Site Specific Prolapse Surgery. I: Reliability and Durability of Native Tissue Paravaginal Repair

Background: The anterior vaginal wall is a fascial diaphragm, tautly strung between the pericervical ring and the urogenital diaphragm, and attached laterally to the two fascial white lines. The pubocervical fascia functions like a trampoline, giving all direction support to the proximal urethra and bladder base. It was traditionally believed that the central fascia of this suspensory hammock attenuates after childbirth, thus forming the bulge of a cystourethrocoele. In reality, healthy fascia is like canvas. It does not stretch, but will tear at pre-determined points. As a matter of engineering principle, these pre-determined points of weakness lie where the lines of force concentrate: namely along the peripheral margins, not within the central hammock. Rotatory cystocele formation has three elements: an apical defect, a lateral defect on at least one side and a fulcrum about which rotation can occur. Correcting this pattern of connective tissue damage in accordance with biomechanical principles mandates 'site-specific' repair of the causative fascial avulsions, either with permanent suture or by placement of a mesh bolster. Objective: To compare native tissue abdominal (APVR) and vaginal paravaginal repair (VPVR), and to investigate whether surgical outcome was independent of operative route.