Site-specific fascial defects in the diagnosis and surgical management of enterocele

John R. Miklos, MD,a Neeraj Kohli, MD,b Vincent Lucente, MD,c and William B. Safe, MDd Atlanta and Marietta, GeO1gia,Cincinnati, Ohio, and Allentown,Pennsylvania

OBJECTIVE: The aim of this study was to assess the surgical feasibility and clinical outcomes of a vaginal enterocele repair that was based on the theory of site-specific defects in the vaginal fascia. STUDY DESIGN: Seventeen patients during a 2-year period with a diagnosis of enterocele and vaginal vault descensus with or without coexisting rectocele underwent surgical correction with a site-specific fascial de- fect repair. An enterocele was defined as vaginal wall prolapse seen during the operation in which the peri- toneum was found to be in direct contact with the vaginal epithelium, with no intervening fascia. Patients were examined at 4 weeks after the operation and then at 6-month intervals, with site-specific analysis of pelvic prolapse at the vaginal apex and posterior vaginal segment. RESULTS: Identification and site-specific fascial defect repair of the enterocele were successfully performed in all 17 cases. All patients also underwent a uterosacral ligament vaginal vault suspension, and 15 patients (88%) underwent concurrent posterior colporrhaphy. There were no intraoperative complications. At a mean follow-up of 6.3 months (range 1-17 months), 2 patients (12%) had mild, asymptomatic vaginal vault descen- sus but no patients (0/17) had evidence of a recurrent enterocele or rectocele. CONCLUSION: Enterocele correction through a fascial defect repair is easily performed through the vaginal route and is associated with excellent surgical outcomes on short-term follow-up. (Am J Obstet Gynecol 1998;179:1418-23.)

Key words: Culdoplasty, enterocele, posterior vaginal hernia

Until more information is available about the cause of the problem (enterocele)and the specific defective anatomy involved, the planning ofa rational surgical procedure to correct the situation will continue to be elusive. RobertZacharinl

Uterovaginal prolapse has posed a diagnostic and ther- treatment of enterocele have been described previously. apeutic challenge to physicians for centuries. As our Vaginal techniques include the vaginal enterocele knowledge of the anatomy and pathophysiology of pelvic repair2 and McCall culdoplasty,3whereas the abdominal prolapse has continued to evolve, a variety of new surgi- approaches include the Moschcowitz culdoplasty,4 the cal techniques and procedures have been described, with Halban procedure, and uterosacral ligament plication.5 expectations that they would improve surgical outcomes. Most advocates of these surgical procedures have de- Although the diagnosis and surgical correction of ante- scribed the surgical repair of the enterocele without rior vaginal segment prolapse have significantly changed specifically defining its anatomy or pathophysiology. during the last 20 years with greater understanding of Previous definitions of the enterocele emphasized clini- midline, transverse,and paravaginal defects in the pubo- cal features, including etiology, location, associated cervical fascia, the diagnosis and management of the en- symptoms, and physical examination findings, with no terocele have continued to challenge the gynecologic mention of the specific anatomic defect. surgeon. Contrary to the traditional belief that uterovaginal A variety of culdoplasty procedures for the surgical prolapse results from a generalized stretching or attenu- ation of the pelvic fascial supports, current observations From the Department ofObstetrics and Gynecology,Northside Hospital,a implicate site-specific defects in the origin of pelvic Good Samaritan Hospital,b Lehigh Valley Medical Center;C and organ prolapse. Richardson et al6 described the patho- Advanced Laparoscopy Training Cente7:d physiology and anatomic basis for cystocelesand recto- Presented at the Twentyjourth Scientific Meeting of the Society of Gynecologic Surgeons, Lake Buena Vista, Florida, March 2-4, 1998. celes as caused by specific defects or detachments of the Reprint requests: John R Miklos, MD, Urogynecology and pubocervical fascia or rectovaginal septum, respectively. Reconstructive Pelvic Surgery, 308 MaxweU Dr, Suite 100, Alpharetta, Recently, Richardson7 postulated that an apical entero- GA 30004. Copyright @ 1998 by Mosby, Inc. cele results from a defect in the integrity of the en- 0002-9378/98 $5.00 + 0 6/6/94154 dopelvic fascia at the vaginal apex. The vagina, a fibro-

