Feasibility and outcome of vaginal paravaginal repair using the Capio suture-capturing device

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1 Int Urogynecol J (2012) 23: DOI /s ORIGINAL ARTICLE Feasibility and outcome of vaginal paravaginal repair using the Capio suture-capturing device Umberto Leone Roberti Maggiore & Simone Ferrero & Sara Mancuso & Sergio Costantini Received: 20 March 2011 / Accepted: 30 August 2011 / Published online: 20 September 2011 # The International Urogynecological Association 2011 Abstract Introduction and hypothesis This investigation describes the feasibility and outcome of vaginal paravaginal repair (VPVR) performed using the Capio suture-capturing device. Methods This prospective study included 36 women with paravaginal fascial defects, symptomatic stage II to IV anterior vaginal wall prolapse, and uterine prolapse equal or more than stage 2. VPVR was performed using the Capio device. In addition, anterior colporrhaphy, posterior colporrhaphy, and vaginal hysterectomy were performed. Results ThemeantimerequiredtoperformtheVPVRwas 12.9 min (range, min). The median blood loss during the VPVR was 35 ml (range, ml). There were no major intraoperative complications. At 2-year follow-up, the rate of recurrent anterior vaginal wall prolapse (stage 2) was 8.6%. Conclusions VPVR performed using the Capio device is associated with minimal dissection of the tissues, blood loss, and operating time and has low recurrence rate at 2- year follow-up. Keywords Anterior vaginal wall prolapse. Prospective study. Recurrence. Sutures. Treatment outcome. Vaginal paravaginal repair Electronic supplementary material The online version of this article (doi: /s ) contains supplementary material, which is available to authorized users. U. Leone Roberti Maggiore : S. Ferrero (*) : S. Mancuso : S. Costantini Department of Obstetrics and Gynecology, San Martino Hospital and University of Genoa, Largo Rosanna Benzi 1, Genoa 16132, Italy simone.ferrero@unige.it Introduction Anterior vaginal wall prolapse is still a challenging matter for urogynecologists. It is the most common form of pelvic organ prolapse [1] and it is a consequence of levator muscle impairment, increase in abdominal pressure, and apical and paravaginal support defects [2]. A complete understanding and identification of anatomical defects are of paramount importance for providing a permanent cure of anterior vaginal wall prolapse. In 1909, White described the support of the anterior vaginal wall and its attachments to the arcus tendinous fasciae pelvis (white line) and introduced a new surgical technique to treat anterior vaginal wall prolapse, then called paravaginal repair [3]. More recently, a new interpretation of the defects of the anterior vaginal wall has been introduced, focusing on the location of the defect in the pubocervical fascia (lateral, transverse, midline, or combinations) [4]. This observation suggested that a single reparative technique might be not be adequate for every single patient, since the location and the severity of the defect are different from case to case and should be individually investigated in order to choose the best surgical procedure. Paravaginal repair permits repair of the anterior vaginal wall lateral defect by restoring pubocervical continuity to the white line. It was originally described as a vaginal technique [3]; subsequently it was performed abdominally [4] and finally, also as a laparoscopic procedure [5]. Vaginal paravaginal repair (VPVR) has a success rate ranging from 67% to 100% but significant complications are reported (including hematomas, abscesses, severe blood losses, and bilateral ureteral obstruction) [6 12]. Human, animal, and synthetic grafts have been used in prospective and retrospective studies to increase the success rate of VPVR [13 15]. A prospective study described the use of

2 342 Int Urogynecol J (2012) 23: cadaveric dermal graft during VPVR in 33 patients. At a mean follow-up of 52 months, recurrence of anterior compartment stage II prolapse occurred in 58.3% of patients, of which only 28.6% were symptomatic [13]. In a retrospective cohort study, VPVR was performed using porcine or human cadaveric dermal implants. After a median follow-up of about 2 years, an objective failure occurred in 47% of the patients treated with the human cadaveric dermal implants and in 11% of those treated with porcine implants [14]. Another retrospective cohort study compared 59 native tissue historical controls to 108 bridging graft VPVR, of which 89 were tissue-inductive xenografts and 19 were polypropylene mesh. After a mean follow-up of 23 months in the first group and 55 months in the historical