ovarian cancer and a 68% reduction in subsequent breast cancer.

Methods. From June 1995 through May 2001, we enrolled 265 women with documented BRCA1 or BRCA2 mutations. Patients were followed by annual questionnaire, telephone contact, and medical-record review. Pathology reports were obtained for all new cancers diagnosed during follow-up.

After excluding women who underwent bilateral salpingo-oophorectomy before genetic testing, who were younger than 35 years at the time of testing, or who did not provide any follow-up information, 173 women with ovaries at risk and a documented BRCA mutation remained. These women participated in formal pre- and post-test genetic counseling and received uniform recommendations for cancer risk reduction, as detailed in the TABLE.

During follow-up, we calculated the incidence of new breast and gynecologic cancers diagnosed in the cohort who elected RRSO and compared it with the incidence of these cancers in women who chose surveillance.

Salpingo-oophorectomy was elected by 101 of the 173 women.

Findings. In 3 of these women, early-stage ovarian or fallopian-tube cancer that had not been detected during preoperative evaluation was found at the time of surgery. In the remaining 98 patients who underwent RRSO, 1 peritoneal cancer and 3 breast cancers were diagnosed during a mean 23 months of follow-up. In the 72 women who chose surveillance, 5 ovarian or peritoneal cancers and 8 breast cancers were diagnosed in a mean 25 months of follow-up.

Kaplan-Meier analysis of time to breast or BRCA-related gynecologic cancer is illustrated in FIGURE 1.

Other studies confirm findings. A second retrospective study by Rebbeck et al¹⁹ was released simultaneously with our findings and showed similar benefits. They found a 53% reduction in subsequent breast cancer risk and a 96% reduction in subsequent ovarian cancer risk. In the summer of 2003, a study from Israel by Rutter et al provided further confirmation of the substantially decreased incidence of cancer following risk-reducing surgery.²⁰

TABLE

Breast and ovarian cancer risk-reduction strategies for women with BRCA1 or BRCA2 mutations

FIGURE 1 Reduction in cancer cases associated with salpingo-oophorectomy

Reprinted with permission from Kauff ND et al.¹⁸

Copyright 2002 Massachusetts Medical Society. All rights reserved.

Good technique and pathologic review may prevent post-oophorectomy cancer

There are 3 theories about the origin of primary peritoneal cancer after oophorectomy:

• The cancer represents undetected occult cancer present at the time of risk-reducing surgery.
• It represents cancer arising in an ovarian remnant left behind after risk-reducing surgery.
• The peritoneal cancer arises de novo from the peritoneal surface epithelium.

Reasonable evidence supports each of these theories; thus, each may play some role in the incidence of “peritoneal” cancer after risk-reducing surgery.^21-23

While surgical technique and detailed pathologic review are unlikely to decrease the incidence of de novo peritoneal cancer, they may play a substantial role in reducing ovarian and related cancers after risk-reducing surgery.

Surgical requirements. Obviously, if a surgery is to be risk-reducing, as much as possible of the tissue at risk should be removed. To do so effectively, the surgeon should be comfortable operating in the retroperitoneum so that the infundibulopelvic ligament can be ligated sufficiently proximal from the ovarian hilum to minimize the possibility of an ovarian remnant. Similarly, if a salpingo-oophorectomy without hysterectomy is to be performed, the fallopian tube should be amputated as close as possible to the uterine cornua (FIGURE 2).

Laparoscopy versus open surgery. RRSO can be performed using either a laparoscopic or open approach. The appropriate choice is best determined by the patient’s history, associated comorbid conditions, need for additional procedures, and experience of the surgeon. At our institution, in the absence of contraindications, we generally offer a laparoscopic approach due to its decreased morbidity.

Concomitant hysterectomy? An area of substantial controversy is whether the uterus should be removed at the time of RRSO. In most studies exploring this issue, hereditary breast-ovarian cancer syndrome does not appear to be associated with an increased risk of uterine cancer.²⁴ However, there is concern that the portion of interstitial fallopian tube left behind after salpingo-oophorectomy may be at risk for malignant transformation.^25,26

In our series, almost 90% of risk-reducing procedures were salpingo-oophorectomies without hysterectomy. If there is an additional benefit to concomitant hysterectomy, it has yet to be demonstrated by clinical trials.

In several studies, a patient’s level of anxiety was more important than objective cancer risk in the choice of RRSO.

Close pathologic scrutiny advised. Microscopic cancer may be found in 2% to 4% of RRSO specimens upon careful pathologic review.^21,27,28 Thus, it is essential that the ovaries and fallopian tubes are sectioned in their entirety and examined by an experienced gynecologic pathologist to minimize the chance that microscopic cancer goes undetected.

It is not clear whether cytology should be routinely done at the time of risk-reducing surgery. A single report documents malignant cells in a woman with a BRCA1 mutation and no obvious foci of malignancy despite hysterectomy with bilateral salpingo-oophorectomy and staging.²⁹ Pending further studies, we routinely send cytology for review.

FIGURE 2 Careful surgical ligation and division to eliminate residual tissue

Source: Devita VT Jr., Hellman S, Rosenberg SA, eds. Progress in Oncology 2003. 2004: Jones and Bartlett Publishers; Sudbury, Mass. Reprinted with permission.

When no BRCA mutation is present

Most of the data cited thus far apply to women with documented BRCA mutations. There is much less information about the relative risks and benefits of RRSO in women with a personal or family history of breast or ovarian cancer who lack a documented BRCA mutation.

Although RRSO may be appropriate for some of these women, in 2004 it is not the standard of care to recommend RRSO to all individuals with a personal or family history suggestive of an inherited predisposition to ovarian cancer. These patients are best managed by an interdisciplinary team of gynecologists, gynecologic oncologists, and clinical geneticists, all with experience caring for women who may have an inherited predisposition.

Is anxiety a factor?

We have limited information about the psychosocial impact of RRSO. Several studies have found that a patient’s level of anxiety is a more important factor than objective cancer risk in the decision to undergo RRSO.^30,31 Unfortunately, we do not yet know whether the surgery successfully reduces these patients’ subjective concerns.

A recent study showed that risk-reducing surgery did not impair women’s overall health or psychological well-being.³² However, 20.7% of the women reported substantial cancer-related anxiety despite the risk-reducing surgery. This issue requires further investigation.

Is estrogen the best option for surgical menopause?

The role of hormone replacement after RRSO is unclear. The issue is important because many women considering salpingo-oophorectomy are in their late 30s or early 40s, when premature surgical menopause is a predictable result. Consequences can include considerable vasomotor and pelvic symptoms.

Preliminary data suggest that a woman’s satisfaction with RRSO depends in large part on its impact on sexual functioning.³² Urogenital symptoms that adversely affected sexual function, such as vaginal dryness and dyspareunia, were the most significant predictors of dissatisfaction with surgery.

Premature surgical menopause also has a substantial impact on osteoporosis risk, while its effect on heart disease remains uncertain.

While nonhormonal therapies can address each of these issues, we need more data on their long-term use. We counsel women considering RRSO that hormone replacement may be an option. We believe it is unlikely to reduce the efficacy of RRSO in preventing ovarian cancer, but it may reduce the protective effect of RRSO against subsequent breast cancer. Until further studies are available, we recommend that decisions regarding hormone replacement be individualized to the patient’s specific symptoms and personal history.

Not all insurers cover RRSO

One study explored insurance carriers’ policies about reimbursing risk-reducing surgical procedures and found that 10% to 11% of private insurers and 48% to 50% of governmental carriers had policies specifically denying coverage for such operations.

An additional 40% to 64% of insurers had no identifiable policy regarding these procedures in women with BRCA mutations.³³ The authors speculated that, without identifiable policies, this critical health-care decision may be subject to arbitrary criteria that result in substantial variation.

When we recently investigated the reimbursement experience of women with BRCA mutations undergoing RRSO at our institution, we found that 97% of the procedures were reimbursed in full, less any applicable coinsurance and deductibles.³⁴ Two important limitations of our study: It was conducted at a tertiary cancer center and was retrospective. It is not known if the findings reflect the experience of women with BRCA mutation who have risk-reducing surgery in other settings.

Unresolved issues

RRSO clearly has a role in preventing breast and ovarian cancer in women at inherited risk. However, several questions remain unanswered:

• Who is the best candidate?
• What is optimal timing of the procedure?
• What, if any, concomitant procedures should be performed?
• What is the role of hormone replacement after the surgery?

These issues will be best addressed through multicenter prospective trials, such as the one now being conducted by the Gynecologic Oncology Group.

Hope also remains that further research will improve serum and radiological detection of early ovarian cancer, and that basic research on the molecular etiology and progression of these cancers will ultimately render it unnecessary to remove organs at risk.

The authors report no financial relationships relevant to this article.

When A.M. Liber encountered a family of 5 sisters and their mother with histologically confirmed papillary adenocarcinoma of the ovary, he recommended frequent gynecologic cancer screening for all family members and suggested prophylactic oophorectomy as an option.¹ The year was 1950.

Flash forward half a century or so, and prophylactic oophorectomy has gained wider acceptance for the prevention of hereditary ovarian and breast cancer, with the only prospective trial to date confirming its overall efficacy for women with BRCA1 and BRCA2 mutations. These mutations are related to the vast majority of inherited ovarian cancers.

Using the evidence published thus far, including the recently published prospective trial, we discuss surgical technique, post-oophorectomy estrogens, psychosocial impact, insurance reimbursement, and other issues.

Three hereditary syndromes

The single biggest risk factor for ovarian cancer is a family history, although only about 10% of cases are believed to be due to an inherited predisposition. Three syndromes are associated with such a predisposition:

• Hereditary breast-ovarian cancer syndrome, caused by mutations in BRCA1 and BRCA2, is thought to be responsible for more than 90% of inherited predisposition to ovarian cancer.
• Hereditary nonpolyposis colon cancer (HNPCC) syndrome is associated with mutations in the mismatch repair genes and a greatly increased risk of cancers of the colon, endometrium, ovaries, and urinary tract. HNPCC accounts for about 2% of inherited ovarian cancers.
• A syndrome of site-specific ovarian cancer also has been proposed, though we lack conclusive evidence that it exists as a separate entity at the genetic level.

How BRCA mutations lead to cancer

BRCA1 and BRCA2 are tumor suppressor genes that play a role in genomic stability and double-stranded DNA break repair. BRCA1 is located on chromosome 17; BRCA2 on chromosome 13. Both genes function as classic tumor suppressors, as described by Knudson.² Only a single working copy of each gene is needed for the genes to effectively suppress tumors.

In patients with no inherited mutation in these genes, carcinogenesis caused by dysfunction of this pathway can occur only if both working copies of the gene are lost. In contrast, women with an inherited mutation in BRCA1 or BRCA2 start out with only a single working copy of the gene. If any cell loses this single copy, DNA repair cannot occur via this pathway, and cancer can develop.

These repair pathways seem to be particularly important in dividing breast and ovarian cells. This explains why women with inherited mutations in these genes develop cancers more frequently and at an earlier age.

Quantifying the risk

Specific risks associated with BRCA1 and BRCA2 mutations include:

• a lifetime risk of breast cancer of up to 85%, with half of these cancers occurring prior to age 50
• a 15% to 45% lifetime risk of ovarian cancer^3,4

Mutations in these genes can be inherited from a mother or father. In the general population, between 1 in 385 and 1 in 800 individuals carry a deleterious mutation in either BRCA1 or BRCA2.

In certain populations, such as Icelandic, French Canadian, or Eastern European Jewish populations, founder effects can contribute to a greatly increased frequency of mutation. For example, the Eastern European Jewish population, from which approximately 90% of North American Jews are descended, has one of the highest known frequencies of BRCA1 and BRCA2 mutation: 1 in 40 individuals carries a deleterious mutation in 1 of these 2 genes.^5,6

Most evidence is historical or retrospective

Liber was not the first to suggest oophorectomy to impact the risk of breast or ovarian cancer: The procedure was initially proposed by Schinziner in 1889 as a treatment for breast cancer.⁷ However, the earliest evidence that oophorectomy was performed as adjuvant therapy did not appear until 7 years later, in 1896 (reviewed by Love and Philips).⁸

In 1968, Feinleib⁹ reported that premenopausal oophorectomy decreased the rate of subsequent breast cancer. Twenty years later, Brinton suggested that prophylactic oophorectomy might reduce breast cancer risk in women with a family history of the disease.¹⁰

In the sole prospective trial, salpingo-oophorectomy was associated with a 75% reduction in breast and gynecologic cancer.

Post-oophorectomy cancers identified. Possible limitations to the strategy became apparent in the early 1980s, when Tobacman and colleagues¹¹ reported adenocarcinoma histologically indistinguishable from ovarian cancer after oophorectomy in a series of women with a strong family history.

In 1993, Piver et al¹² reported a series of 6 cases of primary peritoneal cancer after prophylactic oophorectomy in 324 women from hereditary ovarian cancer families.

In 1997, the Cancer Genetics Studies Consortium reviewed all available data and concluded: “There is insufficient evidence to recommend for or against prophylactic oophorectomy as a measure for reducing ovarian cancer risk. Women with BRCA1 mutations should be counseled that this is an option available to them. Those considering prophylactic oophorectomy should be counseled that cancer has been documented to occur after the procedure.”¹³

Although the Cancer Genetics Studies Consortium did not specifically comment on prophylactic oophorectomy in carriers of BRCA2 mutations, most authorities interpreted these recommendations to apply to these women as well.

Predicting life expectancy. After these findings, several groups undertook decision analyses to evaluate the effect of prophylactic oophorectomy on life expectancy in women with BRCA mutations. Schrag et al¹⁴ reported that prophylactic oophorectomy in a 30-year-old with a BRCA mutation increased life expectancy by 0.3 to 1.7 years. This compares to 0.9 years for adjuvant chemotherapy in node-negative breast cancer.

A subsequent report by Grann and colleagues¹⁵ also suggested that prophylactic oophorectomy was associated with an increased life expectancy of 0.4 to 2.6 years. However, surgery was not cost-effective for quality-adjusted life-years saved.

Investigators cite need for prospective studies. In 1999, Rebbeck and colleagues¹⁶ conducted a retrospective case-control study of 43 women with BRCA1 mutations who underwent oophorectomy and 79 age-matched women with BRCA1 mutations who had ovaries in situ. In this series, oophorectomy was associated with a 47% decreased risk of subsequent breast cancer (hazard ratio 0.53). However, several investigators cited the need for prospective studies before incorporating oophorectomy into routine clinical practice for the prevention of cancer.¹⁷

The first prospective look at risk-reducing surgery

It was in this setting that our group launched a prospective trial to determine whether salpingo-oophorectomy offers any benefit over surveillance in preventing breast and gynecologic (ovarian, fallopian tube, and peritoneal) cancers in women with BRCA mutations.¹⁸

Proportional hazard analysis demonstrated that salpingo-oophorectomy was associated with a 75% reduction in subsequent breast and gynecologic cancer incidence in women with BRCA mutations (hazard ratio 0.25, 95% confidence interval 0.08 to 0.74). When the individual endpoints of breast and gynecologic cancer were observed, risk-reducing salpingo-oophorectomy (RRSO) was associated with an 85% reduction in subsequent ovarian cancer and a 68% reduction in subsequent breast cancer.

Methods. From June 1995 through May 2001, we enrolled 265 women with documented BRCA1 or BRCA2 mutations. Patients were followed by annual questionnaire, telephone contact, and medical-record review. Pathology reports were obtained for all new cancers diagnosed during follow-up.

After excluding women who underwent bilateral salpingo-oophorectomy before genetic testing, who were younger than 35 years at the time of testing, or who did not provide any follow-up information, 173 women with ovaries at risk and a documented BRCA mutation remained. These women participated in formal pre- and post-test genetic counseling and received uniform recommendations for cancer risk reduction, as detailed in the TABLE.