141R Volume 179, Number 6, Pan Miklos et al 1419 Am J Obstet Gynecol muscular tube lined with a superficial epithelial layer, is supported anteriorly by the pubocervical fascia and pos- teriorly by the rectovaginal fascia. In the patient with an intact uterus, the hiatus between the proximal edges these fascial layers is bridged by the cervix and the uter- ine fundus. In rare casesdetachment of the rectovaginal fascia from the posterior surface of the uterus occurs, re- sulting in a posterior enterocele with an intact uterus. More commonly, in the case of a patient who has under- gone previous hysterectomy, failure to reapproximate the pubocervical fascia to the rectovaginal fascia duringvaginal cuff closure or subsequent detachment of these 2 fascial layers results in a fascial defect, generally at the posterior vaginal apex (Fig 1). This break in the integrity of the fibromuscular tube results in an area where the peritoneum comes into direct contact with the vaginal Fig 1. Apical enterocele. Note the separation of the pubocervical fascia of the anterior vaginal wall from the rectovaginal fascia of epithelium, eventually stretching and resulting in an en- the posterior vaginal wall. terocele noted on clinical examination. On the basis of this concept of site-specific defects in the endopelvic fascia as the causeof enteroceles,a series of patients underwent intraoperative diagnosis and surgi- the rectovaginal septum from its normal points of attach- cal correction of the enterocele by means of site-specific ment. fascial repair. Our experience with the surgical feasibility A laparoscopic approach was used to locate and tag and clinical outcomes of the site-specific vaginal entero- with sutures the uterosacral ligaments and a vaginal ap- cele repair is reviewed. proach wasused to repair the enterocele and rectocele in a site-specific manner. Open laparoscopy wasperformed Material and methods in all cases,and accessoryports were placed under direct Seventeenpatients with symptomatic enteroceles, with visualization. The pelvic cavity was examined with a or without concurrent rectoceles, underwent surgical sponge stick or end-to-end anastomosissizer used to ele- correction between February 1996 and January 1998 by vate the vaginal cuff. Each uterosacral ligament was site-specific fascial defect repair to reestablish normal found by placing the vaginal apex under tension to the anatomy. Patientswere initially evaluated in a urogyneco- contralateral side. The ureters were located bilaterally. logic office practice, where they underwent a detailed Next, a permanent 2-0 suture was used to tag the history and physical examination. Vaginal examination uterosacral ligaments at the level of the ischial spine. The with site-specific analysisfor pelvic support defectsinvolv- needle was cut, the suture was tied with an extracorpo- ing the anterior vaginal segment, the cervix or vaginal real knot-tying technique, and the free end of the suture cuff, and the posterior vaginal segment was performed wasdropped into the abdominal cavity for removal dur- before the operation. Pelvic support defectswere graded ing the vaginal repairs. with the patient straining in the supine position accord- Vaginal repair of the enterocele wasperformed next. A ing to the "halfway system" proposed by Baden and transverseincision wasmade through the vaginal epithe- Walker.8 Patients were placed under general anesthesia lium at the posterior hymenal ring. The vaginal epithe- and underwent surgical correction with site-specific fas- lium wasincised in the midline and then dissected off the cial defect repair asdescribed. Patientswere reexamined underlying rectovaginal fascia laterally and proximally at the 4-weekpostoperative visit and then longitudinally with Metzenbaum scissors.As the dissection was carried at 6-month intervals. At each follow-up visit a symptom toward the vaginal apex, a distinct loss of the rectovaginal diary wasreviewed and vaginal examination, with grading fascia with a sudden protrusion of peritoneum {entero- of the prolapse wasperformed. cele sac) wasnoted. The enterocele sac wasentered and Surgical technique. All patients underwent surgical excessperitoneum was excised. Careful examination of correction while they were under general anesthesia. the enterocele sac revealed it to be demarcated posteri- Intraoperative vaginal examination was performed with orly by the edge of the rectovaginal septum and anteri- the patient under anesthesia. The apex and posteriorvaginalorly by the pubocervical fascia. Dissection of the anterior segment were carefully examined for loss of lat- vaginal mucosa from its underlying pubocervical fascia eral sulci, lack of epithelial rugation, and elongation of was performed, beginning at the vaginal apex and ex- the vaginal apex. A rectovaginal examination was also tending to anterior vaginal segment. The edge of the performed to assessfor a rectocele and find defects in pubocervical fascia was located throughout its length at 1420 Miklos et al December 1998 Am] Db.tet Gynecol