controls, the recurrence rate was 30.5% in the native tissue group and 18.5% in the bridging graft group [15]. A literature review [16] showed that the success rate of abdominal paravaginal repair (APVR) is between 76% and 97% [4, 17 20]. To date, there has been no published prospective randomized controlled trial comparing the outcomes of APVR and VPVR. A recent study retrospectively compared APVR and VPVR using native tissue; 52 patients were included in the first group and 59 in the second one. The mean follow-up time was 72 months. The study concluded that anatomic results of APVR were more durable than VPVR while symptom resolution was broadly equivalent. The authors stated that APVR was significantly invasive and unsuitable to be considered the gold standard surgical procedure for displacement cystourethrocele [21]. Few data on the success rate of laparoscopic paravaginal repair (LPVR) are available. In a retrospective study, 171 patients with anterior vaginal wall prolapse secondary to paravaginal defect and stress urinary incontinence were treated by LPVR and Burch urethropexy procedures. No follow-up was reported and the authors concluded that both laparoscopic Burch urethropexy and paravaginal repair are safe (2.3% had an injury to the lower urinary tract) and effective [22]. More recently, in a longitudinal study, 212 women with various stages of anterior vaginal wall prolapse were treated by LPVR. After a mean follow-up of 14.2 months, the recurrence rate (anterior vaginal wall prolapse stage 2) was 23.6% [23]. A retrospective cohort study compared the rates of recurrent cystocele following abdominal sacrocolpopexy with and without paravaginal repair (PVR) concluding that there was no significant difference in combining PVR with sacrocolpopexy although there was a trend for an improved clinical outcome [24]. The objective of this prospective study is to describe the feasibility and outcome of VPVR performed using the Capio suture-capturing device (Boston Scientific Corporation, Natick, MA, USA). The Capio is a 32-cm long device, designed to throw, catch, and retrieve suture, allowing suturing in deep and difficult-to-access cavities with smaller incision and less dissection of the tissues than traditional methods. In a recent anatomical study, the Capio was used to perform bilateral posterior sacrospinous ligament suspension on female cadavers. This study showed that the operations were reproducible with low anatomical risks [25]. Materials and methods Study population This single-center prospective study included patients who underwent surgery between January 2006 and December The inclusion criterion for the study was the presence of paravaginal fascial defects in patients with symptomatic stage II to IV anterior vaginal wall prolapse and uterine prolapse equal or more than stage 2. Patients with previous surgery for pelvic floor diseases were excluded from the study. During the study period, 36 patients fitting the inclusion criteria were invited to participate to the study and accepted. The investigation was approved by the local ethics committee and each patient gave informed consent. The main outcome of this study was to evaluate the feasibility of VPVR performed using the Capio suturecapturing device. Patients were followed-up postoperatively for 2 years. The rate of objective success and the scores of specific questionnaires were examined. The following information were collected for each patient: age, body mass index, medical history, menopause, and hormone replacement therapy. A detailed history of previous gynecological surgery was recorded, and reports of previous surgical procedures were examined. Preoperative investigations and assessment of symptoms All patients underwent physical examination, translabial pelvic floor ultrasonography, and multichannel urodynamic testing (cystometry, urethral profile, and uroflowmetry). The patients underwent stress cough testing and perineal testing assessed by using the Oxford scale modified by Laycock. Prolapse was classified according to the POP quantification (POPQ) system. Urinary incontinence was classified according to International Continence Society definitions [26] and graded according to the Ingelman Sundberg classification. The physical examination was performed with the patient in a dorsal lithotomy position. A single blade of a bivalved speculum was positioned on the posterior vaginal wall to better appreciate the anterior and lateral walls of the vagina. The following criteria were considered suggestive for the diagnosis of paravaginal defect: absence of the lateral sulci, presence of vaginal rugation, and reduction of