During follow-up, we calculated the incidence of new breast and gynecologic cancers diagnosed in the cohort who elected RRSO and compared it with the incidence of these cancers in women who chose surveillance.

Salpingo-oophorectomy was elected by 101 of the 173 women.

Findings. In 3 of these women, early-stage ovarian or fallopian-tube cancer that had not been detected during preoperative evaluation was found at the time of surgery. In the remaining 98 patients who underwent RRSO, 1 peritoneal cancer and 3 breast cancers were diagnosed during a mean 23 months of follow-up. In the 72 women who chose surveillance, 5 ovarian or peritoneal cancers and 8 breast cancers were diagnosed in a mean 25 months of follow-up.

Kaplan-Meier analysis of time to breast or BRCA-related gynecologic cancer is illustrated in FIGURE 1.

Other studies confirm findings. A second retrospective study by Rebbeck et al¹⁹ was released simultaneously with our findings and showed similar benefits. They found a 53% reduction in subsequent breast cancer risk and a 96% reduction in subsequent ovarian cancer risk. In the summer of 2003, a study from Israel by Rutter et al provided further confirmation of the substantially decreased incidence of cancer following risk-reducing surgery.²⁰

TABLE

Breast and ovarian cancer risk-reduction strategies for women with BRCA1 or BRCA2 mutations

FIGURE 1 Reduction in cancer cases associated with salpingo-oophorectomy

Reprinted with permission from Kauff ND et al.¹⁸

Copyright 2002 Massachusetts Medical Society. All rights reserved.

Good technique and pathologic review may prevent post-oophorectomy cancer

There are 3 theories about the origin of primary peritoneal cancer after oophorectomy:

• The cancer represents undetected occult cancer present at the time of risk-reducing surgery.
• It represents cancer arising in an ovarian remnant left behind after risk-reducing surgery.
• The peritoneal cancer arises de novo from the peritoneal surface epithelium.

Reasonable evidence supports each of these theories; thus, each may play some role in the incidence of “peritoneal” cancer after risk-reducing surgery.^21-23

While surgical technique and detailed pathologic review are unlikely to decrease the incidence of de novo peritoneal cancer, they may play a substantial role in reducing ovarian and related cancers after risk-reducing surgery.

Surgical requirements. Obviously, if a surgery is to be risk-reducing, as much as possible of the tissue at risk should be removed. To do so effectively, the surgeon should be comfortable operating in the retroperitoneum so that the infundibulopelvic ligament can be ligated sufficiently proximal from the ovarian hilum to minimize the possibility of an ovarian remnant. Similarly, if a salpingo-oophorectomy without hysterectomy is to be performed, the fallopian tube should be amputated as close as possible to the uterine cornua (FIGURE 2).

Laparoscopy versus open surgery. RRSO can be performed using either a laparoscopic or open approach. The appropriate choice is best determined by the patient’s history, associated comorbid conditions, need for additional procedures, and experience of the surgeon. At our institution, in the absence of contraindications, we generally offer a laparoscopic approach due to its decreased morbidity.

Concomitant hysterectomy? An area of substantial controversy is whether the uterus should be removed at the time of RRSO. In most studies exploring this issue, hereditary breast-ovarian cancer syndrome does not appear to be associated with an increased risk of uterine cancer.²⁴ However, there is concern that the portion of interstitial fallopian tube left behind after salpingo-oophorectomy may be at risk for malignant transformation.^25,26

In our series, almost 90% of risk-reducing procedures were salpingo-oophorectomies without hysterectomy. If there is an additional benefit to concomitant hysterectomy, it has yet to be demonstrated by clinical trials.

In several studies, a patient’s level of anxiety was more important than objective cancer risk in the choice of RRSO.

Close pathologic scrutiny advised. Microscopic cancer may be found in 2% to 4% of RRSO specimens upon careful pathologic review.^21,27,28 Thus, it is essential that the ovaries and fallopian tubes are sectioned in their entirety and examined by an experienced gynecologic pathologist to minimize the chance that microscopic cancer goes undetected.

It is not clear whether cytology should be routinely done at the time of risk-reducing surgery. A single report documents malignant cells in a woman with a BRCA1 mutation and no obvious foci of malignancy despite hysterectomy with bilateral salpingo-oophorectomy and staging.²⁹ Pending further studies, we routinely send cytology for review.

FIGURE 2 Careful surgical ligation and division to eliminate residual tissue

Source: Devita VT Jr., Hellman S, Rosenberg SA, eds. Progress in Oncology 2003. 2004: Jones and Bartlett Publishers; Sudbury, Mass. Reprinted with permission.

When no BRCA mutation is present

Most of the data cited thus far apply to women with documented BRCA mutations. There is much less information about the relative risks and benefits of RRSO in women with a personal or family history of breast or ovarian cancer who lack a documented BRCA mutation.

Although RRSO may be appropriate for some of these women, in 2004 it is not the standard of care to recommend RRSO to all individuals with a personal or family history suggestive of an inherited predisposition to ovarian cancer. These patients are best managed by an interdisciplinary team of gynecologists, gynecologic oncologists, and clinical geneticists, all with experience caring for women who may have an inherited predisposition.

Is anxiety a factor?

We have limited information about the psychosocial impact of RRSO. Several studies have found that a patient’s level of anxiety is a more important factor than objective cancer risk in the decision to undergo RRSO.^30,31 Unfortunately, we do not yet know whether the surgery successfully reduces these patients’ subjective concerns.

A recent study showed that risk-reducing surgery did not impair women’s overall health or psychological well-being.³² However, 20.7% of the women reported substantial cancer-related anxiety despite the risk-reducing surgery. This issue requires further investigation.

Is estrogen the best option for surgical menopause?

The role of hormone replacement after RRSO is unclear. The issue is important because many women considering salpingo-oophorectomy are in their late 30s or early 40s, when premature surgical menopause is a predictable result. Consequences can include considerable vasomotor and pelvic symptoms.

Preliminary data suggest that a woman’s satisfaction with RRSO depends in large part on its impact on sexual functioning.³² Urogenital symptoms that adversely affected sexual function, such as vaginal dryness and dyspareunia, were the most significant predictors of dissatisfaction with surgery.

Premature surgical menopause also has a substantial impact on osteoporosis risk, while its effect on heart disease remains uncertain.

While nonhormonal therapies can address each of these issues, we need more data on their long-term use. We counsel women considering RRSO that hormone replacement may be an option. We believe it is unlikely to reduce the efficacy of RRSO in preventing ovarian cancer, but it may reduce the protective effect of RRSO against subsequent breast cancer. Until further studies are available, we recommend that decisions regarding hormone replacement be individualized to the patient’s specific symptoms and personal history.

Not all insurers cover RRSO

One study explored insurance carriers’ policies about reimbursing risk-reducing surgical procedures and found that 10% to 11% of private insurers and 48% to 50% of governmental carriers had policies specifically denying coverage for such operations.

An additional 40% to 64% of insurers had no identifiable policy regarding these procedures in women with BRCA mutations.³³ The authors speculated that, without identifiable policies, this critical health-care decision may be subject to arbitrary criteria that result in substantial variation.

When we recently investigated the reimbursement experience of women with BRCA mutations undergoing RRSO at our institution, we found that 97% of the procedures were reimbursed in full, less any applicable coinsurance and deductibles.³⁴ Two important limitations of our study: It was conducted at a tertiary cancer center and was retrospective. It is not known if the findings reflect the experience of women with BRCA mutation who have risk-reducing surgery in other settings.

Unresolved issues

RRSO clearly has a role in preventing breast and ovarian cancer in women at inherited risk. However, several questions remain unanswered:

• Who is the best candidate?
• What is optimal timing of the procedure?
• What, if any, concomitant procedures should be performed?
• What is the role of hormone replacement after the surgery?

These issues will be best addressed through multicenter prospective trials, such as the one now being conducted by the Gynecologic Oncology Group.

Hope also remains that further research will improve serum and radiological detection of early ovarian cancer, and that basic research on the molecular etiology and progression of these cancers will ultimately render it unnecessary to remove organs at risk.

The authors report no financial relationships relevant to this article.

When A.M. Liber encountered a family of 5 sisters and their mother with histologically confirmed papillary adenocarcinoma of the ovary, he recommended frequent gynecologic cancer screening for all family members and suggested prophylactic oophorectomy as an option.¹ The year was 1950.

Flash forward half a century or so, and prophylactic oophorectomy has gained wider acceptance for the prevention of hereditary ovarian and breast cancer, with the only prospective trial to date confirming its overall efficacy for women with BRCA1 and BRCA2 mutations. These mutations are related to the vast majority of inherited ovarian cancers.

Using the evidence published thus far, including the recently published prospective trial, we discuss surgical technique, post-oophorectomy estrogens, psychosocial impact, insurance reimbursement, and other issues.

Three hereditary syndromes

The single biggest risk factor for ovarian cancer is a family history, although only about 10% of cases are believed to be due to an inherited predisposition. Three syndromes are associated with such a predisposition:

• Hereditary breast-ovarian cancer syndrome, caused by mutations in BRCA1 and BRCA2, is thought to be responsible for more than 90% of inherited predisposition to ovarian cancer.
• Hereditary nonpolyposis colon cancer (HNPCC) syndrome is associated with mutations in the mismatch repair genes and a greatly increased risk of cancers of the colon, endometrium, ovaries, and urinary tract. HNPCC accounts for about 2% of inherited ovarian cancers.
• A syndrome of site-specific ovarian cancer also has been proposed, though we lack conclusive evidence that it exists as a separate entity at the genetic level.

How BRCA mutations lead to cancer

BRCA1 and BRCA2 are tumor suppressor genes that play a role in genomic stability and double-stranded DNA break repair. BRCA1 is located on chromosome 17; BRCA2 on chromosome 13. Both genes function as classic tumor suppressors, as described by Knudson.² Only a single working copy of each gene is needed for the genes to effectively suppress tumors.

In patients with no inherited mutation in these genes, carcinogenesis caused by dysfunction of this pathway can occur only if both working copies of the gene are lost. In contrast, women with an inherited mutation in BRCA1 or BRCA2 start out with only a single working copy of the gene. If any cell loses this single copy, DNA repair cannot occur via this pathway, and cancer can develop.

These repair pathways seem to be particularly important in dividing breast and ovarian cells. This explains why women with inherited mutations in these genes develop cancers more frequently and at an earlier age.

Quantifying the risk

Specific risks associated with BRCA1 and BRCA2 mutations include:

• a lifetime risk of breast cancer of up to 85%, with half of these cancers occurring prior to age 50
• a 15% to 45% lifetime risk of ovarian cancer^3,4

Mutations in these genes can be inherited from a mother or father. In the general population, between 1 in 385 and 1 in 800 individuals carry a deleterious mutation in either BRCA1 or BRCA2.

In certain populations, such as Icelandic, French Canadian, or Eastern European Jewish populations, founder effects can contribute to a greatly increased frequency of mutation. For example, the Eastern European Jewish population, from which approximately 90% of North American Jews are descended, has one of the highest known frequencies of BRCA1 and BRCA2 mutation: 1 in 40 individuals carries a deleterious mutation in 1 of these 2 genes.^5,6

Most evidence is historical or retrospective

Liber was not the first to suggest oophorectomy to impact the risk of breast or ovarian cancer: The procedure was initially proposed by Schinziner in 1889 as a treatment for breast cancer.⁷ However, the earliest evidence that oophorectomy was performed as adjuvant therapy did not appear until 7 years later, in 1896 (reviewed by Love and Philips).⁸

In 1968, Feinleib⁹ reported that premenopausal oophorectomy decreased the rate of subsequent breast cancer. Twenty years later, Brinton suggested that prophylactic oophorectomy might reduce breast cancer risk in women with a family history of the disease.¹⁰

In the sole prospective trial, salpingo-oophorectomy was associated with a 75% reduction in breast and gynecologic cancer.

Post-oophorectomy cancers identified. Possible limitations to the strategy became apparent in the early 1980s, when Tobacman and colleagues¹¹ reported adenocarcinoma histologically indistinguishable from ovarian cancer after oophorectomy in a series of women with a strong family history.

In 1993, Piver et al¹² reported a series of 6 cases of primary peritoneal cancer after prophylactic oophorectomy in 324 women from hereditary ovarian cancer families.

In 1997, the Cancer Genetics Studies Consortium reviewed all available data and concluded: “There is insufficient evidence to recommend for or against prophylactic oophorectomy as a measure for reducing ovarian cancer risk. Women with BRCA1 mutations should be counseled that this is an option available to them. Those considering prophylactic oophorectomy should be counseled that cancer has been documented to occur after the procedure.”¹³

Although the Cancer Genetics Studies Consortium did not specifically comment on prophylactic oophorectomy in carriers of BRCA2 mutations, most authorities interpreted these recommendations to apply to these women as well.

Predicting life expectancy. After these findings, several groups undertook decision analyses to evaluate the effect of prophylactic oophorectomy on life expectancy in women with BRCA mutations. Schrag et al¹⁴ reported that prophylactic oophorectomy in a 30-year-old with a BRCA mutation increased life expectancy by 0.3 to 1.7 years. This compares to 0.9 years for adjuvant chemotherapy in node-negative breast cancer.

A subsequent report by Grann and colleagues¹⁵ also suggested that prophylactic oophorectomy was associated with an increased life expectancy of 0.4 to 2.6 years. However, surgery was not cost-effective for quality-adjusted life-years saved.

Investigators cite need for prospective studies. In 1999, Rebbeck and colleagues¹⁶ conducted a retrospective case-control study of 43 women with BRCA1 mutations who underwent oophorectomy and 79 age-matched women with BRCA1 mutations who had ovaries in situ. In this series, oophorectomy was associated with a 47% decreased risk of subsequent breast cancer (hazard ratio 0.53). However, several investigators cited the need for prospective studies before incorporating oophorectomy into routine clinical practice for the prevention of cancer.¹⁷

The first prospective look at risk-reducing surgery

It was in this setting that our group launched a prospective trial to determine whether salpingo-oophorectomy offers any benefit over surveillance in preventing breast and gynecologic (ovarian, fallopian tube, and peritoneal) cancers in women with BRCA mutations.¹⁸

Proportional hazard analysis demonstrated that salpingo-oophorectomy was associated with a 75% reduction in subsequent breast and gynecologic cancer incidence in women with BRCA mutations (hazard ratio 0.25, 95% confidence interval 0.08 to 0.74). When the individual endpoints of breast and gynecologic cancer were observed, risk-reducing salpingo-oophorectomy (RRSO) was associated with an 85% reduction in subsequent ovarian cancer and a 68% reduction in subsequent breast cancer.

Methods. From June 1995 through May 2001, we enrolled 265 women with documented BRCA1 or BRCA2 mutations. Patients were followed by annual questionnaire, telephone contact, and medical-record review. Pathology reports were obtained for all new cancers diagnosed during follow-up.

After excluding women who underwent bilateral salpingo-oophorectomy before genetic testing, who were younger than 35 years at the time of testing, or who did not provide any follow-up information, 173 women with ovaries at risk and a documented BRCA mutation remained. These women participated in formal pre- and post-test genetic counseling and received uniform recommendations for cancer risk reduction, as detailed in the TABLE.

During follow-up, we calculated the incidence of new breast and gynecologic cancers diagnosed in the cohort who elected RRSO and compared it with the incidence of these cancers in women who chose surveillance.

Salpingo-oophorectomy was elected by 101 of the 173 women.

Findings. In 3 of these women, early-stage ovarian or fallopian-tube cancer that had not been detected during preoperative evaluation was found at the time of surgery. In the remaining 98 patients who underwent RRSO, 1 peritoneal cancer and 3 breast cancers were diagnosed during a mean 23 months of follow-up. In the 72 women who chose surveillance, 5 ovarian or peritoneal cancers and 8 breast cancers were diagnosed in a mean 25 months of follow-up.