Table I. Previous pelvic operations in all patients (N = Table II. Primary reported symptoms of patients with 17) prolapsed vaginal vault with enterocele (N = 17)

Procedure % Reported symptom

Abdominal hysterectomy 53 Pressure 17 Paravaginal repairVaginal 53 Protrusion 16 hysterectomy (includes LAVH) 47 Difficulty defecating 9 Anterior-posterior repair 29 Impaired coitus 8 Retropubic urethropexy 29 Urinary incontinence 3 Endoscopic needle suspension 29 Voiding difficulty 3 Posterior repair 21 Culdoplasty 12 Suburethral sling 6 grade 4 enteroceles. All patients were noted to have LAVH, Laparoscopically assistedvaginal hysterectomy. grade 1 vaginal vault decensus. Fifteen patients (88%) had a coexisting rectocele. None of the patients were found on office examination to have clinically evident the vaginal apex. The uterosacral ligaments were reat- prolapse of the anterior vaginal segment or urethral hy- tached to the vaginal apex to provide vaginal vault sup- permobility. The presenting primary complaint ~aried port by passing the previously placed uterosacral liga- within the study group (Table II). ment sutures through the apical fascia on each side, with All patients underwent a vaginal enterocele repair with an end of the suture incorporating the anterior pubocer- laparoscopically assisteduterosacral vaginal vault suspen- vical fascia and the oth~r end incorporating the posterior sion. Fifteen patients underwent concurrent posterior rectovaginal fascia. Next the enterocele wasrepaired with colpoperineorraphy. The enterocele with associatedde- closure of the fascial defect by reapproximating the pub- fect in the endopelvic fascia waslocated during the oper- ocervical fascia anteriorly to the rectovaginal fascia poste- ation in all 17 patients. Site-specific fascial defect repair riorly with a series of 4 to 6 interrupted 2-0 permanent su- of the enterocele wassuccessfully performed in each case tures. Mter closure of the enterocele defect, the without intraoperative complications. The average esti- uterosacral suspensionsutures were tied down, resulting mated blood loss was 104 mL (range 20-300mL). in suspension of the newly created vaginal apex. A lap- Two postoperative complications were noted in the aroscopic approach was used to place an additional study group. One woman with a history of cardiac ar- uterosacral ligament suspension suture on both sides. rhythmia had postoperative atrial fibrillation. The patient was given intravenous indigo carmine, and Postoperative ileus and pneumonia necessitating read- transurethral cystoscopywas performed to document bi- mission 14 days after the operation developed in the lateral ureteral patency. other patient. The average length of hospitalization was Posterior colpoperineorraphywas then performed in a 1.3 days (range 1-3 days), with 12 patients being dis- site-specific manner, as previously described,7 with a se- charged after a 1-daypostoperative stay. ries of 2-0 permanent sutures. Finally, excessvaginal ep- The mean follow-up period was 6.3 months (range 1- ithelium wasexcised and the epithelial edges were reap- 17 months). No patients had evidence of persistent or re- proximated in the midline with a continuous 3-0 current pelvic prolapse at the 4-weekpostoperative visit. absorbable suture. The vagina was packed with a sterile On longitudinal follow-up at 6-month intervals, 2 pa- gauze dressing and an indwelling Foley catheter was in- tients were noted to have mild, asymptomatic vaginal serted for postoperative bladder drainage. vault decensus without signs of associatedenterocele or rectocele. Neither of these defects wasas large as before Results the operation. The first patient wasa 77-year-old,para 4, During the 2-year study period 17 women underwent postmenopausalwhite woman with a previous history of site-specific fascial defect repair and uterosacral ligament abdominal hysterectomy and retropubic urethropexy vaginal vault suspension through a combined laparo- who underwent vaginal repair of her grade 2 enterocele. scopic and vaginal approach. The average age of the She wasnoted to have persistentgrade 1 vaginal vault de- study group was 64.2 years (range 41-80 years), with a censusat 6 weeksand at 12 months after the operation. The mean parity of 3.2 (range 1-6). Fifteen of the 17 patients second patient wasa 69-year-old,para 3, postmenopausal (88%) were postmenopausal. All patients had under- woman with a history of previousabdominal hysterectomy gone a previous hysterectomyand additional pelvic oper- and Burch colposuspension. Mter vaginal repair of her ations (Table 1). Before the operation, 2 patients had a grade 2 enterocele,she wasnoted to have good support of grade 1 enterocele, 14 patients had a grade 2 enterocele, the vaginal apex and posterior vaginal segment at her 6- and 1 patient had a grade 3 enterocele. No patients had week postoperativevisit but grade 1 prolapse of the vaginal~