3 Int Urogynecol J (2012) 23: the anterior vaginal wall prolapse after applying a bivalved open speculum to both sides of the anterior vaginal wall while the patient is performing a Valsalva maneuver. However, the definitive diagnosis of paravaginal defect was always confirmed during surgery. Then, the prolapse was reduced with sponge-holding forceps, and the presence of urinary leakage (occult stress incontinence) was recorded with maximal straining. Patients with stress urinary incontinence or mixed urinary incontinence were treated by positioning a transobturator adjustable tape (TOA, Agency for Medical Innovations, A.M.I., Austria) after a first-line conservative management of 8 12 weeks. TOA is a type I nonabsorbable macroporous monofilament polypropylene tape. The tape contains two groups of threads, the first of which is 1.5 cm laterally to the mean point of the tape. At the end of the operation, the thread is exteriorized through the anterior vaginal wall thus allowing the loosening of the tape. The second group is situated in each branch of the tape and consists of three threads that are used to increase tension. Patients symptoms were recorded before surgery by using standardized questionnaires administered in Italian: the Short Urogenital Distress Inventory (UDI-6), the Incontinence Impact Questionnaire (IIQ-7), and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 (PISQ-12). The IIQ-7 and the UDI-6 are instruments used to assess life impact and symptom distress respectively of urinary incontinence and genital prolapse for patients. The short form versions may be more useful than the long form versions in many clinical and research applications. The PISQ-12 is a validated and self-administered instrument to evaluate sexual function in women with POP and/or urinary incontinence. Surgical technique The same surgical team performed all the procedures. VPVR was always associated to anterior colporrhaphy (midline plication), posterior colporrhaphy, and vaginal hysterectomy followed by McCall colpoplasty procedure. The VPVR technique using the Capio device was standardized. The aim of this part of VPVR was to restore the laterally damaged pubocervical fascia with a suspension to the white line and restore the vaginal sulci. A midline incision of the anterior wall of the vagina was performed followed by the dissection of the vaginal mucosa off the pubocervical fascia. An anterior colporrhaphy (midline plication) was carried out in all the patients. At this time, the surgeon completed a blunt finger dissection gaining access to the paravescical space. Finger palpation allowed identification of the arcus tendineus fasciae pelvis, from the ischial spine to the inferolateral pubic bone, and the obturator fascia. Once the access to the retropubic space allowed the passage of a finger, the dissection was not enlarged. The Capio suture-capturing device was inserted in the paravescical space above the white line, 1 to 1.5 cm anteromedial to the ischial spine. The contralateral hand index finger was used to protect the bladder and, then, to apply a light pressure on the tip of the Capio. Two to four sutures were placed, depending on the size of the defect (Fig. 1). The same procedure was repeated on the other side. After each suture was placed, the sutures were attached to the lateral edge of the pubocervical fascia and to the undersurface of the vaginal epithelium. Then, the sutures were tied beginning from the nearest to the ischial spine and ending with the periurethral/ apical one. Therefore, the lateral defect was restored and the operation was concluded with the anterior vaginal wall closure with a Vicryl (Ethicon Inc, Sommerville, NJ, USA) 2 0 suture. All incontinent women were treated with a TOA. Since the paravaginal spaces were already prepared, the next phase of the operation was to perform small bilateral incision of the skin in the genitofemoral folder at the level of clitoris. The helicoidal tunneler was introduced on one side, passed through the obturator foramen, and reached the finger tip in the paraurethral space. Then, the tape was connected to the guide and with a wrist rotation motion in the opposite direction of the tunneler introduction, the tape exited through the coetaneous incision. The same procedure was performed on the contralateral side and the tape was tensioned. The first group threads were crossed and exteriorized through the anterior vaginal wall while the second group threads were exteriorized through the skin incisions. Surgical information was prospectively collected, including operation time, method of anesthesia, estimated blood loss, and intraoperative complications. In particular, a theater nurse recorded the time required to perform the