Kaplan-Meier analysis of time to breast or BRCA-related gynecologic cancer is illustrated in FIGURE 1.

Other studies confirm findings. A second retrospective study by Rebbeck et al¹⁹ was released simultaneously with our findings and showed similar benefits. They found a 53% reduction in subsequent breast cancer risk and a 96% reduction in subsequent ovarian cancer risk. In the summer of 2003, a study from Israel by Rutter et al provided further confirmation of the substantially decreased incidence of cancer following risk-reducing surgery.²⁰

TABLE

Breast and ovarian cancer risk-reduction strategies for women with BRCA1 or BRCA2 mutations

FIGURE 1 Reduction in cancer cases associated with salpingo-oophorectomy

Reprinted with permission from Kauff ND et al.¹⁸

Copyright 2002 Massachusetts Medical Society. All rights reserved.

Good technique and pathologic review may prevent post-oophorectomy cancer

There are 3 theories about the origin of primary peritoneal cancer after oophorectomy:

• The cancer represents undetected occult cancer present at the time of risk-reducing surgery.
• It represents cancer arising in an ovarian remnant left behind after risk-reducing surgery.
• The peritoneal cancer arises de novo from the peritoneal surface epithelium.

Reasonable evidence supports each of these theories; thus, each may play some role in the incidence of “peritoneal” cancer after risk-reducing surgery.^21-23

While surgical technique and detailed pathologic review are unlikely to decrease the incidence of de novo peritoneal cancer, they may play a substantial role in reducing ovarian and related cancers after risk-reducing surgery.

Surgical requirements. Obviously, if a surgery is to be risk-reducing, as much as possible of the tissue at risk should be removed. To do so effectively, the surgeon should be comfortable operating in the retroperitoneum so that the infundibulopelvic ligament can be ligated sufficiently proximal from the ovarian hilum to minimize the possibility of an ovarian remnant. Similarly, if a salpingo-oophorectomy without hysterectomy is to be performed, the fallopian tube should be amputated as close as possible to the uterine cornua (FIGURE 2).

Laparoscopy versus open surgery. RRSO can be performed using either a laparoscopic or open approach. The appropriate choice is best determined by the patient’s history, associated comorbid conditions, need for additional procedures, and experience of the surgeon. At our institution, in the absence of contraindications, we generally offer a laparoscopic approach due to its decreased morbidity.

Concomitant hysterectomy? An area of substantial controversy is whether the uterus should be removed at the time of RRSO. In most studies exploring this issue, hereditary breast-ovarian cancer syndrome does not appear to be associated with an increased risk of uterine cancer.²⁴ However, there is concern that the portion of interstitial fallopian tube left behind after salpingo-oophorectomy may be at risk for malignant transformation.^25,26

In our series, almost 90% of risk-reducing procedures were salpingo-oophorectomies without hysterectomy. If there is an additional benefit to concomitant hysterectomy, it has yet to be demonstrated by clinical trials.

In several studies, a patient’s level of anxiety was more important than objective cancer risk in the choice of RRSO.

Close pathologic scrutiny advised. Microscopic cancer may be found in 2% to 4% of RRSO specimens upon careful pathologic review.^21,27,28 Thus, it is essential that the ovaries and fallopian tubes are sectioned in their entirety and examined by an experienced gynecologic pathologist to minimize the chance that microscopic cancer goes undetected.

It is not clear whether cytology should be routinely done at the time of risk-reducing surgery. A single report documents malignant cells in a woman with a BRCA1 mutation and no obvious foci of malignancy despite hysterectomy with bilateral salpingo-oophorectomy and staging.²⁹ Pending further studies, we routinely send cytology for review.

FIGURE 2 Careful surgical ligation and division to eliminate residual tissue

Source: Devita VT Jr., Hellman S, Rosenberg SA, eds. Progress in Oncology 2003. 2004: Jones and Bartlett Publishers; Sudbury, Mass. Reprinted with permission.

When no BRCA mutation is present

Most of the data cited thus far apply to women with documented BRCA mutations. There is much less information about the relative risks and benefits of RRSO in women with a personal or family history of breast or ovarian cancer who lack a documented BRCA mutation.

Although RRSO may be appropriate for some of these women, in 2004 it is not the standard of care to recommend RRSO to all individuals with a personal or family history suggestive of an inherited predisposition to ovarian cancer. These patients are best managed by an interdisciplinary team of gynecologists, gynecologic oncologists, and clinical geneticists, all with experience caring for women who may have an inherited predisposition.

Is anxiety a factor?

We have limited information about the psychosocial impact of RRSO. Several studies have found that a patient’s level of anxiety is a more important factor than objective cancer risk in the decision to undergo RRSO.^30,31 Unfortunately, we do not yet know whether the surgery successfully reduces these patients’ subjective concerns.

A recent study showed that risk-reducing surgery did not impair women’s overall health or psychological well-being.³² However, 20.7% of the women reported substantial cancer-related anxiety despite the risk-reducing surgery. This issue requires further investigation.

Is estrogen the best option for surgical menopause?

The role of hormone replacement after RRSO is unclear. The issue is important because many women considering salpingo-oophorectomy are in their late 30s or early 40s, when premature surgical menopause is a predictable result. Consequences can include considerable vasomotor and pelvic symptoms.

Preliminary data suggest that a woman’s satisfaction with RRSO depends in large part on its impact on sexual functioning.³² Urogenital symptoms that adversely affected sexual function, such as vaginal dryness and dyspareunia, were the most significant predictors of dissatisfaction with surgery.

Premature surgical menopause also has a substantial impact on osteoporosis risk, while its effect on heart disease remains uncertain.

While nonhormonal therapies can address each of these issues, we need more data on their long-term use. We counsel women considering RRSO that hormone replacement may be an option. We believe it is unlikely to reduce the efficacy of RRSO in preventing ovarian cancer, but it may reduce the protective effect of RRSO against subsequent breast cancer. Until further studies are available, we recommend that decisions regarding hormone replacement be individualized to the patient’s specific symptoms and personal history.

Not all insurers cover RRSO

One study explored insurance carriers’ policies about reimbursing risk-reducing surgical procedures and found that 10% to 11% of private insurers and 48% to 50% of governmental carriers had policies specifically denying coverage for such operations.

An additional 40% to 64% of insurers had no identifiable policy regarding these procedures in women with BRCA mutations.³³ The authors speculated that, without identifiable policies, this critical health-care decision may be subject to arbitrary criteria that result in substantial variation.

When we recently investigated the reimbursement experience of women with BRCA mutations undergoing RRSO at our institution, we found that 97% of the procedures were reimbursed in full, less any applicable coinsurance and deductibles.³⁴ Two important limitations of our study: It was conducted at a tertiary cancer center and was retrospective. It is not known if the findings reflect the experience of women with BRCA mutation who have risk-reducing surgery in other settings.

Unresolved issues

RRSO clearly has a role in preventing breast and ovarian cancer in women at inherited risk. However, several questions remain unanswered:

• Who is the best candidate?
• What is optimal timing of the procedure?
• What, if any, concomitant procedures should be performed?
• What is the role of hormone replacement after the surgery?

These issues will be best addressed through multicenter prospective trials, such as the one now being conducted by the Gynecologic Oncology Group.

Hope also remains that further research will improve serum and radiological detection of early ovarian cancer, and that basic research on the molecular etiology and progression of these cancers will ultimately render it unnecessary to remove organs at risk.

The authors report no financial relationships relevant to this article.

Novel surgical devices and techniques have transformed operative laparoscopy by improving the inefficiencies in tissue extraction that limited early acceptance.

In the beginning, it was relatively easy to isolate a myoma and dissect it from the underlying myometrium, but it took hours to extract the tissue using a hand-held morcellator. This article focuses on the 4 techniques commonly used today, as well as the products that make them possible.

In appropriately selected patients, the ability to remove tissue through any of these methods facilitates patient recovery and healing and limits hospitalization time.

Posterior colpotomy

In the 1980s and early 1990s, it was common for tissue to be extracted through a posterior colpotomy. This is not surprising given that gynecologists were trained to perform transvaginal tubal ligation and to use colpotomies when incising and draining tubo-ovarian abscesses—not to mention our ease in entering the posterior cul-de-sac during vaginal surgery.

The elasticity of the vagina facilitates removal of fairly sizeable masses. Large ovarian cysts or masses can be brought to the cul-de-sac and incised and drained in a manner that markedly reduces the risk of intraperitoneal spillage.

There are disadvantages, however. For example, if the surgeon wants to maintain laparoscopic visualization once the colpotomy has been made, the tissue to be removed must be grasped and brought toward the opening to plug the defect and maintain pneumoperitoneum.

This may not be particularly problematic if there is only 1 mass to be removed, but it can be troublesome if there are several. An option is to place the masses in the posterior cul-de-sac so they can be readily grasped once the posterior colpotomy has been made.

One conceptual concern is the issue of subsequent adhesion formation, especially in patients desiring fertility. Unfortunately, no substantive trials exist to better answer this question.

Removal through the trocar or trocar site

Although some physicians still remove tissue through a posterior colpotomy, most have abandoned that approach in favor of extraction through a primary or lateral laparoscopic port. Indeed, this is the simplest technique for extracting tissue. I often change from a 10-mm laparoscope to a 5-mm instrument, placing the smaller endoscope in one of the lower ports and removing tissue under direct visualization through the 10- or 11-mm infraumbilical port.

If a cystic mass placed in a laparoscopic bag is too large to be removed, carefully aspirate it with a large-gauge needle.

Trapped tissue. One potential problem is the trapping of tissue in trocars that contain a flap valve. If this occurs, remove the trocar, clear the tissue, and replace the trocar in the original site using a blunt instrument such as the 10-mm laparoscope. Do not use the sharp inner blade to replace this port, as it is unduly risky.

For large masses, remove the port to create extra space. It also may be necessary to enlarge the skin or the fascial incision using a blunt instrument such as forceps.

Before the widespread availability of laparoscopic bags, tissue extraction was generally performed in this manner.

Risks include spillage of cyst contents during extraction and development of a hernia secondary to the wider disruption of fascia. This risk is particularly high in the infraumbilical area, which is inherently weak to begin with. It is thus critical—in any methodology—that the fascia be appropriately closed.

Laparoscopic bags

Many of the laparoscopic bags now widely available are easily opened once they have been placed in the abdomen, though some must be opened with graspers after the bag is positioned in the peritoneal cavity. Laparoscopic bags have greater utility when the extracted tissue is soft, such as with a dermoid cyst or ovary. Dense tissue is more difficult to manage.

Some surgeons fashion their own bags using sterile gloves or baggies.

Durability. The bags vary in their ability to withstand manipulation and puncture. For example, one type of nylon bag has a polyurethane inner coating and drawstring closure, making it quite durable. It also comes in a range of sizes, allowing the surgeon to choose the bag most suitable for the mass being removed.

To use a laparoscopic bag, insert it through the infraumbilical trocar and place the mass inside it. Then remove the trocar to provide maximal room for the mass to be extracted.

If the mass is cystic and too large to be removed, carefully aspirate it with a largegauge needle, taking care not to puncture the bag. Otherwise, morcellate the mass in the sac and remove it piecemeal, allowing no spillage of contents.

This may be performed under laparoscopic visualization through the lower ancillary trocars or trocar site. If a larger port has been placed—or there is a clinical need for one—tissue extraction also could be performed through the lower port.

Risks include bag breakage and potential spillage. In addition, it sometimes is necessary to change to a larger bag.

Morcellators

Early morcellators were hand-held, requiring the operator to continuously bite into the tissue and remove the small fragments. While this approach was effective for soft tissues and small myomas, it was ineffective for larger or more solid masses.

“Orange peel” technique. Scissors have been used to achieve the same effect as the handheld morcellator. Harrith Hasson described the “orange peel” technique, in which the surgeon uses scissors to peel away the tissue as one would peel an orange.¹ The long, thin strips of tissue then can be extracted through the trocar. Unfortunately, laparoscopic scissors are often too small or dull to adequately incise larger fibroids.

Automatic morcellators have markedly enhanced our ability to perform laparoscopic myomectomy and similar procedures. They also have had a strong impact on nongynecologic procedures such as splenectomy or nephrectomy, in which large amounts of tissue must be removed. Although these devices are costly, the time savings associated with their use are significant. Current devices range from disposable to semidisposable and are available in a wide variety of sizes.

Even dense tissues such as partially calcified leiomyomata are readily removed with automatic morcellators.

Hasson’s orange-peel technique also can be employed with automatic morcellators. This allows long, thin strips of tissue to be removed while facilitating constant visualization of anatomy surrounding the tissue being extracted.

An alternative is making multiple “through-passes” into the myoma using the morcellator. In this method, the strips of tissue obtained will be smaller and the myoma will develop a Swiss-cheese appearance. Note that this approach takes longer and may increase the number of myoma fragments that fall into the pelvis and need to be removed.

Effective for a range of masses. Not surprisingly, even dense tissues such as partially calcified leiomyomata are readily removed with automatic morcellators, and the size of masses is less significant than with “manual” approaches. Nevertheless, it is critical that the surgeon maintain constant visualization and that tissue be brought toward the morcellator and away from underlying structures (FIGURE).

Do not move the morcellator toward the tissue. Because of its sharpness, the automatic morcellator will cut through vital structures as easily as it penetrates fibroids.

FIGURE Automatic morcellation: Move excised tissue toward device

To prevent injury, tissue should be brought toward the morcellator and away from underlying structures. Do not move the morcellator toward the tissue or vital structures may be cut.

Spillage

An early and continuing concern regarding ovarian cystectomy or oophorectomy is spillage of the mass’s contents into the peritoneal cavity. This is more of an issue in the case of borderline or malignant ovarian lesions or mucinous or dermoid ovarian cysts. In fact, nowhere is there more contention than over the clinical ramifications of spillage in the case of malignancy.

Mixed data on impact of spillage. Clinical data suggest that the impact of spillage is inconsequential, whereas other evidence suggests a worsening prognosis.^2-5 In the event of spillage, most gynecologic oncologists would convert an ovarian cancer patient with a 1A or 1B staged lesion to stage 1C and would likely administer chemotherapy.

Concern about spillage of a mucinous or dermoid cyst centers on the theoretical risk of pseudomyxoma peritonei or, in the case of a teratoma, chemical peritonitis. Some surgeons routinely enter dermoids and intentionally spill the contents.^6,7 Of note, we lack significant case series of ensuing infections or problems with this technique. Still, removing an intact cyst negates this issue and expedites surgery, eliminating the need to irrigate the abdomen and pelvis with large quantities of fluid.

Ectopic pregnancy has also been a concern, as there have been reports of chorionic tissue being disseminated in the abdomen and pelvis during laparoscopic procedures.⁸

Nowhere is there more contention than over the clinical ramifications of spillage in the case of malignancy.

Patient selection

Preoperative evaluation is a critical component of patient selection. A thorough ultrasound examination can help determine who is and who is not an appropriate candidate for laparoscopic management.

Cases that suggest a high risk of ovarian malignancy may be best managed in the traditional manner, as may patients with a large number of myomas or other compounding factors.

Dr. Bieber reports no financial relationships relevant to this article.

Novel surgical devices and techniques have transformed operative laparoscopy by improving the inefficiencies in tissue extraction that limited early acceptance.

In the beginning, it was relatively easy to isolate a myoma and dissect it from the underlying myometrium, but it took hours to extract the tissue using a hand-held morcellator. This article focuses on the 4 techniques commonly used today, as well as the products that make them possible.

In appropriately selected patients, the ability to remove tissue through any of these methods facilitates patient recovery and healing and limits hospitalization time.