No. Volume 179, Number 6, Part 1 Miklos et al 1421 Am] Obstet Gynecol

vault subsequently developed 5 months after the opera- ments and the posterior peritoneum, which are brought tion. Neither patient has required subsequenttherapy. together in the midline. Despite the variety of proce- dures described for the surgical correction of enterocele, Comment few descriptions have approached the enterocele as a The effective surgical correction of pelvic prolapse has hernia with associatedanatomic repair. continued to challenge the gynecologic surgeon for cen- A critical understanding of the anatomy of pelvic sup- turies. Although our understanding and surgical treat- ports forms the basis for effective anatomic restoration ment of pelvic relaxation have evolved significantly dur- and surgical correction. The vagina is essentially a flat- ing the last severalyears, the optimal surgical cure of the tened fibromuscular tube that is lined by vaginal epithe- enterocele remains controversial. This may be due to sev- lium and enveloped by endopelvic fascia. The anatomy eral factors. First, the diagnosis of an enterocele is some- of pelvic support has been previously described by times challenging, and enterocele is often overlooked on DeLancey.11 According to his description, there are 3 clinical examination. Second,a precise understanding of principal levels of vaginal support. Suspension of the the anatomic defect that is responsible for the enterocele upper quarter of the vagina (levell) is provided by the has been poorly reported in previous articles in the liter- cardinal-uterosacral ligament complex. Lateral attach- ature. Third, pelvic prolapse seemsto be a multifactorial ment of the middle half of the vagina (level 2) is process involving multiple anatomic sites in the vagina, achieved by the paracolpium, extending to the lateral making a comparative assessmentof surgical outcomes pelvic sidewalls. Finally, the lower quarter of the vagina difficult. Despite these limitations, increased understand- (level 3) is maintained by fusion of the lower vagina to ing of the anatomy and pathophysiology of the entero- the urogenital diaphragm and perineal body. In addition cele should result in modifications of our surgical ap- to these various levels of pelvic support, the vagina has proach, which it is hoped will result in improved surgical structural integrity provided by the pubocervical fascia outcomes. anteriorly and the rectovaginal septum posteriorly. Historically, both transvaginal and transabdominal cul- Although the fascial layers have been described anatomi- doplasty techniques have been used to prevent and re- cally as well as surgically,histologic analysisby Weber and pair enteroceles. In 1912 Moschcowitz4reported his ex- Walter12has revealed that they in fact are a component perience in treating rectal prolapse with 6 to 8 of the smooth muscular wall of the vagina. In light of permanent sutures placed in a concentric pattern begin- these findings, the gynecologic surgeon must acknowl- ning at the base of the cul-de-sacand continuing until edge that the pubocervical and rectovaginal fascia are the entire pouch of Douglas was obliterated. Although surgical entities that may be used as descriptive terms, Moschcowitz4did not originally describe his technique as rather than histologic entities that reflect their true com- a surgical cure for enterocele, this procedure has formed position. the cornerstone of abdominal repair of enterocele for Within the framework of this basic understanding of many years. Nichols and Randal19described a similar the anatomy of pelvic supports, Richardson7 postulated method of obliterating the cul-de-sac of Douglas as sug- that all types of vaginal prolapse, whether anterior or pos- gested by Halban,lO who had proposed that a series of terior, are actually hernias that represent a break in the stitches be placed in a sagittal direction. Uterosacralliga- continuity of the fibrous tissue tube or a loss of its sus- ment plication has also been described in the surgical pension, attachment, or fusion to adjacent structures. He treatment of the enterocele, with the goal of obliterating had previously