VPVR that was defined as the part of the intervention which begins with the anterior incision of vaginal wall, followed by preparation of paravescical spaces, positioning of the sutures on the white line by using the Capio device, tying of the sutures, and concluded with anterior colporrhaphy. The blood loss during the VPVR was estimated by changing the vacuum-filled container connected to the aspirator at the beginning of the VPVR. In addition, for the purpose of the study, surgical drapes that do not absorb blood were used; the drapes were changed before beginning the VPVR and all visible blood was aspirated in the vacuum-filled container at the end of the procedure. Length of hospital stay and postsurgical complications were recorded. On the second day after the surgery, the catheter was removed and the urinary situation evaluated to decide if it was necessary to regulate the TOA, by tightening the inguinal threads if urine leakage was demonstrated, or loosening the vaginal threads if the residual was >50 ml. Before discharge from the hospital, vaginal examination was performed to investigate the

4 344 Int Urogynecol J (2012) 23: Fig. 1 On the left, the arcus tendineus fasciae pelvis is shown (arrow). On the right, the suture is applied on the arcus tendineus fasciae pelvis by using the Capio device presence of complications of surgery (such as vaginal hematoma or access). Patients were followed-up at 3, 6, 12, and 24 months. The follow-up consultations included physical examination and ultrasonography. The patients answered the UDI-6, the IIQ-7, and the PISQ-12 at 1- and 2-year follow-up. Success was defined as the absence of a recurrent anterior vaginal wall prolapse of stage 2. Statistical analysis The signed rank test was used to compare the scores of the UDI-6, the IIQ-7, and the PISQ-12 before and after surgery. Statistical analysis was performed using the SigmaStat 3.5 software (SPSS, Chicago, USA). P<0.05 was considered as statistically significant. Results Thirty-six women were enrolled in the study. The median age of the patients was 67.5 years (range, years), the median body mass index was 24 kg/m 2 (range, kg/m 2 ), and the median parity was 2 (range, 0 6) with two nulliparous women. All patients were menopausal and only six women (16.7%) were treated for 5 years with hormone replacement therapy. Twenty patients (47.2%) had coexisting rectocele and 10 (27.8%) had enterocele. Table 1 shows the stages of anterior vaginal wall prolapse, uterine prolapse, rectocele, and enterocele estimated using the POPQ system. Twenty-one patients (58.3%) had urinary incontinence, of these, 14 had urodynamic stress incontinence, 5 had urinary incontinence associated with intrinsic sphincter deficiency, and 2 had mixed urinary incontinence. Three patients had occult stress incontinence. At the urodynamic assessment, these women showed urodynamic stress incontinence. Therefore, patients with urodynamic stress incontinence were 17 in total. All these 24 (66.7%) incontinent patients were treated by positioning the TOA. All patients underwent surgery under spinal anesthesia. The median length of the operation was 86 min (range, min) with a median estimated blood loss of 200 ml (range, ml). The mean time required to perform the VPVR by using the Capio suture-capturing device was 12.9 min (range, min). The median blood loss during the VPVR was 35 ml (range, ml). There were no major intraoperative complications and no patient required blood transfusion. Three patients had fever (maximum of 39 C) the day after surgery. In one patient, the cause of fever was undetermined; the other two patients had urinary tract infections (caused by Klebsiella pneumoniae in one woman and by Proteus mirabilis in the other woman). The three patients were successfully managed with antibiotic therapy. There was no hematoma or abscess. The catheter was always removed on the second day after surgery accordingly to our clinical protocol. One patient had urinary retention that was treated by loosening the tape, pulling the Table 1 Preoperative defects (POPQ system) Data are presented as number of cases and percentage of total population Stage of the defect Uterus Anterior vaginal wall prolapse Rectocele Enterocele I 0 (0.0%) 0 (0.0%) 5 (13.9%) 6 (16.6%) II 18 (50.0%) 16 (44.4%) 15 (41.7%) 3 (8.3%) III 13 (36.1%) 14 (38.9%) 0 (0.0%) 1 (2.8%) IV 5 (13.9%) 6 (16.6%) 0 (0.0%) 0 (0.0%) Total 36 (100%) 36 (100%) 20 (55.6%) 10 (27.8%)