Posterior colpotomy

In the 1980s and early 1990s, it was common for tissue to be extracted through a posterior colpotomy. This is not surprising given that gynecologists were trained to perform transvaginal tubal ligation and to use colpotomies when incising and draining tubo-ovarian abscesses—not to mention our ease in entering the posterior cul-de-sac during vaginal surgery.

The elasticity of the vagina facilitates removal of fairly sizeable masses. Large ovarian cysts or masses can be brought to the cul-de-sac and incised and drained in a manner that markedly reduces the risk of intraperitoneal spillage.

There are disadvantages, however. For example, if the surgeon wants to maintain laparoscopic visualization once the colpotomy has been made, the tissue to be removed must be grasped and brought toward the opening to plug the defect and maintain pneumoperitoneum.

This may not be particularly problematic if there is only 1 mass to be removed, but it can be troublesome if there are several. An option is to place the masses in the posterior cul-de-sac so they can be readily grasped once the posterior colpotomy has been made.

One conceptual concern is the issue of subsequent adhesion formation, especially in patients desiring fertility. Unfortunately, no substantive trials exist to better answer this question.

Removal through the trocar or trocar site

Although some physicians still remove tissue through a posterior colpotomy, most have abandoned that approach in favor of extraction through a primary or lateral laparoscopic port. Indeed, this is the simplest technique for extracting tissue. I often change from a 10-mm laparoscope to a 5-mm instrument, placing the smaller endoscope in one of the lower ports and removing tissue under direct visualization through the 10- or 11-mm infraumbilical port.

If a cystic mass placed in a laparoscopic bag is too large to be removed, carefully aspirate it with a large-gauge needle.

Trapped tissue. One potential problem is the trapping of tissue in trocars that contain a flap valve. If this occurs, remove the trocar, clear the tissue, and replace the trocar in the original site using a blunt instrument such as the 10-mm laparoscope. Do not use the sharp inner blade to replace this port, as it is unduly risky.

For large masses, remove the port to create extra space. It also may be necessary to enlarge the skin or the fascial incision using a blunt instrument such as forceps.

Before the widespread availability of laparoscopic bags, tissue extraction was generally performed in this manner.

Risks include spillage of cyst contents during extraction and development of a hernia secondary to the wider disruption of fascia. This risk is particularly high in the infraumbilical area, which is inherently weak to begin with. It is thus critical—in any methodology—that the fascia be appropriately closed.

Laparoscopic bags

Many of the laparoscopic bags now widely available are easily opened once they have been placed in the abdomen, though some must be opened with graspers after the bag is positioned in the peritoneal cavity. Laparoscopic bags have greater utility when the extracted tissue is soft, such as with a dermoid cyst or ovary. Dense tissue is more difficult to manage.

Some surgeons fashion their own bags using sterile gloves or baggies.

Durability. The bags vary in their ability to withstand manipulation and puncture. For example, one type of nylon bag has a polyurethane inner coating and drawstring closure, making it quite durable. It also comes in a range of sizes, allowing the surgeon to choose the bag most suitable for the mass being removed.

To use a laparoscopic bag, insert it through the infraumbilical trocar and place the mass inside it. Then remove the trocar to provide maximal room for the mass to be extracted.

If the mass is cystic and too large to be removed, carefully aspirate it with a largegauge needle, taking care not to puncture the bag. Otherwise, morcellate the mass in the sac and remove it piecemeal, allowing no spillage of contents.

This may be performed under laparoscopic visualization through the lower ancillary trocars or trocar site. If a larger port has been placed—or there is a clinical need for one—tissue extraction also could be performed through the lower port.

Risks include bag breakage and potential spillage. In addition, it sometimes is necessary to change to a larger bag.

Morcellators

Early morcellators were hand-held, requiring the operator to continuously bite into the tissue and remove the small fragments. While this approach was effective for soft tissues and small myomas, it was ineffective for larger or more solid masses.

“Orange peel” technique. Scissors have been used to achieve the same effect as the handheld morcellator. Harrith Hasson described the “orange peel” technique, in which the surgeon uses scissors to peel away the tissue as one would peel an orange.¹ The long, thin strips of tissue then can be extracted through the trocar. Unfortunately, laparoscopic scissors are often too small or dull to adequately incise larger fibroids.

Automatic morcellators have markedly enhanced our ability to perform laparoscopic myomectomy and similar procedures. They also have had a strong impact on nongynecologic procedures such as splenectomy or nephrectomy, in which large amounts of tissue must be removed. Although these devices are costly, the time savings associated with their use are significant. Current devices range from disposable to semidisposable and are available in a wide variety of sizes.

Even dense tissues such as partially calcified leiomyomata are readily removed with automatic morcellators.

Hasson’s orange-peel technique also can be employed with automatic morcellators. This allows long, thin strips of tissue to be removed while facilitating constant visualization of anatomy surrounding the tissue being extracted.

An alternative is making multiple “through-passes” into the myoma using the morcellator. In this method, the strips of tissue obtained will be smaller and the myoma will develop a Swiss-cheese appearance. Note that this approach takes longer and may increase the number of myoma fragments that fall into the pelvis and need to be removed.

Effective for a range of masses. Not surprisingly, even dense tissues such as partially calcified leiomyomata are readily removed with automatic morcellators, and the size of masses is less significant than with “manual” approaches. Nevertheless, it is critical that the surgeon maintain constant visualization and that tissue be brought toward the morcellator and away from underlying structures (FIGURE).

Do not move the morcellator toward the tissue. Because of its sharpness, the automatic morcellator will cut through vital structures as easily as it penetrates fibroids.

FIGURE Automatic morcellation: Move excised tissue toward device

To prevent injury, tissue should be brought toward the morcellator and away from underlying structures. Do not move the morcellator toward the tissue or vital structures may be cut.

Spillage

An early and continuing concern regarding ovarian cystectomy or oophorectomy is spillage of the mass’s contents into the peritoneal cavity. This is more of an issue in the case of borderline or malignant ovarian lesions or mucinous or dermoid ovarian cysts. In fact, nowhere is there more contention than over the clinical ramifications of spillage in the case of malignancy.

Mixed data on impact of spillage. Clinical data suggest that the impact of spillage is inconsequential, whereas other evidence suggests a worsening prognosis.^2-5 In the event of spillage, most gynecologic oncologists would convert an ovarian cancer patient with a 1A or 1B staged lesion to stage 1C and would likely administer chemotherapy.

Concern about spillage of a mucinous or dermoid cyst centers on the theoretical risk of pseudomyxoma peritonei or, in the case of a teratoma, chemical peritonitis. Some surgeons routinely enter dermoids and intentionally spill the contents.^6,7 Of note, we lack significant case series of ensuing infections or problems with this technique. Still, removing an intact cyst negates this issue and expedites surgery, eliminating the need to irrigate the abdomen and pelvis with large quantities of fluid.

Ectopic pregnancy has also been a concern, as there have been reports of chorionic tissue being disseminated in the abdomen and pelvis during laparoscopic procedures.⁸

Nowhere is there more contention than over the clinical ramifications of spillage in the case of malignancy.

Patient selection

Preoperative evaluation is a critical component of patient selection. A thorough ultrasound examination can help determine who is and who is not an appropriate candidate for laparoscopic management.

Cases that suggest a high risk of ovarian malignancy may be best managed in the traditional manner, as may patients with a large number of myomas or other compounding factors.

Dr. Bieber reports no financial relationships relevant to this article.

Novel surgical devices and techniques have transformed operative laparoscopy by improving the inefficiencies in tissue extraction that limited early acceptance.

In the beginning, it was relatively easy to isolate a myoma and dissect it from the underlying myometrium, but it took hours to extract the tissue using a hand-held morcellator. This article focuses on the 4 techniques commonly used today, as well as the products that make them possible.

In appropriately selected patients, the ability to remove tissue through any of these methods facilitates patient recovery and healing and limits hospitalization time.

Posterior colpotomy

In the 1980s and early 1990s, it was common for tissue to be extracted through a posterior colpotomy. This is not surprising given that gynecologists were trained to perform transvaginal tubal ligation and to use colpotomies when incising and draining tubo-ovarian abscesses—not to mention our ease in entering the posterior cul-de-sac during vaginal surgery.

The elasticity of the vagina facilitates removal of fairly sizeable masses. Large ovarian cysts or masses can be brought to the cul-de-sac and incised and drained in a manner that markedly reduces the risk of intraperitoneal spillage.

There are disadvantages, however. For example, if the surgeon wants to maintain laparoscopic visualization once the colpotomy has been made, the tissue to be removed must be grasped and brought toward the opening to plug the defect and maintain pneumoperitoneum.

This may not be particularly problematic if there is only 1 mass to be removed, but it can be troublesome if there are several. An option is to place the masses in the posterior cul-de-sac so they can be readily grasped once the posterior colpotomy has been made.

One conceptual concern is the issue of subsequent adhesion formation, especially in patients desiring fertility. Unfortunately, no substantive trials exist to better answer this question.

Removal through the trocar or trocar site

Although some physicians still remove tissue through a posterior colpotomy, most have abandoned that approach in favor of extraction through a primary or lateral laparoscopic port. Indeed, this is the simplest technique for extracting tissue. I often change from a 10-mm laparoscope to a 5-mm instrument, placing the smaller endoscope in one of the lower ports and removing tissue under direct visualization through the 10- or 11-mm infraumbilical port.

If a cystic mass placed in a laparoscopic bag is too large to be removed, carefully aspirate it with a large-gauge needle.

Trapped tissue. One potential problem is the trapping of tissue in trocars that contain a flap valve. If this occurs, remove the trocar, clear the tissue, and replace the trocar in the original site using a blunt instrument such as the 10-mm laparoscope. Do not use the sharp inner blade to replace this port, as it is unduly risky.

For large masses, remove the port to create extra space. It also may be necessary to enlarge the skin or the fascial incision using a blunt instrument such as forceps.

Before the widespread availability of laparoscopic bags, tissue extraction was generally performed in this manner.

Risks include spillage of cyst contents during extraction and development of a hernia secondary to the wider disruption of fascia. This risk is particularly high in the infraumbilical area, which is inherently weak to begin with. It is thus critical—in any methodology—that the fascia be appropriately closed.

Laparoscopic bags

Many of the laparoscopic bags now widely available are easily opened once they have been placed in the abdomen, though some must be opened with graspers after the bag is positioned in the peritoneal cavity. Laparoscopic bags have greater utility when the extracted tissue is soft, such as with a dermoid cyst or ovary. Dense tissue is more difficult to manage.

Some surgeons fashion their own bags using sterile gloves or baggies.

Durability. The bags vary in their ability to withstand manipulation and puncture. For example, one type of nylon bag has a polyurethane inner coating and drawstring closure, making it quite durable. It also comes in a range of sizes, allowing the surgeon to choose the bag most suitable for the mass being removed.

To use a laparoscopic bag, insert it through the infraumbilical trocar and place the mass inside it. Then remove the trocar to provide maximal room for the mass to be extracted.

If the mass is cystic and too large to be removed, carefully aspirate it with a largegauge needle, taking care not to puncture the bag. Otherwise, morcellate the mass in the sac and remove it piecemeal, allowing no spillage of contents.

This may be performed under laparoscopic visualization through the lower ancillary trocars or trocar site. If a larger port has been placed—or there is a clinical need for one—tissue extraction also could be performed through the lower port.

Risks include bag breakage and potential spillage. In addition, it sometimes is necessary to change to a larger bag.

Morcellators

Early morcellators were hand-held, requiring the operator to continuously bite into the tissue and remove the small fragments. While this approach was effective for soft tissues and small myomas, it was ineffective for larger or more solid masses.

“Orange peel” technique. Scissors have been used to achieve the same effect as the handheld morcellator. Harrith Hasson described the “orange peel” technique, in which the surgeon uses scissors to peel away the tissue as one would peel an orange.¹ The long, thin strips of tissue then can be extracted through the trocar. Unfortunately, laparoscopic scissors are often too small or dull to adequately incise larger fibroids.

Automatic morcellators have markedly enhanced our ability to perform laparoscopic myomectomy and similar procedures. They also have had a strong impact on nongynecologic procedures such as splenectomy or nephrectomy, in which large amounts of tissue must be removed. Although these devices are costly, the time savings associated with their use are significant. Current devices range from disposable to semidisposable and are available in a wide variety of sizes.

Even dense tissues such as partially calcified leiomyomata are readily removed with automatic morcellators.

Hasson’s orange-peel technique also can be employed with automatic morcellators. This allows long, thin strips of tissue to be removed while facilitating constant visualization of anatomy surrounding the tissue being extracted.

An alternative is making multiple “through-passes” into the myoma using the morcellator. In this method, the strips of tissue obtained will be smaller and the myoma will develop a Swiss-cheese appearance. Note that this approach takes longer and may increase the number of myoma fragments that fall into the pelvis and need to be removed.

Effective for a range of masses. Not surprisingly, even dense tissues such as partially calcified leiomyomata are readily removed with automatic morcellators, and the size of masses is less significant than with “manual” approaches. Nevertheless, it is critical that the surgeon maintain constant visualization and that tissue be brought toward the morcellator and away from underlying structures (FIGURE).

Do not move the morcellator toward the tissue. Because of its sharpness, the automatic morcellator will cut through vital structures as easily as it penetrates fibroids.

FIGURE Automatic morcellation: Move excised tissue toward device

To prevent injury, tissue should be brought toward the morcellator and away from underlying structures. Do not move the morcellator toward the tissue or vital structures may be cut.

Spillage

An early and continuing concern regarding ovarian cystectomy or oophorectomy is spillage of the mass’s contents into the peritoneal cavity. This is more of an issue in the case of borderline or malignant ovarian lesions or mucinous or dermoid ovarian cysts. In fact, nowhere is there more contention than over the clinical ramifications of spillage in the case of malignancy.

Mixed data on impact of spillage. Clinical data suggest that the impact of spillage is inconsequential, whereas other evidence suggests a worsening prognosis.^2-5 In the event of spillage, most gynecologic oncologists would convert an ovarian cancer patient with a 1A or 1B staged lesion to stage 1C and would likely administer chemotherapy.

Concern about spillage of a mucinous or dermoid cyst centers on the theoretical risk of pseudomyxoma peritonei or, in the case of a teratoma, chemical peritonitis. Some surgeons routinely enter dermoids and intentionally spill the contents.^6,7 Of note, we lack significant case series of ensuing infections or problems with this technique. Still, removing an intact cyst negates this issue and expedites surgery, eliminating the need to irrigate the abdomen and pelvis with large quantities of fluid.

Ectopic pregnancy has also been a concern, as there have been reports of chorionic tissue being disseminated in the abdomen and pelvis during laparoscopic procedures.⁸

Nowhere is there more contention than over the clinical ramifications of spillage in the case of malignancy.

Patient selection

Preoperative evaluation is a critical component of patient selection. A thorough ultrasound examination can help determine who is and who is not an appropriate candidate for laparoscopic management.

Cases that suggest a high risk of ovarian malignancy may be best managed in the traditional manner, as may patients with a large number of myomas or other compounding factors.

Dr. Bieber reports no financial relationships relevant to this article.

Although laparotomy is still considered the standard for ovarian cyst removal, over the past 15 years minimally invasive surgery has gained wider acceptance in cases where preoperative assessment suggests an adnexal mass is benign.

Unfortunately, minimally invasive management of a large ovarian cyst (greater than 10 cm) is particularly challenging for several reasons:

• The cyst can rupture and spill its contents into the peritoneum,
• the cyst’s size limits the surgical field, and
• an unexpected malignancy may be revealed.