described lateral, transverse,and midline the cul-de-sac.5Despite these abdominal procedures, en- defects in the pubocervical fascia as the causeof anterior terocele repair has classically been performed through vaginal segment prolapse and advocated a site-specific the vaginal approach. Ward's description2 in 1922 eluci- fascial defect repair in the surgical treatment of cysto- dated the cardinal principles of a midline dissection of cele. Recently,he eloquently described the anatomic de- the posterior vaginal wall with location of the enterocele fects in the etiology of rectocele and enterocele. separate from any rectocele present, excision with high Structurally, a vaginal enterocele results from direct con- ligation of the enterocele, and reapproximation of the tact of the peritoneum with the vaginal epithelium with uterosacral ligaments as close to the rectum as possible. no intervening fascia. Vaginal enteroceles can be classi- Many surgeons have endorsed this basic technique, fied in 3 groups according to the location of the break in achieving favorable intermediate but poor long-term re- the fibrous tissue tube of the vagina: anterior, apical, and sults. Other surgeons have advocated culdoplasty for en- posterior. The apical enterocele, limited to the patient terocele correction and prevention. McCall's classic pos- who has undergone hysterectomy,is the most common terior culdoplasty,3 described in 1957, obliterates the of these defects. This defect results when there is failure redundant cul-de-sac of Douglas by means of a series of of fusion or reattachment of the anterior pubocervical continuous sutures incorporating the uterosacral liga- fascia to the posterior rectovaginal fascia at the vaginal 1422 Miklos et al December 1998 Am] Obstet Gynecol apex. The resulting fascial defect allows direct contact of placement. A more logical approach seems to be direct the peritoneum with the underlying vaginal epithelium, location of the site-specific defect and subsequentrepair. eventually stretching and clinically resulting in an enter- It is to be hoped that this surgical approach will provide ocele. On the basis of this hypothesis, Richardson recom- improved outcomes on a long-term basis.In developing a mended that surgical correction of the enterocele defect surgical plan for the management of pelvic prolapse, the must involve reconstruction of the vaginal fibrous tissue astute clinician must realize that our understanding of tube, reestablishment of the suspension and lateral at- the anatomy and pathophysiology of such complex dis- tachment of the reconstructed vaginal tube, and excision easeprocesses is continually evolving and should adapt of the redundant peritoneum and vaginal epithelium. his or her surgical technique to incorporate these new Our current surgical approach to enterocele repair is developments in the hopes of achieving better out- based on the anatomic considerations and surgical rec- comes. ommendations made previously by Richardson regard- ing the site-specific fascial defect repair of pelvic pro- REFERENCES lapse. Patients with posterior vaginal wall prolapse 1. ZacharinRF. Pulsionenterocele: reviewof functional anatomy underwent site-specific fascial defect repair of the recto- of the pelvicfloor. ObstetGynecoI1980;55:135-40. cele and enterocele, as well as resuspension of the apical 2. Ward GG. Techniqueof repair of enterocele (posteriorvaginal hernia) and rectocele.JAMA1922;79:709-13. supports. Our preliminary experience with this approach 3. McCallMH. Posteriorculdeplasty. Obstet GynecoI1957;10:595- demonstrated that the enterocele fascial defect could be 602. accurately located and corrected through the vaginal ap- 4. MoschcowitzAV. The pathogenesis,anatomy and cure of pro- lapseof the rectum. Surg GynecolObstet 1912;15:7-12. proach in 100% of the patients studied. Unfortunately, 5. ReadCD. Enterocele.AmJ ObstetGynecoI1951;62:74~57. this observational seriesis limited by the small number of 6. RichardsonAC, LyonsJB, WilliamsNL. A new look at pelvic re- patients enrolled in this study. This small number was laxation. AmJ ObstetGynecoI1976;126:568-73. 7. RichardsonAC. The anatomic defectsin rectoceleand entero- due to the strict inclusion criteria, which excluded pa- cele.J PelvicSurg 1995;1:214-21. tients with significant prolapse of the anterior vaginal 8. Baden WB, Walker T. Surgical repair of vaginal defects. segment or vaginal vault in an effort to provide a uniform Philadelphia:JBLippincott; 1992.p. 18~94. 9. Nichols DH, Randall CL. Vaginal surgery. 