5 Int Urogynecol J (2012) 23: vaginal threads. Four women had a positive stress test after surgery and the tape was tightened. The mean (±SD) length of the hospitalization was 3.3±0.5 days. The whole population completed the 2-year follow-up, at which point the rate of recurrent anterior vaginal wall prolapse (stage 2) was 8.6% (3/36) (Table 2). The three patients with recurrent anterior vaginal wall prolapse were asymptomatic at 2-year follow-up and no further surgery was performed. Before surgery, two of these patients had stage III anterior vaginal wall prolapse and one had stage IV anterior vaginal wall prolapse. Out of 24 patients treated for urinary incontinence by positioning TOA, 2 (8.3%) had a recurrence at 2-year follow-up. They both had stress urinary incontinence of first degree according to Ingelmann Sundberg that was confirmed by urodynamics. However, before surgery, these patients had third-degree stress urinary incontinence and, therefore, the recurrent symptoms were well accepted by the patients who did not require any further treatment. There were two cases of de novo stress incontinence after surgery, which were treated by positioning the TOA. At 1-year follow-up, none of these patients had recurrence. Two patients treated with the TOA complained urgency symptoms; they were referred to rehabilitation and their symptoms improved. Twenty-four patients (66.7%) were sexually active before surgery, seven of these patients (29.1%) suffered dyspareunia. After surgery, all 24 women continued to have regular sexual activity. Out of seven women suffering dyspareunia before surgery, one reported persistence of this symptom at follow-up. Two patients had de novo dyspareunia after surgery. Table 3 shows that the scores of the UDI-6, the IIQ-7, and the PISQ- 12 significantly decreased at 1-year follow-up and this improvement persisted at 2-year follow-up demonstrating a significant and persistent amelioration of patients symptoms. Discussion Anterior vaginal wall defects are caused by the progressive weakening of the structures supporting the urethra and the bladder. These defects are difficult to treat successfully and they still remain a challenge for urogynecologists. The description by Richardson et al. [4], in 1976, of the location of the pubocervical defect introduced a new interpretation of the management of anterior vaginal wall prolapse that every single defect should be treated by the most indicated surgical technique or by the association of different procedures. Traditional anterior colporrhaphy, which means midline plication of the pubocervical fascia, is indicated for central damages of the fascia. It is a widely used procedure to restore anterior vaginal wall defect with a success rate ranging from 37% to 100% [4]. It is over a century since White first described the paravaginal repair for the treatment of lateral defect anterior vaginal wall prolapse [3]. This technique can be performed abdominally, vaginally, or laparoscopically. Several studies showed that VPVR is an effective technique for the treatment of paravaginal defects [6 12] (Table 4); however, complications of surgery should be considered. Traditional VPVR is a difficult technique and surgeons performing this procedure should have an extensive experience in pelvic floor surgery and a precise knowledge of pelvic anatomy and spaces in order to avoid complications. Young et al. [11] showed that VPVR is associated with significant risk of blood loss in the retropubic space [10]. In a study including 100 patients, hemorrhage occurred in 3% of the patients and 16% of them received perioperative transfusions. In addition, 23 major and 14 minor postoperative complications were described. Another study including 45 patients who underwent VPVR described several complications of surgery including one bilateral ureteric obstruction, one retropubic hematoma requiring further surgery, and two vaginal abscesses [10]. Traditional VPVR is a relatively invasive technique because of the need to perform a wide dissection of the paravescical spaces that is required to visualize the arcus tendineus. Furthermore, Breisky Deaver or right angle retractors are applied to aid the identification of this structure. The current study shows the feasibility of VPVR Table 2 Stage of the anterior vaginal wall prolapse (POPQ system) before surgery and at follow-up Stage of anterior vaginal wall prolapse Before surgery (n=36) 3-month follow-up 6-month follow-up 1-year follow-up (n=36) 2-year follow-up (n=36) No prolapse 30 (83.3%) 25 (69.4%) 23 (63.9%) 20 (55.6%) I 0 (0.0%) 5 (13.9%) 10 (27.8%) 11 (30.5%) 13 (36.1%) II 16 (44.4%) 1 (2.8%) 1 (2.8%) 2 (5.6%) 3 (8.3%) III 14 (38.9%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0%) IV 6 (16.6%) 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%) Total 36 (100%) 36 (100%) 36 (100%) 36 (100%) 36 (100%) Data are presented as number of cases and percentage of total population