An innovative minilaparotomy technique for the removal of benign ovarian cysts offers the advantages of laparoscopic and laparoscopic-assisted procedures while bypassing the major disadvantages: the necessity for specialized and expensive equipment, lengthy operative time, and long learning curves.¹ (The minimally invasive procedures currently available for the treatment of ovarian cysts include laparoscopic cystectomy, laparoscopic-assisted minilaparotomy cystectomy, laparoscopic-assisted vaginal cystectomy, combined percutaneous ultrasound cyst aspiration and laparoscopic cystectomy, transvaginal cystectomy, and the traditional minilaparotomy cystectomy.^2-10)

The procedure is faster, less expensive, carries fewer potential risks than traditional alternatives, and offers these advantages:

• can be performed under regional anesthesia
• relies on standard open techniques
• uses inexpensive instrumentation
• is easy to learn
• can be used for very large cysts
• eliminates the risk of intraperitoneal spillage of cyst contents
• offers similar postoperative convalescence and mean time to return to work as laparoscopic or laparoscopic-assisted management of large ovarian cysts

General Ob/Gyns—not gynecologic oncologists—perform most surgeries on patients with adnexal masses, since ovarian cancer is relatively uncommon in the absence of preoperative risk factors for malignancy. Our approach offers an appealing option to Ob/Gyns reluctant to abandon routine traditional laparotomy for such ovarian cysts.

Selecting the right patient

Adequate preoperative assessment diminishes the risk of unexpected malignancy in a patient undergoing surgery for an ovarian mass to less than 1%.⁴ At this time, the combination of menopausal status, cancer antigen (CA) 125 level, physical examination, and ultrasound is the best strategy for evaluating the patient with an ovarian cyst.¹¹

Signs of malignancy. Ultrasound features that suggest malignancy include irregular borders, thick septa, solid areas, internal and external excrescences, matted bowel, and ascites. Benign cysts, on the other hand, are usually unilateral and have regular borders, thin septa, no solid areas, and no internal excrescences.⁴ The measurement of blood flow within the mass by color Doppler may improve the accuracy of ultrasound in differentiating benign from malignant cysts.^4,12

On physical examination, an adnexal mass that is fixed, irregular, or solid also suggests a neoplasm. An elevated CA 125 combined with a complex adnexal mass is likely to be associated with malignancy. The test is even more specific in postmenopausal women with adnexal masses.^4,12

However, plasma levels of CA 125 also can be elevated in several benign gynecologic conditions such as endometriosis, simple ovarian cysts, pelvic inflammatory disease, ovarian torsion, fibroids, and in physiologic conditions such as menstruation and pregnancy.¹³

Anticipate the need to convert to laparotomy. Every patient’s surgical consent should include a possible conversion to laparotomy. To avoid incomplete surgical treatment and significant delays in proper therapy, a gynecologic surgeon experienced in the management of ovarian cancer should be readily available, in the event an unexpected malignancy is encountered. Ideally, the staging surgery and definite treatment should be performed at the time of initial minilaparotomy. Comprehensive surgical staging and treatment include thorough exploration of the pelvis and abdomen, omentectomy, pelvic and paraaortic lymph node sampling, multiple peritoneal biopsies and washings, bilateral salpingo-oophorectomy, hysterectomy, and debulking, when indicated.

Prepare for surgery with position, incision, and retraction

Before beginning, it is crucial to correctly position the patient, make the appropriate incision, and insert the right retractor.¹

Position. After administering regional or general anesthesia, place the patient in a modified lithotomy, as for laparoscopic surgery. Tuck the arms alongside the torso and place the legs in boot stirrups. Avoid hip flexion and allow adequate thigh abduction to expose the vagina. Perform a careful pelvic examination to determine the size and mobility of the adnexal mass.

When properly placed, this retractor creates an atraumatic, circular area of self-retraction, enabling superior exposure

Place an indwelling transurethral catheter, and pass a sturdy, hinged uterine manipulator such as the Pelosi Uterine Manipulator (Apple Medical Corp, Marlboro, Mass) transcervically into the uterine cavity (FIGURE 1).

The cruciate incision. With a conventional scalpel make a small suprapubic transverse incision through the skin and subcutaneous tissue (FIGURE 2). After clearing subcutaneous fat from the midline, incise the rectus fascia and the peritoneum in a vertical direction.

A vertical skin incision can be selected if the preoperative workup suggests a later extension of the original minilaparotomy incision may be required, or if there is a prior vertical incision.

Retraction. Use a soft sleeve-type self-retaining plastic retractor, such as Mobius (Apple Medical Corp) (FIGURE 3 ). When properly placed, this retractor creates an atraumatic, circular area of self-retraction, enabling superior exposure of the pelvis (FIGURE 4).

During surgery it may be necessary to adjust the outer ring if the sleeve loosens. Narrow Deaver or Richardson retractors, if required, provide additional retraction. The bowel may be gently packed, if necessary, but typically it is adequately displaced by the large ovarian cyst.

The atraumatic retraction provided by the soft, self-retaining abdominal retractor minimizes the possibility of tissue trauma, nerve damage, bruising, and postoperative pain. At the same time, the continuous 360° retraction force on the incision maximizes surgical exposure, providing a significantly larger working area than conventional retractors. For example, when applied to a 6-cm incision, the self-retaining retractor creates a 28-cm² exposed working area, compared with only 18 cm² provided by a conventional 4-point metal retractor.

The adjustable height of the self-retaining retractor adapts to wounds of varying depth and works on virtually any tissue thickness—a feature that makes the device effective for obese patients. Further, by lining the abdominal incision, the retractor’s plastic sleeve protects the wound’s edges from contamination and potential implantation of malignant cells, making the device ideal for managing ovarian cysts.

FIGURE 1 Hinged uterine manipulator

The manipulator facilitates exposure of the cyst and contralateral adnexa, as well as uterine elevation/rotation.

FIGURE 2 Cruciate incision

Make a 2.5- to 5-cm suprapubic transverse skin incision. Using the Bovie device, incise the subcutaneous fat transversely along the full length of the skin incision down to the level of the anterior rectus fascia. Clear the subcutaneous fat from the midline superiorly and inferiorly to expose 5 to 6 cm of the rectus fascia in the vertical axis. Use blunt digital dissection to assist in mobilizing the subcutaneous fat. Incise the anterior rectus fascia vertically through the full length of the cleared area. Retract the rectus muscles from the midline to expose the underlying transversalis fascia and the peritoneum. Control small bleeding points with the Bovie device. Enter the peritoneum either digitally or with scissors above the bladder dome and extend the peritoneal incision to the full length of the fascial incision.

FIGURE 3 Self-retaining retractor

The retractor consists of a flexible plastic inner ring and a firmer outer ring connected by a soft plastic sleeve.

FIGURE 4360° retraction force

Squeeze the inner ring of the soft, sleeve-type, self-retaining retractor into the peritoneal cavity through the cruciate abdominal incision and allow it to spring open against the parietal peritoneum. Make a digital assessment to ensure that viscera is not trapped between the inner ring and the abdominal wall. Place the entire sleeve on traction by lifting the outer ring. Then roll the outer ring onto the sleeve, collecting excess length, until it sits firmly against the skin. The atraumatic retraction provided by the sleeve-type retractor maximizes exposure of the pelvis. Note how a portion of the large cyst is clearly seen through the atraumatic, circular area of retraction.

Cyst assessment

Visually and digitally inspect the cyst and carefully evaluate the uterus, pelvis, and contralateral adnexa. Determine the extent of adhesions and any unexpected pelvic pathology. When needed, use traditional small retractors or gentle packing to gain additional exposure. If the cystic mass appears suspicious (internal and external excrescences on the cyst, ovaries, or peritoneal surfaces, or ascites), obtain pelvic washings with a suction-irrigation cannula, send the fluid for cytologic examination, and convert the minilaparotomy to a standard exploratory laparotomy. Extensive adhesions to the bowel, broad ligament, or pelvic sidewall and unexpected extensive endometriosis may also require a conversion to standard laparotomy.

Reduce cyst size by decompression

Simple aspiration is inadvisable. To remove a large ovarian cyst using the Pelosi minilaparotomy, reduce the size of the cyst to permit safe and effective mobilization and resection through the small abdominal incision. Simple aspiration of the cyst, with its potential for spilling the contents, is not a wise strategy for several reasons. First, many ovarian cysts contain functional epithelium with a high recurrence rate (8% to 67%). Second, studies show that 10% to 66% of ovarian cyst fluid aspirates initially diagnosed as benign actually are malignant. Further, relying on negative cytology from the aspirate of an ovarian cyst without tissue biopsy may delay appropriate surgery, and the puncture of an unexpected malignant cyst may seed the peritoneal cavity and possibly worsen the patient’s prognosis.^11,12

This technique, suitable for all ovarian cysts, makes it possible to aspirate a large cyst without leakage.

Whether spillage of cancer cells actually worsens the prognosis of a patient with a neoplastic cyst remains controversial because of conflicting study results. Nonetheless, the possibility of intraperitoneal dissemination of neoplastic cells from a ruptured cyst cannot be considered innocuous, and the potential negative effect on a patient’s prognosis should not be ignored.¹⁴ Make every attempt, therefore, to avoid rupturing the cyst and spilling the fluid into the peritoneal cavity.

A shared flaw plagues aspiration devices. Different devices are available for intraoperative cyst aspiration during laparoscopic, transvaginal, or laparotomy approaches.^3,4,6 In addition to long needles, drainage trocars, suction cannulas, and suprapubic bladder catheters, special aspiration instruments have been developed.¹⁵ They include a metal vacuum system with an aspirator trocar that seals the surface of the cyst, and a catheter system that pinches the punctured cyst wall between double balloons to prevent spillage.¹⁶ In addition, several commercial bags are available to prevent intraperitoneal spillage during removal of ovarian cysts.

All these devices have a universal flaw, however: After a thin-walled cyst initially is punctured, none of these products can prevent the spontaneous dehiscence of the cyst and the resulting spillage of its contents into the abdominal cavity. Vacuum systems work well for large cysts with smooth, round surfaces, but in those with irregular surfaces, both application and maintaining the seal are difficult.¹⁷ Fortunately, our technique makes it possible to aspirate a large ovarian cyst without leakage, and the method is suitable for all ovarian cysts regardless of surface type or wall thickness.

Glue the dressing to the cyst to capture leakage. Using a gauze pad, carefully dry the area of the ovarian cyst that is visible through the self-retaining retractor. Then generously spread sterile surgical glue such as Dermabond (Ethicon, Somerville, NJ) on the cyst wall surface (FIGURE 5A). Dermabond is the commercial name for 2-octyl cyanoacrylate, a sterile skin adhesive used as an alternative to stitches to close the edges of small wounds. It is similar to commercial adhesives such as Super Glue and Krazy Glue.

Remove the paper cover of a transparent plastic surgical dressing and place the adhesive side directly onto the glued cyst surface until you are sure the adhesive is completely fixed (FIGURES 5B AND 5C). The 35 cm x 35 cm Steri-Drape or the transparent Tegaderm (both from 3M Health Care, St. Paul, Minn) dressing is effective. A standard nonadhesive plastic dressing or a sterile plastic bag also can be used, as long as the free edges extend beyond the outer rim of the self-retaining retractor.

With a needle aspirator, pierce the cyst through the glued plastic dressing and carefully aspirate the fluid (FIGURES 6A AND 6B). Any leakage is trapped inside the plastic dressing rather than the abdominal cavity. Continue the aspiration until the collapsed cyst and ovary can be gradually delivered through the abdominal incision (FIGURE 6C). Note that the selfretaining retractor also protects the abdominal incision from potential contamination and implantation of neoplastic cells.

Once the cyst and ovary are extracted, you can readily perform an extracorporeal cystectomy, after which the repaired ovary is returned to the abdominal cavity. Be careful to avoid letting any fluid flow back into the peritoneal cavity during cyst removal. When indicated, an extracorporeal adnexectomy can readily be performed.

The presence of oily material or hairs in the aspirated fluid and on the needle tip readily identifies a dermoid cyst.

Dermoid cysts require extra care. Preventing intraperitoneal spillage is especially important when removing a large dermoid cyst, to avoid the possibility of chemical peritonitis, dense adhesions, and fistulas. The presence of oily material or hairs in the aspirated fluid and on the needle tip readily identifies a dermoid cyst. Quite frequently, a large-diameter suction cannula is required to remove the waxy contents. If the dermoid cyst is very large, aspiration alone will not empty it entirely. Complete emptying is not necessary, however. The primary goal of aspiration is to reduce the size and tension of the cyst to permit delivery through the abdominal incision.

Closing the cruciate incision is quicker and requires less exposure than a scaled-down Pfannenstiel’s incision.

Before concluding the procedure, irrigate the peritoneal cavity to remove any remnants of cyst contents that may have spilled—especially important with a dermoid cyst. Perform any additional indicated procedures through the minilaparotomy incision, such as a contralateral ovarian cystectomy, salpingo-oophorectomy, or hysterectomy. After the surgery is completed, remove the self-retaining retractor by hooking a finger through the bottom ring and pulling it gently out of the incision. Closing the cruciate incision is quicker and requires less exposure to complete than a scaled-down Pfannenstiel’s incision. Apply a vertical pressure dressing over the incision to prevent postoperative wound hematoma or seroma formation. Remove the dressing 24 hours later.

FIGURE 5A ‘Leak-proofing’ the aspiration

After drying the surface of the cyst, apply sterile surgical glue to the cyst wall (2 to 3 ampules are usually required to cover the cyst surface).

FIGURE 5B ‘Leak-proofing’ the aspiration

Apply the adhesive side of a clear plastic wound dressing directly onto the cyst’s surface, making sure that the dressing is large enough to fully cover the self-retaining retractor. Using either a piece of folded gauze or your fingers, press the plastic dressing against the adhesive-coated cyst for about 3 to 5 minutes until the adhesive is completely fixed.

FIGURE 5C ‘Leak-proofing’ the aspiration

Remove the paper cover of the wound dressing.

FIGURE 6A Aspirating the cyst

Pierce the dressing and carefully aspirate the fluid until the cyst is partially collapsed.

FIGURE 6B Aspirating the cyst

Place atraumatic clamps on the cyst wall to further control drainage. Any leakage is trapped inside the plastic dressing rather than draining into the abdominal cavity.

FIGURE 6C Aspirating the cyst

Continue the aspiration until the collapsed cyst and ovary can be delivered gradually through the abdominal incision, after detaching the adhesive plastic dressing from the edges of the self-retaining retractor. The portion of the plastic sleeve that is glued to the cyst surface remains attached to the cyst until the cyst is extracted. Following extraction, perform an extracorporeal cystectomy and return the repaired ovary to the abdominal cavity.

Good results

Using our approach, we have treated 38 patients with ovarian cysts of diameters greater than 20 cm thought to be benign by preoperative workup (FIGURE 7). We encountered no malignancies. All surgeries were successfully completed without laparoscopy or conversion to traditional laparotomy and with good cosmesis (FIGURE 8).

Other procedures performed in some of these patients using the same technique included contralateral cystectomy, salpingo-oophorectomy, subtotal and total hysterectomy, adhesiolysis, and appendectomy. We encountered no intraoperative or postoperative complications. Operating times ranged from 18 to 65 minutes. All patients were discharged home within 36 hours and returned to work in a mean of 12 days. Pathology findings of the ovarian cysts included endometrioma, dermoid cyst, serous cystadenoma, and mucinous cystadenoma.

FIGURE 7 Effective for large cysts

Following removal, the collapsed cyst was refilled with 1,300 mL of normal saline to demonstrate its actual size.

FIGURE 8 Good cosmetic results

Cosmetic appearance of the small cruciate abdominal incision 10 days after surgery.Dr. Pelosi II reports that he is a consultant for Apple Medical Corporation. Dr. Pelosi III reports no affiliations or financial arrangements with any companies whose products are mentioned in this article.