3rd ed. Baltimore: outcomes analysis. Women with pelvic support defects Williams & Wilkins; 1989.p. 31~27. rarely have a single site of involvement, and longitudinal 10. Halban J. GynakologischeOperationslehr. Berlin: Urban und assessmentof surgical outcomes is difficult for patients Schwarzenberg;1932. 11. DeLanceyJO. Anatomic aspect of vaginal eversion after hys- undergoing complex, multisite reconstructive opera- terectomy.AmJ ObstetGyencoI1992;166:1717-28. tions. In addition, the short time frame of follow-up 12. WeberAM, WalterMD. Anterior vaginalprolapse: review of the (mean 6.3 months) limits the strength of our outcome anatomy and technique of surgical repair. Obstet Gynecol 1997;89:311-8. data. Initial results are encouraging and may predict 13. Shull BL, Capen CV, Riggs MW, Kuehl TJ. Preoperative and long-term outcomes. Shull et al13reported that absence postoperativeanalysis of site-specificpelvic support defectsin 81 of any pelvic support defect at the 6-week visit is associ- women treated with sacrospinousligament suspension and pelvicreconstruction. Am J ObstetGyneco11992; 166: 1764-71. ated with a 3% likelihood that the patient will require subsequent reconstructive surgery within 2 to 5 years. Discussion Becausepelvic prolapse is a time-dependent, multifactor- ial process, long-term follow-up may result in a higher DR RALPH CHESSON,New Orleans, Louisiana. Independent of this review, I recently attended the rate and an increased grade of r~current vault decensus Advanced Laparoscopy Training Center in Marietta, or enterocele. This report is intended as a preliminary Georgia, which facilitated my understanding of tIle pro- description of the surgical technique as well as an analy- cedure performed by tIlese autIlors. The anatomic visual- sis of short-term outcomes, and we hope to report long- ization by tIle laparoscopic expert Bill Saye and term results in this series of patients in the future. anatomist Cullen Richardson at this course greatly en- Previous articles on surgical techniques in the treat- hanced conceptualization of tIle anatomic surgical repair ment of the enterocele have focused primarily on oblit- of an enterocele. eration and correction of the posterior cul-de-sac. The concept tIlat an enterocele is tIle loss of continu- However, according to Richardson's anatomic descrip- ity of tIle uterosacral complex witIl tIle pubocervical fas- tion of the enterocele as caused by site-specific fascial de- cia or tIle rectovaginal septum is tIle key concept of tIlis fects, the enterocele occurs either at the vaginal apex or article. The autIlors have selected a well-defined group of patients who had almost pure enterocele, allowing tIlem along the posterior vaginal wall. Thus the cul-de-sacis a to isolate tIle entity of enterocele and its r~pair. By means stable structure posterior to the enterocele sac. Previous of a laparoscopic approach to locate tIle uterosacralliga- culdoplasty techniques have been reported to carry sub- ments, a suture wasplaced tIlrough tIle uterosacralliga- optimal cure rates in the treatment of enterocele. This ment for eventual apical elevation of tIle vaginal cuff. A may be due to the chance inclusion of either the fascial vaginal approach was tIlen used to enter tIle enterocele, margins Or the uterosacral ligaments during suture locate tIle pubocervical fascia, and locate tIle rectovagi- Volume 179, Number 6, Part 1 Miklos et al 1423 Am] Obstet Gynecol

nal septum. The previously located uterosacral ligaments inadequate closure of the vaginal epithelium at the time were then reapproximated to the ipsilateral pubocervical of the operation. These patients are initially treated with fascia and rectovaginal septum, thereby reestablishing pelvic rest and transvaginal estrogen cream as long as no the continuity of these structures. No attempt wasmade signs of infection are noted. If suture erosion is still visi- to ob,literate the cul-de-sacfrom the abdominal approach ble 6 months after the operation, we remove the suture or to plicate the uterosacral ligaments on the vaginal ap- transvaginally. By this time adequate surgical scarring, proach. In their short follow-up of these patients there with resulting repair of the enterocele defect, should were no significant failures. have occurred. Because we remove the suture at 6 The uterosacral ligaments, pubocervical fascia, and months if needed, we have had no problems with persis- rectovaginal septum are all fibromuscular structures that tent granulation tissue. We routinely use 2-0 Ethibond are neither ligament nor fascia. Their strength lies in (Ethicon, Inc, Somerville, NJ) suture on an M0-7 needle their combined integrity. The repair of this vaginal her- for most of our transvaginal work, being careful not to nia with already injured fibromuscular