6 346 Int Urogynecol J (2012) 23: Table 3 Pre-surgery and post-surgery questionnaire results Before surgery 1-year follow-up 2-year follow-up UDI-6 (mean±sd, n) 49.4±13.2 (n=36) 14.1±8.4 (n=36) 14.8±7.7 (n=36) UDI-6 p value p<0.001 (compared with before surgery) p<0.001 (compared with before surgery) p=0.322 (compared with 1-year follow-up) IIQ-7 (mean±sd, n) 77.8±10.6 (n=36) 18.8±11.9 (n=36) 20.4±11.4 (n=36) IIQ-7 p value p<0.001 (compared with before surgery) p<0.001 (compared with before surgery) p=0.023 (compared with 1-year follow-up) PISQ-12 (mean±sd, n) a 79.2±11.0 (n=24) 35.1±9.2 (n=24) 31.6±5.8 (n=24) PISQ-12 p value p<0.001 (compared with before surgery) p<0.001 (compared with before surgery) p<0.001 (compared with 1-year follow-up) UDI-6 Short Urogenital Distress Inventory, IIQ-7 Incontinence Impact Questionnaire, PISQ-12 Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire-12 a PISQ-12 was performed only in sexually active women by using Capio device in patients with symptomatic lateral defect and anterior vaginal wall prolapse (stage 2). VPVR was chosen because this technique is the most suitable to repair coexisting pelvic floor defects and to treat stress urinary incontinence. Moreover, vaginal procedures offer advantages in terms of decreasing the time required to return to normal activities, the incidence of febrile episodes or unspecified infections after surgery, and the duration of hospital stay [27]. In our experience, the modified VPVR technique using the Capio device considerably simplifies the classical procedure. The preparation of the paravescical spaces is limited to permit a finger identification and location of the white line and it is not necessary to use retractors. The use of the Capio device makes the suturing part of the procedure much easier. In fact, the Capio is introduced in the prepared space, just above the white line and with the contralateral hand index finger moving the bladder away. Then, the same finger applies a light pressure on the tip of the Capio and the suture is positioned in a rapid and safe way, exactly in the desired position. In our study, the estimated blood loss and operating time of this part of the procedure were minimal. Mallipeddi et al. [10] reported a median blood loss of 400 ml (range, 100 1,000 ml). Elkins et al. [9] described that the blood loss during VPVR was between 500 and 1,000 ml with an operating time of min per side. In the current study, a lower blood loss was observed for the whole operation (median, 200 ml; range, ml). In particular, minimal blood loss occurred during the VPVR (median, 35 ml; range, ml). Furthermore, performing the VPVR using the Capio device required for both sides 12.9 min (range, min). No intraoperative complication occurred in the current study. The major limitation of this study consists in the fact that it was not a randomized study and there was no control group undergoing the traditional VPVR. However, it was difficult in a single center to recruit the number of patients required to perform a randomized controlled study. Given the current lack of published reports regarding the use of the Capio device in VPVR, we believe that the findings of the current study may stimulate future randomized controlled trials investigating the use of the Capio device in VPVR in larger series of patients. In the current study, an adjustable tape was always positioned in incontinent patients. Urinary incontinence is a common female disorder with an overall prevalence of Table 4 Success rate of VPVR in previously published studies Number of patients (n) Success rate (%) Follow-up (months) a Data are reported in years Shull et al. [7] a Grody et al. [8] Elkins et al. [9] Mallipeddi et al. [10] Young et al. [11] Viana et al. [12] Leone Roberti Maggiore et al

7 Int Urogynecol J (2012) 23: %, while stress urinary incontinence and mixed urinary incontinence have a prevalence of 23.7% and 14.5%, respectively [28]. These urinary disorders are commonly associated with other pelvic floor defects and are treated during the same operation. Suburethral slings are currently the main treatment for stress incontinence, since improvement in their design and engineering make them less invasive while maintaining efficacy [29, 30]. We believe that all pelvic floor surgery should move in the minimally invasive direction, conserving the same cure rates. The surgical technique described in this study facilitates the treatment of anterior compartment defects and incontinence in a safe and effective way, with minimal dissection of the tissues, blood loss, and operating time. At 2-year follow-up, the cure rate of VPVR using the Capio device combined with midline plication