Although laparotomy is still considered the standard for ovarian cyst removal, over the past 15 years minimally invasive surgery has gained wider acceptance in cases where preoperative assessment suggests an adnexal mass is benign.

Unfortunately, minimally invasive management of a large ovarian cyst (greater than 10 cm) is particularly challenging for several reasons:

• The cyst can rupture and spill its contents into the peritoneum,
• the cyst’s size limits the surgical field, and
• an unexpected malignancy may be revealed.

An innovative minilaparotomy technique for the removal of benign ovarian cysts offers the advantages of laparoscopic and laparoscopic-assisted procedures while bypassing the major disadvantages: the necessity for specialized and expensive equipment, lengthy operative time, and long learning curves.¹ (The minimally invasive procedures currently available for the treatment of ovarian cysts include laparoscopic cystectomy, laparoscopic-assisted minilaparotomy cystectomy, laparoscopic-assisted vaginal cystectomy, combined percutaneous ultrasound cyst aspiration and laparoscopic cystectomy, transvaginal cystectomy, and the traditional minilaparotomy cystectomy.^2-10)

The procedure is faster, less expensive, carries fewer potential risks than traditional alternatives, and offers these advantages:

• can be performed under regional anesthesia
• relies on standard open techniques
• uses inexpensive instrumentation
• is easy to learn
• can be used for very large cysts
• eliminates the risk of intraperitoneal spillage of cyst contents
• offers similar postoperative convalescence and mean time to return to work as laparoscopic or laparoscopic-assisted management of large ovarian cysts

General Ob/Gyns—not gynecologic oncologists—perform most surgeries on patients with adnexal masses, since ovarian cancer is relatively uncommon in the absence of preoperative risk factors for malignancy. Our approach offers an appealing option to Ob/Gyns reluctant to abandon routine traditional laparotomy for such ovarian cysts.

Selecting the right patient

Adequate preoperative assessment diminishes the risk of unexpected malignancy in a patient undergoing surgery for an ovarian mass to less than 1%.⁴ At this time, the combination of menopausal status, cancer antigen (CA) 125 level, physical examination, and ultrasound is the best strategy for evaluating the patient with an ovarian cyst.¹¹

Signs of malignancy. Ultrasound features that suggest malignancy include irregular borders, thick septa, solid areas, internal and external excrescences, matted bowel, and ascites. Benign cysts, on the other hand, are usually unilateral and have regular borders, thin septa, no solid areas, and no internal excrescences.⁴ The measurement of blood flow within the mass by color Doppler may improve the accuracy of ultrasound in differentiating benign from malignant cysts.^4,12

On physical examination, an adnexal mass that is fixed, irregular, or solid also suggests a neoplasm. An elevated CA 125 combined with a complex adnexal mass is likely to be associated with malignancy. The test is even more specific in postmenopausal women with adnexal masses.^4,12

However, plasma levels of CA 125 also can be elevated in several benign gynecologic conditions such as endometriosis, simple ovarian cysts, pelvic inflammatory disease, ovarian torsion, fibroids, and in physiologic conditions such as menstruation and pregnancy.¹³

Anticipate the need to convert to laparotomy. Every patient’s surgical consent should include a possible conversion to laparotomy. To avoid incomplete surgical treatment and significant delays in proper therapy, a gynecologic surgeon experienced in the management of ovarian cancer should be readily available, in the event an unexpected malignancy is encountered. Ideally, the staging surgery and definite treatment should be performed at the time of initial minilaparotomy. Comprehensive surgical staging and treatment include thorough exploration of the pelvis and abdomen, omentectomy, pelvic and paraaortic lymph node sampling, multiple peritoneal biopsies and washings, bilateral salpingo-oophorectomy, hysterectomy, and debulking, when indicated.

Prepare for surgery with position, incision, and retraction

Before beginning, it is crucial to correctly position the patient, make the appropriate incision, and insert the right retractor.¹

Position. After administering regional or general anesthesia, place the patient in a modified lithotomy, as for laparoscopic surgery. Tuck the arms alongside the torso and place the legs in boot stirrups. Avoid hip flexion and allow adequate thigh abduction to expose the vagina. Perform a careful pelvic examination to determine the size and mobility of the adnexal mass.

When properly placed, this retractor creates an atraumatic, circular area of self-retraction, enabling superior exposure

Place an indwelling transurethral catheter, and pass a sturdy, hinged uterine manipulator such as the Pelosi Uterine Manipulator (Apple Medical Corp, Marlboro, Mass) transcervically into the uterine cavity (FIGURE 1).

The cruciate incision. With a conventional scalpel make a small suprapubic transverse incision through the skin and subcutaneous tissue (FIGURE 2). After clearing subcutaneous fat from the midline, incise the rectus fascia and the peritoneum in a vertical direction.

A vertical skin incision can be selected if the preoperative workup suggests a later extension of the original minilaparotomy incision may be required, or if there is a prior vertical incision.

Retraction. Use a soft sleeve-type self-retaining plastic retractor, such as Mobius (Apple Medical Corp) (FIGURE 3 ). When properly placed, this retractor creates an atraumatic, circular area of self-retraction, enabling superior exposure of the pelvis (FIGURE 4).

During surgery it may be necessary to adjust the outer ring if the sleeve loosens. Narrow Deaver or Richardson retractors, if required, provide additional retraction. The bowel may be gently packed, if necessary, but typically it is adequately displaced by the large ovarian cyst.

The atraumatic retraction provided by the soft, self-retaining abdominal retractor minimizes the possibility of tissue trauma, nerve damage, bruising, and postoperative pain. At the same time, the continuous 360° retraction force on the incision maximizes surgical exposure, providing a significantly larger working area than conventional retractors. For example, when applied to a 6-cm incision, the self-retaining retractor creates a 28-cm² exposed working area, compared with only 18 cm² provided by a conventional 4-point metal retractor.

The adjustable height of the self-retaining retractor adapts to wounds of varying depth and works on virtually any tissue thickness—a feature that makes the device effective for obese patients. Further, by lining the abdominal incision, the retractor’s plastic sleeve protects the wound’s edges from contamination and potential implantation of malignant cells, making the device ideal for managing ovarian cysts.

FIGURE 1 Hinged uterine manipulator

The manipulator facilitates exposure of the cyst and contralateral adnexa, as well as uterine elevation/rotation.

FIGURE 2 Cruciate incision

Make a 2.5- to 5-cm suprapubic transverse skin incision. Using the Bovie device, incise the subcutaneous fat transversely along the full length of the skin incision down to the level of the anterior rectus fascia. Clear the subcutaneous fat from the midline superiorly and inferiorly to expose 5 to 6 cm of the rectus fascia in the vertical axis. Use blunt digital dissection to assist in mobilizing the subcutaneous fat. Incise the anterior rectus fascia vertically through the full length of the cleared area. Retract the rectus muscles from the midline to expose the underlying transversalis fascia and the peritoneum. Control small bleeding points with the Bovie device. Enter the peritoneum either digitally or with scissors above the bladder dome and extend the peritoneal incision to the full length of the fascial incision.

FIGURE 3 Self-retaining retractor

The retractor consists of a flexible plastic inner ring and a firmer outer ring connected by a soft plastic sleeve.

FIGURE 4360° retraction force

Squeeze the inner ring of the soft, sleeve-type, self-retaining retractor into the peritoneal cavity through the cruciate abdominal incision and allow it to spring open against the parietal peritoneum. Make a digital assessment to ensure that viscera is not trapped between the inner ring and the abdominal wall. Place the entire sleeve on traction by lifting the outer ring. Then roll the outer ring onto the sleeve, collecting excess length, until it sits firmly against the skin. The atraumatic retraction provided by the sleeve-type retractor maximizes exposure of the pelvis. Note how a portion of the large cyst is clearly seen through the atraumatic, circular area of retraction.

Cyst assessment

Visually and digitally inspect the cyst and carefully evaluate the uterus, pelvis, and contralateral adnexa. Determine the extent of adhesions and any unexpected pelvic pathology. When needed, use traditional small retractors or gentle packing to gain additional exposure. If the cystic mass appears suspicious (internal and external excrescences on the cyst, ovaries, or peritoneal surfaces, or ascites), obtain pelvic washings with a suction-irrigation cannula, send the fluid for cytologic examination, and convert the minilaparotomy to a standard exploratory laparotomy. Extensive adhesions to the bowel, broad ligament, or pelvic sidewall and unexpected extensive endometriosis may also require a conversion to standard laparotomy.

Reduce cyst size by decompression

Simple aspiration is inadvisable. To remove a large ovarian cyst using the Pelosi minilaparotomy, reduce the size of the cyst to permit safe and effective mobilization and resection through the small abdominal incision. Simple aspiration of the cyst, with its potential for spilling the contents, is not a wise strategy for several reasons. First, many ovarian cysts contain functional epithelium with a high recurrence rate (8% to 67%). Second, studies show that 10% to 66% of ovarian cyst fluid aspirates initially diagnosed as benign actually are malignant. Further, relying on negative cytology from the aspirate of an ovarian cyst without tissue biopsy may delay appropriate surgery, and the puncture of an unexpected malignant cyst may seed the peritoneal cavity and possibly worsen the patient’s prognosis.^11,12

This technique, suitable for all ovarian cysts, makes it possible to aspirate a large cyst without leakage.

Whether spillage of cancer cells actually worsens the prognosis of a patient with a neoplastic cyst remains controversial because of conflicting study results. Nonetheless, the possibility of intraperitoneal dissemination of neoplastic cells from a ruptured cyst cannot be considered innocuous, and the potential negative effect on a patient’s prognosis should not be ignored.¹⁴ Make every attempt, therefore, to avoid rupturing the cyst and spilling the fluid into the peritoneal cavity.

A shared flaw plagues aspiration devices. Different devices are available for intraoperative cyst aspiration during laparoscopic, transvaginal, or laparotomy approaches.^3,4,6 In addition to long needles, drainage trocars, suction cannulas, and suprapubic bladder catheters, special aspiration instruments have been developed.¹⁵ They include a metal vacuum system with an aspirator trocar that seals the surface of the cyst, and a catheter system that pinches the punctured cyst wall between double balloons to prevent spillage.¹⁶ In addition, several commercial bags are available to prevent intraperitoneal spillage during removal of ovarian cysts.

All these devices have a universal flaw, however: After a thin-walled cyst initially is punctured, none of these products can prevent the spontaneous dehiscence of the cyst and the resulting spillage of its contents into the abdominal cavity. Vacuum systems work well for large cysts with smooth, round surfaces, but in those with irregular surfaces, both application and maintaining the seal are difficult.¹⁷ Fortunately, our technique makes it possible to aspirate a large ovarian cyst without leakage, and the method is suitable for all ovarian cysts regardless of surface type or wall thickness.

Glue the dressing to the cyst to capture leakage. Using a gauze pad, carefully dry the area of the ovarian cyst that is visible through the self-retaining retractor. Then generously spread sterile surgical glue such as Dermabond (Ethicon, Somerville, NJ) on the cyst wall surface (FIGURE 5A). Dermabond is the commercial name for 2-octyl cyanoacrylate, a sterile skin adhesive used as an alternative to stitches to close the edges of small wounds. It is similar to commercial adhesives such as Super Glue and Krazy Glue.

Remove the paper cover of a transparent plastic surgical dressing and place the adhesive side directly onto the glued cyst surface until you are sure the adhesive is completely fixed (FIGURES 5B AND 5C). The 35 cm x 35 cm Steri-Drape or the transparent Tegaderm (both from 3M Health Care, St. Paul, Minn) dressing is effective. A standard nonadhesive plastic dressing or a sterile plastic bag also can be used, as long as the free edges extend beyond the outer rim of the self-retaining retractor.

With a needle aspirator, pierce the cyst through the glued plastic dressing and carefully aspirate the fluid (FIGURES 6A AND 6B). Any leakage is trapped inside the plastic dressing rather than the abdominal cavity. Continue the aspiration until the collapsed cyst and ovary can be gradually delivered through the abdominal incision (FIGURE 6C). Note that the selfretaining retractor also protects the abdominal incision from potential contamination and implantation of neoplastic cells.

Once the cyst and ovary are extracted, you can readily perform an extracorporeal cystectomy, after which the repaired ovary is returned to the abdominal cavity. Be careful to avoid letting any fluid flow back into the peritoneal cavity during cyst removal. When indicated, an extracorporeal adnexectomy can readily be performed.

The presence of oily material or hairs in the aspirated fluid and on the needle tip readily identifies a dermoid cyst.

Dermoid cysts require extra care. Preventing intraperitoneal spillage is especially important when removing a large dermoid cyst, to avoid the possibility of chemical peritonitis, dense adhesions, and fistulas. The presence of oily material or hairs in the aspirated fluid and on the needle tip readily identifies a dermoid cyst. Quite frequently, a large-diameter suction cannula is required to remove the waxy contents. If the dermoid cyst is very large, aspiration alone will not empty it entirely. Complete emptying is not necessary, however. The primary goal of aspiration is to reduce the size and tension of the cyst to permit delivery through the abdominal incision.

Closing the cruciate incision is quicker and requires less exposure than a scaled-down Pfannenstiel’s incision.

Before concluding the procedure, irrigate the peritoneal cavity to remove any remnants of cyst contents that may have spilled—especially important with a dermoid cyst. Perform any additional indicated procedures through the minilaparotomy incision, such as a contralateral ovarian cystectomy, salpingo-oophorectomy, or hysterectomy. After the surgery is completed, remove the self-retaining retractor by hooking a finger through the bottom ring and pulling it gently out of the incision. Closing the cruciate incision is quicker and requires less exposure to complete than a scaled-down Pfannenstiel’s incision. Apply a vertical pressure dressing over the incision to prevent postoperative wound hematoma or seroma formation. Remove the dressing 24 hours later.

FIGURE 5A ‘Leak-proofing’ the aspiration

After drying the surface of the cyst, apply sterile surgical glue to the cyst wall (2 to 3 ampules are usually required to cover the cyst surface).

FIGURE 5B ‘Leak-proofing’ the aspiration

Apply the adhesive side of a clear plastic wound dressing directly onto the cyst’s surface, making sure that the dressing is large enough to fully cover the self-retaining retractor. Using either a piece of folded gauze or your fingers, press the plastic dressing against the adhesive-coated cyst for about 3 to 5 minutes until the adhesive is completely fixed.

FIGURE 5C ‘Leak-proofing’ the aspiration

Remove the paper cover of the wound dressing.

FIGURE 6A Aspirating the cyst

Pierce the dressing and carefully aspirate the fluid until the cyst is partially collapsed.

FIGURE 6B Aspirating the cyst

Place atraumatic clamps on the cyst wall to further control drainage. Any leakage is trapped inside the plastic dressing rather than draining into the abdominal cavity.

FIGURE 6C Aspirating the cyst

Continue the aspiration until the collapsed cyst and ovary can be delivered gradually through the abdominal incision, after detaching the adhesive plastic dressing from the edges of the self-retaining retractor. The portion of the plastic sleeve that is glued to the cyst surface remains attached to the cyst until the cyst is extracted. Following extraction, perform an extracorporeal cystectomy and return the repaired ovary to the abdominal cavity.

Good results

Using our approach, we have treated 38 patients with ovarian cysts of diameters greater than 20 cm thought to be benign by preoperative workup (FIGURE 7). We encountered no malignancies. All surgeries were successfully completed without laparoscopy or conversion to traditional laparotomy and with good cosmesis (FIGURE 8).

Other procedures performed in some of these patients using the same technique included contralateral cystectomy, salpingo-oophorectomy, subtotal and total hysterectomy, adhesiolysis, and appendectomy. We encountered no intraoperative or postoperative complications. Operating times ranged from 18 to 65 minutes. All patients were discharged home within 36 hours and returned to work in a mean of 12 days. Pathology findings of the ovarian cysts included endometrioma, dermoid cyst, serous cystadenoma, and mucinous cystadenoma.