tissue instead of leave large suture tags that may result in irritation and with fascia mayjeopardize the long-term successof this subsequent erosion of the vaginal epithelium. procedure. Studies of the integrity of the uterosacralliga- In our series 3 patients were noted to have reported ments are necessaryto establish how long these tissues symptoms consistent with urge incontinence and 3 pa- will last when used for reconstruction. tients were noted to have voiding dysfunction. Those pa- Urinary symptoms were present in 6 patients (35%), tients with incontinence were initially treated with con- and only I patient (6%) had an enterocele through the servative therapy consisting of anticholinergic introitus. This series of almost pure enteroceles elimi- medication and strict timed voiding. Follow-up evalua- nated the patients with severe prolapse, and this re- tion included urodynamic testing, which revealed that striction may be reflected in the lack of failures. I none of these 3 patients had genuine stress inconti- would like to promote the use of the Pelvic Organ nence. The low incidence of stressincontinence in our Prolapse Quantification,l the classification system en- series may be attributable to our exclusion of patients dorsed by this Society to help in descriptions used in with significant anterior vaginal prolapse. The voiding our journals. dysfunction in 3 of our patients may have been related to I have severalquestions for the authors. We have been their pelvic prolapse, and urodynamic testing was per- using 2-0 permanent sutures in our similar vaginal re- formed with reduction of the prolapsed vaginal segment pairs, and we have had recurrent minor problems with with the lower half of a bivalve speculum. Anecdotally, we granulation tissue. I would like to know what type of per- noted that the patients with preoperative voiding dys- manent suture you are using and whether you have had function had improvement after the operation, but this problems with granulation tissue. Three patients were improvement may have been due to the previously men- noted to have reports of incontinence and 3 were noted tioned conservativetherapy. to have reports of voiding dysfunction. Were urodynamic The incidence of postoperative dyspareunia associ- studies performed on these patients after the prolapse ated with narrowing of the vagina after use of this surgi- wasreduced? Did your procedure relieve their symptoms? cal technique has been negligible. In our series 9 of the 17 patients had sexual dysfunction associated with the prolapse before the operation. From 3 to 4 of these pa- REFERENCE tients had persistent mild dyspareunia after the opera- Bump RC, Mattiasson A, B0 K, Brubaker LP, DeLancey]OL, tion, but I believe that this will improve with time as the Klarskov P, et aI. The standardization of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am] Obstet surgical site heals and the vagina stretches. This GynecoI1996;175:10-7. anatomic approach should not result in a decreasein the vaginal caliber. After meticulous dissection of the vaginal DR MIKLos (Closing). I agree with Dr Chesson's rec- epithelium from the underlying rectovaginal fascia, the ommendation that the Pelvic Organ Prolapse rectovaginal fascia wasexposed. We have found that the Quantification classification systemwould have been a rectovaginal fascia does not stretch or shorten and seems more descriptive and current way to describe the pro- to be consistent in its length, approximately 5 to 7 cm, lapse in our series, but the grading systempreviously de- despite the prolapse being as large as 9 to 10 cm outside scribed by Baden and Walker was the most convenient to the vagina. This measurementis largely due to stretching use because3 different centers were involved in collect- of the vaginal epithelium. Becausethe rectovaginal fascia ing data for this study. We acknowledge the role of the is constant in length and width, anatomic reapproxima- Pelvic Organ Prolapse Quantification classification sys- tion to the pubocervical fascia does not result in signifi- tem in the contemporary diagnosis of pelvic prolapse cant narrowing or shortening of the vagina, provided and hope to use it in future studies. that the patient has an adequate amount of posterior wall In response to Dr Chesson's comments regarding su- fascia. Regarding uterosacral ligament plication, we tend ture erosion into the vagina, we have found that suture to avoid this procedure becausewe believe that it is not erosion has occurred in a small percentage of patients at an anatomic repair and may result in compensatory ab- the 4-week postoperative visit and is probably related to normalities.