was 91.4% and all questionnaire scores were considerably improved. Conflicts of interest References None. 1. Hendrix SL, Clark A, Nygaard I, Aragaki A, Barnabei V, McTiernan A (2002) Pelvic organ prolapse in the Women s Health Initiative: gravity and gravidity. Am J Obstet Gynecol 186: Chen L, Ashton-Miller JA, DeLancey JO (2009) A 3D finite element model of anterior vaginal wall support to evaluate mechanisms underlying cystocele formation. J Biomech 42: White GR (1909) Cystocele. JAMA 853: Richardson AC, Lyon JB, Williams NL (1976) A new look at pelvic relaxation. Am J Obstet Gynecol 126: Richardson AC, Saye WB, Miklos JR (1997) Repairing paravaginal defects laparoscopically. Contemp Obstet Gynecol 42: White GR (1912) An anatomic operation for the cure of cistocele. Am J Obstet Dis Women Children 126: Shull BL, Benn SJ, Kuehl TJ (1994) Surgical management of prolapse of the anterior vaginal segment: an analysis of support defects, operative morbidity, and anatomic outcome. Am J Obstet Gynecol 171: Grody MHT, Nyirjesy P, Kelley LM, Millar L (1995) Paraurethral fascial sling urethropexy and vaginal paravaginal defects cystopexy in the correction of urethrovesical prolapse. Int Urogynecol J Pelvic Floor Dysfunct 6: Elkins TE, Chesson RR, Videla F, Menefee S, Yordan R, Barksdale PA (2000) Transvaginal paravaginal repair: a useful adjunctive procedure in pelvic relaxation surgery. J Pelvic Surg 6: Mallipeddi PK, Steele AC, Kohli N, Karram MM (2001) Anatomic and functional outcome of vaginal paravaginal repair in the correction of anterior vaginal wall prolapse. Int Urogynecol J Pelvic Floor Dysfunct 12: Young SB, Daman JJ, Bony LG (2001) Vaginal paravaginal repair: one-year outcomes. Am J Obstet Gynecol 185: Viana R, Colaço J, Vieira A, Gonçalves V, Retto H (2006) Cystocele vaginal approach to repairing paravaginal fascial defects. Int Urogynecol J Pelvic Floor Dysfunct 17: Ward RM, Sung VW, Clemons JL, Myers DL (2007) Vaginal paravaginal repair with an AlloDerm graft: long-term outcomes. Am J Obstet Gynecol 197:670.e Novi JM, Mulvihil BH, Arya L (2009) Vaginal paravaginal repair using porcine or human cadaveric dermal implant: a survival analysis. Int Surg 94: Reid RI, Luo K (2011) Site-specific prolapse surgery. II. Vaginal paravaginal repair augmented with either synthetic mesh or remodelling xenograft. Int Urogynecol J Pelvic Floor Dysfunct 22: Maher C, Baessler K (2006) Surgical management of anterior vaginal wall prolapse: an evidencebased literature review. Int Urogynecol J Pelvic Floor Dysfunct 17: Richardson AC, Edmonds PB, Williams NL (1981) Treatment of stress urinary incontinence due to paravaginal fascial defect. Obstet Gynecol 57: Bruce RG, El-Galley RE, Galloway NT (1999) Paravaginal defect repair in the treatment of female stress urinary incontinence and cystocele. Urology 54: Scotti RJ, Garely AD, Greston WM, Flora RF, Olson TR (1998) Paravaginal repair of lateral vaginal wall defects by fixation to the ischial periosteum and obturator membrane. Am J Obstet Gynecol 179: Shull BL, Baden WF (1989) A six-year experience with paravaginal defect repair for stress urinary incontinence. Am J Obstet Gynecol 160: Reid RI, You H, Luo K (2011) Site-specific prolapse surgery. I. Reliability and durability of native tissue paravaginal repair. Int Urogynecol J Pelvic Floor Dysfunct 22: Miklos JR, Kohli N (2000) Laparoscopic paravaginal repair plus burch colposuspension: review and descriptive technique. Urology 56: Behnia-Willison F, Seman EI, Cook JR, O Shea RT, Keirse MJ (2007) Laparoscopic paravaginal repair of anterior compartment prolapse. J Minim Invasive Gynecol 14: Shippey SH, Quiroz LH, Sanses TV, Knoepp LR, Cundiff GW, Handa VL (2010) Anatomic outcomes of abdominal sacrocolpopexy with or without paravaginal repair. Int Urogynecol J Pelvic Floor Dysfunct 21: Ouzaid I, Ben Rhouma S, de Tayrac R, Costa P, Prudhomme M, Delmas V (2010) Mini-invasive posterior sacrospinous ligament fixation using the CAPIO needle driver: an anatomical study. Prog Urol 20: Haylen BT, de Ridder D, Freeman RM et al (2010) An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Int Urogynecol J Pelvic Floor Dysfunct 21: Nieboer TE, Johnson N, Lethaby A et al (2009) Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 3:CD Minassian VA, Stewart WF, Wood GC (2008) Urinary incontinence in women: variation in prevalence estimates and risk factors. Obstet Gynecol 111: Ogah J, Cody JD, Rogerson L (2009) Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women. Cochrane Database Syst Rev 4:CD Rehman H, Bezerra CC, Bruschini H, Cody JD (2011) Traditional suburethral sling operations for urinary incontinence in women. Cochrane Database Syst Rev 1:CD001754