FIGURE 7 Effective for large cysts

Following removal, the collapsed cyst was refilled with 1,300 mL of normal saline to demonstrate its actual size.

FIGURE 8 Good cosmetic results

Cosmetic appearance of the small cruciate abdominal incision 10 days after surgery.Dr. Pelosi II reports that he is a consultant for Apple Medical Corporation. Dr. Pelosi III reports no affiliations or financial arrangements with any companies whose products are mentioned in this article.

Although laparotomy is still considered the standard for ovarian cyst removal, over the past 15 years minimally invasive surgery has gained wider acceptance in cases where preoperative assessment suggests an adnexal mass is benign.

Unfortunately, minimally invasive management of a large ovarian cyst (greater than 10 cm) is particularly challenging for several reasons:

• The cyst can rupture and spill its contents into the peritoneum,
• the cyst’s size limits the surgical field, and
• an unexpected malignancy may be revealed.

An innovative minilaparotomy technique for the removal of benign ovarian cysts offers the advantages of laparoscopic and laparoscopic-assisted procedures while bypassing the major disadvantages: the necessity for specialized and expensive equipment, lengthy operative time, and long learning curves.¹ (The minimally invasive procedures currently available for the treatment of ovarian cysts include laparoscopic cystectomy, laparoscopic-assisted minilaparotomy cystectomy, laparoscopic-assisted vaginal cystectomy, combined percutaneous ultrasound cyst aspiration and laparoscopic cystectomy, transvaginal cystectomy, and the traditional minilaparotomy cystectomy.^2-10)

The procedure is faster, less expensive, carries fewer potential risks than traditional alternatives, and offers these advantages:

• can be performed under regional anesthesia
• relies on standard open techniques
• uses inexpensive instrumentation
• is easy to learn
• can be used for very large cysts
• eliminates the risk of intraperitoneal spillage of cyst contents
• offers similar postoperative convalescence and mean time to return to work as laparoscopic or laparoscopic-assisted management of large ovarian cysts

General Ob/Gyns—not gynecologic oncologists—perform most surgeries on patients with adnexal masses, since ovarian cancer is relatively uncommon in the absence of preoperative risk factors for malignancy. Our approach offers an appealing option to Ob/Gyns reluctant to abandon routine traditional laparotomy for such ovarian cysts.

Selecting the right patient

Adequate preoperative assessment diminishes the risk of unexpected malignancy in a patient undergoing surgery for an ovarian mass to less than 1%.⁴ At this time, the combination of menopausal status, cancer antigen (CA) 125 level, physical examination, and ultrasound is the best strategy for evaluating the patient with an ovarian cyst.¹¹

Signs of malignancy. Ultrasound features that suggest malignancy include irregular borders, thick septa, solid areas, internal and external excrescences, matted bowel, and ascites. Benign cysts, on the other hand, are usually unilateral and have regular borders, thin septa, no solid areas, and no internal excrescences.⁴ The measurement of blood flow within the mass by color Doppler may improve the accuracy of ultrasound in differentiating benign from malignant cysts.^4,12

On physical examination, an adnexal mass that is fixed, irregular, or solid also suggests a neoplasm. An elevated CA 125 combined with a complex adnexal mass is likely to be associated with malignancy. The test is even more specific in postmenopausal women with adnexal masses.^4,12

However, plasma levels of CA 125 also can be elevated in several benign gynecologic conditions such as endometriosis, simple ovarian cysts, pelvic inflammatory disease, ovarian torsion, fibroids, and in physiologic conditions such as menstruation and pregnancy.¹³

Anticipate the need to convert to laparotomy. Every patient’s surgical consent should include a possible conversion to laparotomy. To avoid incomplete surgical treatment and significant delays in proper therapy, a gynecologic surgeon experienced in the management of ovarian cancer should be readily available, in the event an unexpected malignancy is encountered. Ideally, the staging surgery and definite treatment should be performed at the time of initial minilaparotomy. Comprehensive surgical staging and treatment include thorough exploration of the pelvis and abdomen, omentectomy, pelvic and paraaortic lymph node sampling, multiple peritoneal biopsies and washings, bilateral salpingo-oophorectomy, hysterectomy, and debulking, when indicated.

Prepare for surgery with position, incision, and retraction

Before beginning, it is crucial to correctly position the patient, make the appropriate incision, and insert the right retractor.¹

Position. After administering regional or general anesthesia, place the patient in a modified lithotomy, as for laparoscopic surgery. Tuck the arms alongside the torso and place the legs in boot stirrups. Avoid hip flexion and allow adequate thigh abduction to expose the vagina. Perform a careful pelvic examination to determine the size and mobility of the adnexal mass.

When properly placed, this retractor creates an atraumatic, circular area of self-retraction, enabling superior exposure

Place an indwelling transurethral catheter, and pass a sturdy, hinged uterine manipulator such as the Pelosi Uterine Manipulator (Apple Medical Corp, Marlboro, Mass) transcervically into the uterine cavity (FIGURE 1).

The cruciate incision. With a conventional scalpel make a small suprapubic transverse incision through the skin and subcutaneous tissue (FIGURE 2). After clearing subcutaneous fat from the midline, incise the rectus fascia and the peritoneum in a vertical direction.

A vertical skin incision can be selected if the preoperative workup suggests a later extension of the original minilaparotomy incision may be required, or if there is a prior vertical incision.

Retraction. Use a soft sleeve-type self-retaining plastic retractor, such as Mobius (Apple Medical Corp) (FIGURE 3 ). When properly placed, this retractor creates an atraumatic, circular area of self-retraction, enabling superior exposure of the pelvis (FIGURE 4).

During surgery it may be necessary to adjust the outer ring if the sleeve loosens. Narrow Deaver or Richardson retractors, if required, provide additional retraction. The bowel may be gently packed, if necessary, but typically it is adequately displaced by the large ovarian cyst.

The atraumatic retraction provided by the soft, self-retaining abdominal retractor minimizes the possibility of tissue trauma, nerve damage, bruising, and postoperative pain. At the same time, the continuous 360° retraction force on the incision maximizes surgical exposure, providing a significantly larger working area than conventional retractors. For example, when applied to a 6-cm incision, the self-retaining retractor creates a 28-cm² exposed working area, compared with only 18 cm² provided by a conventional 4-point metal retractor.

The adjustable height of the self-retaining retractor adapts to wounds of varying depth and works on virtually any tissue thickness—a feature that makes the device effective for obese patients. Further, by lining the abdominal incision, the retractor’s plastic sleeve protects the wound’s edges from contamination and potential implantation of malignant cells, making the device ideal for managing ovarian cysts.

FIGURE 1 Hinged uterine manipulator

The manipulator facilitates exposure of the cyst and contralateral adnexa, as well as uterine elevation/rotation.

FIGURE 2 Cruciate incision

Make a 2.5- to 5-cm suprapubic transverse skin incision. Using the Bovie device, incise the subcutaneous fat transversely along the full length of the skin incision down to the level of the anterior rectus fascia. Clear the subcutaneous fat from the midline superiorly and inferiorly to expose 5 to 6 cm of the rectus fascia in the vertical axis. Use blunt digital dissection to assist in mobilizing the subcutaneous fat. Incise the anterior rectus fascia vertically through the full length of the cleared area. Retract the rectus muscles from the midline to expose the underlying transversalis fascia and the peritoneum. Control small bleeding points with the Bovie device. Enter the peritoneum either digitally or with scissors above the bladder dome and extend the peritoneal incision to the full length of the fascial incision.

FIGURE 3 Self-retaining retractor

The retractor consists of a flexible plastic inner ring and a firmer outer ring connected by a soft plastic sleeve.

FIGURE 4360° retraction force

Squeeze the inner ring of the soft, sleeve-type, self-retaining retractor into the peritoneal cavity through the cruciate abdominal incision and allow it to spring open against the parietal peritoneum. Make a digital assessment to ensure that viscera is not trapped between the inner ring and the abdominal wall. Place the entire sleeve on traction by lifting the outer ring. Then roll the outer ring onto the sleeve, collecting excess length, until it sits firmly against the skin. The atraumatic retraction provided by the sleeve-type retractor maximizes exposure of the pelvis. Note how a portion of the large cyst is clearly seen through the atraumatic, circular area of retraction.

Cyst assessment

Visually and digitally inspect the cyst and carefully evaluate the uterus, pelvis, and contralateral adnexa. Determine the extent of adhesions and any unexpected pelvic pathology. When needed, use traditional small retractors or gentle packing to gain additional exposure. If the cystic mass appears suspicious (internal and external excrescences on the cyst, ovaries, or peritoneal surfaces, or ascites), obtain pelvic washings with a suction-irrigation cannula, send the fluid for cytologic examination, and convert the minilaparotomy to a standard exploratory laparotomy. Extensive adhesions to the bowel, broad ligament, or pelvic sidewall and unexpected extensive endometriosis may also require a conversion to standard laparotomy.

Reduce cyst size by decompression

Simple aspiration is inadvisable. To remove a large ovarian cyst using the Pelosi minilaparotomy, reduce the size of the cyst to permit safe and effective mobilization and resection through the small abdominal incision. Simple aspiration of the cyst, with its potential for spilling the contents, is not a wise strategy for several reasons. First, many ovarian cysts contain functional epithelium with a high recurrence rate (8% to 67%). Second, studies show that 10% to 66% of ovarian cyst fluid aspirates initially diagnosed as benign actually are malignant. Further, relying on negative cytology from the aspirate of an ovarian cyst without tissue biopsy may delay appropriate surgery, and the puncture of an unexpected malignant cyst may seed the peritoneal cavity and possibly worsen the patient’s prognosis.^11,12

This technique, suitable for all ovarian cysts, makes it possible to aspirate a large cyst without leakage.

Whether spillage of cancer cells actually worsens the prognosis of a patient with a neoplastic cyst remains controversial because of conflicting study results. Nonetheless, the possibility of intraperitoneal dissemination of neoplastic cells from a ruptured cyst cannot be considered innocuous, and the potential negative effect on a patient’s prognosis should not be ignored.¹⁴ Make every attempt, therefore, to avoid rupturing the cyst and spilling the fluid into the peritoneal cavity.

A shared flaw plagues aspiration devices. Different devices are available for intraoperative cyst aspiration during laparoscopic, transvaginal, or laparotomy approaches.^3,4,6 In addition to long needles, drainage trocars, suction cannulas, and suprapubic bladder catheters, special aspiration instruments have been developed.¹⁵ They include a metal vacuum system with an aspirator trocar that seals the surface of the cyst, and a catheter system that pinches the punctured cyst wall between double balloons to prevent spillage.¹⁶ In addition, several commercial bags are available to prevent intraperitoneal spillage during removal of ovarian cysts.

All these devices have a universal flaw, however: After a thin-walled cyst initially is punctured, none of these products can prevent the spontaneous dehiscence of the cyst and the resulting spillage of its contents into the abdominal cavity. Vacuum systems work well for large cysts with smooth, round surfaces, but in those with irregular surfaces, both application and maintaining the seal are difficult.¹⁷ Fortunately, our technique makes it possible to aspirate a large ovarian cyst without leakage, and the method is suitable for all ovarian cysts regardless of surface type or wall thickness.

Glue the dressing to the cyst to capture leakage. Using a gauze pad, carefully dry the area of the ovarian cyst that is visible through the self-retaining retractor. Then generously spread sterile surgical glue such as Dermabond (Ethicon, Somerville, NJ) on the cyst wall surface (FIGURE 5A). Dermabond is the commercial name for 2-octyl cyanoacrylate, a sterile skin adhesive used as an alternative to stitches to close the edges of small wounds. It is similar to commercial adhesives such as Super Glue and Krazy Glue.

Remove the paper cover of a transparent plastic surgical dressing and place the adhesive side directly onto the glued cyst surface until you are sure the adhesive is completely fixed (FIGURES 5B AND 5C). The 35 cm x 35 cm Steri-Drape or the transparent Tegaderm (both from 3M Health Care, St. Paul, Minn) dressing is effective. A standard nonadhesive plastic dressing or a sterile plastic bag also can be used, as long as the free edges extend beyond the outer rim of the self-retaining retractor.

With a needle aspirator, pierce the cyst through the glued plastic dressing and carefully aspirate the fluid (FIGURES 6A AND 6B). Any leakage is trapped inside the plastic dressing rather than the abdominal cavity. Continue the aspiration until the collapsed cyst and ovary can be gradually delivered through the abdominal incision (FIGURE 6C). Note that the selfretaining retractor also protects the abdominal incision from potential contamination and implantation of neoplastic cells.

Once the cyst and ovary are extracted, you can readily perform an extracorporeal cystectomy, after which the repaired ovary is returned to the abdominal cavity. Be careful to avoid letting any fluid flow back into the peritoneal cavity during cyst removal. When indicated, an extracorporeal adnexectomy can readily be performed.

The presence of oily material or hairs in the aspirated fluid and on the needle tip readily identifies a dermoid cyst.

Dermoid cysts require extra care. Preventing intraperitoneal spillage is especially important when removing a large dermoid cyst, to avoid the possibility of chemical peritonitis, dense adhesions, and fistulas. The presence of oily material or hairs in the aspirated fluid and on the needle tip readily identifies a dermoid cyst. Quite frequently, a large-diameter suction cannula is required to remove the waxy contents. If the dermoid cyst is very large, aspiration alone will not empty it entirely. Complete emptying is not necessary, however. The primary goal of aspiration is to reduce the size and tension of the cyst to permit delivery through the abdominal incision.

Closing the cruciate incision is quicker and requires less exposure than a scaled-down Pfannenstiel’s incision.

Before concluding the procedure, irrigate the peritoneal cavity to remove any remnants of cyst contents that may have spilled—especially important with a dermoid cyst. Perform any additional indicated procedures through the minilaparotomy incision, such as a contralateral ovarian cystectomy, salpingo-oophorectomy, or hysterectomy. After the surgery is completed, remove the self-retaining retractor by hooking a finger through the bottom ring and pulling it gently out of the incision. Closing the cruciate incision is quicker and requires less exposure to complete than a scaled-down Pfannenstiel’s incision. Apply a vertical pressure dressing over the incision to prevent postoperative wound hematoma or seroma formation. Remove the dressing 24 hours later.

FIGURE 5A ‘Leak-proofing’ the aspiration

After drying the surface of the cyst, apply sterile surgical glue to the cyst wall (2 to 3 ampules are usually required to cover the cyst surface).

FIGURE 5B ‘Leak-proofing’ the aspiration

Apply the adhesive side of a clear plastic wound dressing directly onto the cyst’s surface, making sure that the dressing is large enough to fully cover the self-retaining retractor. Using either a piece of folded gauze or your fingers, press the plastic dressing against the adhesive-coated cyst for about 3 to 5 minutes until the adhesive is completely fixed.

FIGURE 5C ‘Leak-proofing’ the aspiration

Remove the paper cover of the wound dressing.

FIGURE 6A Aspirating the cyst

Pierce the dressing and carefully aspirate the fluid until the cyst is partially collapsed.

FIGURE 6B Aspirating the cyst

Place atraumatic clamps on the cyst wall to further control drainage. Any leakage is trapped inside the plastic dressing rather than draining into the abdominal cavity.

FIGURE 6C Aspirating the cyst

Continue the aspiration until the collapsed cyst and ovary can be delivered gradually through the abdominal incision, after detaching the adhesive plastic dressing from the edges of the self-retaining retractor. The portion of the plastic sleeve that is glued to the cyst surface remains attached to the cyst until the cyst is extracted. Following extraction, perform an extracorporeal cystectomy and return the repaired ovary to the abdominal cavity.

Good results

Using our approach, we have treated 38 patients with ovarian cysts of diameters greater than 20 cm thought to be benign by preoperative workup (FIGURE 7). We encountered no malignancies. All surgeries were successfully completed without laparoscopy or conversion to traditional laparotomy and with good cosmesis (FIGURE 8).

Other procedures performed in some of these patients using the same technique included contralateral cystectomy, salpingo-oophorectomy, subtotal and total hysterectomy, adhesiolysis, and appendectomy. We encountered no intraoperative or postoperative complications. Operating times ranged from 18 to 65 minutes. All patients were discharged home within 36 hours and returned to work in a mean of 12 days. Pathology findings of the ovarian cysts included endometrioma, dermoid cyst, serous cystadenoma, and mucinous cystadenoma.

FIGURE 7 Effective for large cysts

Following removal, the collapsed cyst was refilled with 1,300 mL of normal saline to demonstrate its actual size.

FIGURE 8 Good cosmetic results

Cosmetic appearance of the small cruciate abdominal incision 10 days after surgery.Dr. Pelosi II reports that he is a consultant for Apple Medical Corporation. Dr. Pelosi III reports no affiliations or financial arrangements with any companies whose products are mentioned in this article.

Why did it take us 2 centuries to learn how to do it right? Posterior pelvic repair for the correction of rectocele combined with restoration of the perineal body has been on gynecologic OR schedules since time immemorial, so one would think we knew what we were doing. Yet only in the past 10 years has there been progressive general recognition of the true nature of the anatomic lesions responsible for rectocele formation, thereby finally pointing us in the right direction.

Although it was always assumed, correctly, that the major factor initiating rectoceles is tissue trauma sustained in vaginal birth, traditionally we were taught, and we believed, that the end result was attenuation and deterioration of the rectovaginal septum (RVS) connective tissue. Similar tissue changes also initiated at vaginal delivery were ascribed to the proximal and distal connective tissue attachments of the RVS, respectively; the cardinal-uterosacral ligament complex; and the perineal body—but tears were never entertained in our perceptions. We know, as emphasized by Nichols in the 1960s and 1970s,^1-3 that all of these elements, together with the bilateral RVS connection to levator fascia plus the levator plate of the pelvic floor, constitute the normal vaginal axis when all elements are intact.

To be concise, the disrupted vaginal axis, including its 2 major anatomic abnormalities, rectocele and perineal body defects, was thought to be the direct result of disintegration over time after the initiating shock of vaginal delivery. Specific tissue tears were, until now, an unrealized concept. As a result, we routinely resorted to makeshift methods in attempts to restore posterior pelvic configuration. Today, thanks to A. Cullen Richardson, we are much better informed.^4,5

Sutured reunion of RVS tears key to rectocele eradication

This article centers on today’s concepts of the defects isolated within the RVS, a critical part of the vaginal axis. No longer is there any question about the key role of sutured reunion of RVS tears in eradicating rectocele. We must acknowledge, however, that such anatomic restoration alone is insufficient without simultaneous fixed suspension of the posterior vaginal vault above and perineal body reconstitution below, as Nichols emphasized.³

The overall goal in corrective posterior pelvic surgery must always be restoration of the normal vaginal axis in order to preserve the pelvic valve mechanism, as described by Porges.⁶

The primary reason for connective tissue defects is tears, not attenuation. Richardson dramatically and conclusively demonstrated this fact in the early 1990s, after prolonged and intensive investigation of the anatomy.^4,5,7 This astonishing disclosure was nowhere more obvious than in the defective RVS, where discrete separations in otherwise intact tissue could be uncovered and reattached by simple standard stitching technique. We had simply never looked for these torn segments (which were never obvious), so we never found them. Once we were convinced of Richardson’s concepts, the torn edges became easily identifiable in practically every case of rectocele. Suddenly, we were able to restore the natural anatomic integrity of the RVS by reuniting these torn edges. With absolute confidence, we eliminated the rectocele.^8-16

The critical digital technique

The key to this logical operative technique was the rectal examining finger. Using this digital strategy, not only could we definitively outline the rectocele on outpatient examination, but we could delineate the exact extent of the rectocele intraoperatively. This is accomplished by performing the first rectal exam just before vaginal mucosal dissection, and then, most accurately, after full dissection and exposure of the entire operative field, thus clearly exposing the torn edges in the RVS. A final anorectal exam is performed to check the restored anatomic configuration of the RVS before vaginal mucosal reunification.⁸

Transverse tears

Transverse tears are the most common: either detachment from below, adjacent to the perineal body, or separation at the top in juxtaposition to the fibrous uterosacral extensions in the area of the cul-de-sac. FIGURES 1 AND 2 convey the “before and after” aspects, showing Allis clamps drawing the retracted edge to the site of the tear followed by the revelation of the actual repair accomplished by interrupted O-caliber sutures, either delayed absorbable or nonabsorbable. A rectally inserted index finger initially demonstrates that, except for scraps of areolar tissue, the anorectal wall is the only layer that prevents the examining finger from falling into the operative field as it produces rectocele simulation with forward pressure. When the clamps draw the long-torn RVS segments into normal anatomic positions, the anorectal finger cannot advance at all, despite strong effort, because of the natural firm barrier effect of the anatomically restored RVS.⁸

FIGURE 1 Lower transverse tear

FIGURE 2 Upper transverse tear

U-shaped tears

Another not uncommon type of defect can be U-shaped, either at the bottom, as depicted in FIGURE 3, or at the top of the posterior pelvic compartment. Similarly linear (longitudinal) tears near one side or the other directly adjacent to the pelvic sidewalls, rarely in the midline, are not unusual and can be repaired in the same manner.

FIGURE 3 U-shaped tear

Hockey-stick tears

Occasionally, a hockey-stick lesion, combining a longitudinal tear and a transverse tear in continuity, as shown in FIGURE 4, is discovered.

FIGURE 4 Hockey-stick tear

Double defect

A more uncommon type of combined or double defect, in which the Denonvilliers fascia (RVS) has been torn both adjacent to the vault and in the perineal area but retains strong attachments bilaterally, is shown in FIGURE 5.

FIGURE 5 Double defect

A contented vaginal environment

The major breakthrough is the concept that tears in the Denonvilliers fascia, not attenuation, are the cause of rectoceles. These tears—transverse, longitudinal, U-shaped, multidirectional, even stellate—can be identified almost always without difficulty with the aid of a rectal examining finger and edge-grasping clamps at surgery. The repair itself is not only anatomically logical but also much easier and more confidence-inspiring than the traditional, now archaic, method of fishing around for scraps of levator fascia and muscle to approximate, under tension, in the midline.

This defect-directed repair, born of common sense (ie, comprehension and application of normal anatomy), is structurally nonconstrictive and functionally nonrestrictive—truly a contented vaginal environment.

All sketches from TeLinde’s Operative Gynecology, 9th edition, with permission from Lippincott, Williams, and Wilkins, Publishers.

Dr. Grody reports no financial relationship with any companies whose products are mentioned in this article.

Why did it take us 2 centuries to learn how to do it right? Posterior pelvic repair for the correction of rectocele combined with restoration of the perineal body has been on gynecologic OR schedules since time immemorial, so one would think we knew what we were doing. Yet only in the past 10 years has there been progressive general recognition of the true nature of the anatomic lesions responsible for rectocele formation, thereby finally pointing us in the right direction.

Although it was always assumed, correctly, that the major factor initiating rectoceles is tissue trauma sustained in vaginal birth, traditionally we were taught, and we believed, that the end result was attenuation and deterioration of the rectovaginal septum (RVS) connective tissue. Similar tissue changes also initiated at vaginal delivery were ascribed to the proximal and distal connective tissue attachments of the RVS, respectively; the cardinal-uterosacral ligament complex; and the perineal body—but tears were never entertained in our perceptions. We know, as emphasized by Nichols in the 1960s and 1970s,^1-3 that all of these elements, together with the bilateral RVS connection to levator fascia plus the levator plate of the pelvic floor, constitute the normal vaginal axis when all elements are intact.

To be concise, the disrupted vaginal axis, including its 2 major anatomic abnormalities, rectocele and perineal body defects, was thought to be the direct result of disintegration over time after the initiating shock of vaginal delivery. Specific tissue tears were, until now, an unrealized concept. As a result, we routinely resorted to makeshift methods in attempts to restore posterior pelvic configuration. Today, thanks to A. Cullen Richardson, we are much better informed.^4,5

Sutured reunion of RVS tears key to rectocele eradication

This article centers on today’s concepts of the defects isolated within the RVS, a critical part of the vaginal axis. No longer is there any question about the key role of sutured reunion of RVS tears in eradicating rectocele. We must acknowledge, however, that such anatomic restoration alone is insufficient without simultaneous fixed suspension of the posterior vaginal vault above and perineal body reconstitution below, as Nichols emphasized.³

The overall goal in corrective posterior pelvic surgery must always be restoration of the normal vaginal axis in order to preserve the pelvic valve mechanism, as described by Porges.⁶

The primary reason for connective tissue defects is tears, not attenuation. Richardson dramatically and conclusively demonstrated this fact in the early 1990s, after prolonged and intensive investigation of the anatomy.^4,5,7 This astonishing disclosure was nowhere more obvious than in the defective RVS, where discrete separations in otherwise intact tissue could be uncovered and reattached by simple standard stitching technique. We had simply never looked for these torn segments (which were never obvious), so we never found them. Once we were convinced of Richardson’s concepts, the torn edges became easily identifiable in practically every case of rectocele. Suddenly, we were able to restore the natural anatomic integrity of the RVS by reuniting these torn edges. With absolute confidence, we eliminated the rectocele.^8-16

The critical digital technique

The key to this logical operative technique was the rectal examining finger. Using this digital strategy, not only could we definitively outline the rectocele on outpatient examination, but we could delineate the exact extent of the rectocele intraoperatively. This is accomplished by performing the first rectal exam just before vaginal mucosal dissection, and then, most accurately, after full dissection and exposure of the entire operative field, thus clearly exposing the torn edges in the RVS. A final anorectal exam is performed to check the restored anatomic configuration of the RVS before vaginal mucosal reunification.⁸

Transverse tears

Transverse tears are the most common: either detachment from below, adjacent to the perineal body, or separation at the top in juxtaposition to the fibrous uterosacral extensions in the area of the cul-de-sac. FIGURES 1 AND 2 convey the “before and after” aspects, showing Allis clamps drawing the retracted edge to the site of the tear followed by the revelation of the actual repair accomplished by interrupted O-caliber sutures, either delayed absorbable or nonabsorbable. A rectally inserted index finger initially demonstrates that, except for scraps of areolar tissue, the anorectal wall is the only layer that prevents the examining finger from falling into the operative field as it produces rectocele simulation with forward pressure. When the clamps draw the long-torn RVS segments into normal anatomic positions, the anorectal finger cannot advance at all, despite strong effort, because of the natural firm barrier effect of the anatomically restored RVS.⁸

FIGURE 1 Lower transverse tear

FIGURE 2 Upper transverse tear

U-shaped tears

Another not uncommon type of defect can be U-shaped, either at the bottom, as depicted in FIGURE 3, or at the top of the posterior pelvic compartment. Similarly linear (longitudinal) tears near one side or the other directly adjacent to the pelvic sidewalls, rarely in the midline, are not unusual and can be repaired in the same manner.

FIGURE 3 U-shaped tear

Hockey-stick tears

Occasionally, a hockey-stick lesion, combining a longitudinal tear and a transverse tear in continuity, as shown in FIGURE 4, is discovered.

FIGURE 4 Hockey-stick tear

Double defect

A more uncommon type of combined or double defect, in which the Denonvilliers fascia (RVS) has been torn both adjacent to the vault and in the perineal area but retains strong attachments bilaterally, is shown in FIGURE 5.

FIGURE 5 Double defect

A contented vaginal environment

The major breakthrough is the concept that tears in the Denonvilliers fascia, not attenuation, are the cause of rectoceles. These tears—transverse, longitudinal, U-shaped, multidirectional, even stellate—can be identified almost always without difficulty with the aid of a rectal examining finger and edge-grasping clamps at surgery. The repair itself is not only anatomically logical but also much easier and more confidence-inspiring than the traditional, now archaic, method of fishing around for scraps of levator fascia and muscle to approximate, under tension, in the midline.

This defect-directed repair, born of common sense (ie, comprehension and application of normal anatomy), is structurally nonconstrictive and functionally nonrestrictive—truly a contented vaginal environment.

All sketches from TeLinde’s Operative Gynecology, 9th edition, with permission from Lippincott, Williams, and Wilkins, Publishers.

Dr. Grody reports no financial relationship with any companies whose products are mentioned in this article.

Why did it take us 2 centuries to learn how to do it right? Posterior pelvic repair for the correction of rectocele combined with restoration of the perineal body has been on gynecologic OR schedules since time immemorial, so one would think we knew what we were doing. Yet only in the past 10 years has there been progressive general recognition of the true nature of the anatomic lesions responsible for rectocele formation, thereby finally pointing us in the right direction.

Although it was always assumed, correctly, that the major factor initiating rectoceles is tissue trauma sustained in vaginal birth, traditionally we were taught, and we believed, that the end result was attenuation and deterioration of the rectovaginal septum (RVS) connective tissue. Similar tissue changes also initiated at vaginal delivery were ascribed to the proximal and distal connective tissue attachments of the RVS, respectively; the cardinal-uterosacral ligament complex; and the perineal body—but tears were never entertained in our perceptions. We know, as emphasized by Nichols in the 1960s and 1970s,^1-3 that all of these elements, together with the bilateral RVS connection to levator fascia plus the levator plate of the pelvic floor, constitute the normal vaginal axis when all elements are intact.

To be concise, the disrupted vaginal axis, including its 2 major anatomic abnormalities, rectocele and perineal body defects, was thought to be the direct result of disintegration over time after the initiating shock of vaginal delivery. Specific tissue tears were, until now, an unrealized concept. As a result, we routinely resorted to makeshift methods in attempts to restore posterior pelvic configuration. Today, thanks to A. Cullen Richardson, we are much better informed.^4,5

Sutured reunion of RVS tears key to rectocele eradication

This article centers on today’s concepts of the defects isolated within the RVS, a critical part of the vaginal axis. No longer is there any question about the key role of sutured reunion of RVS tears in eradicating rectocele. We must acknowledge, however, that such anatomic restoration alone is insufficient without simultaneous fixed suspension of the posterior vaginal vault above and perineal body reconstitution below, as Nichols emphasized.³

The overall goal in corrective posterior pelvic surgery must always be restoration of the normal vaginal axis in order to preserve the pelvic valve mechanism, as described by Porges.⁶

The primary reason for connective tissue defects is tears, not attenuation. Richardson dramatically and conclusively demonstrated this fact in the early 1990s, after prolonged and intensive investigation of the anatomy.^4,5,7 This astonishing disclosure was nowhere more obvious than in the defective RVS, where discrete separations in otherwise intact tissue could be uncovered and reattached by simple standard stitching technique. We had simply never looked for these torn segments (which were never obvious), so we never found them. Once we were convinced of Richardson’s concepts, the torn edges became easily identifiable in practically every case of rectocele. Suddenly, we were able to restore the natural anatomic integrity of the RVS by reuniting these torn edges. With absolute confidence, we eliminated the rectocele.^8-16

The critical digital technique

The key to this logical operative technique was the rectal examining finger. Using this digital strategy, not only could we definitively outline the rectocele on outpatient examination, but we could delineate the exact extent of the rectocele intraoperatively. This is accomplished by performing the first rectal exam just before vaginal mucosal dissection, and then, most accurately, after full dissection and exposure of the entire operative field, thus clearly exposing the torn edges in the RVS. A final anorectal exam is performed to check the restored anatomic configuration of the RVS before vaginal mucosal reunification.⁸