Archives of Women’s Health & Gynecology doi: 10.39127/2677-7124/AWHG:1000103 Tawfik W. Arch Women Heal Gyn: 103. Research Article Clinical Outcomes of Laparoscopic Repair of Paravaginal Defects Waleed Tawfik* Department of Obstetrics and Gynecology, Faculty of Medicine, Benha University, Benha, Egypt. *Corresponding author: Waleed Tawfik: Lecturer of Obstetrics and Gynecology, Faculty of Medicine, Benha University, Benha, Egypt. Citation: Tawfik W (2020) Clinical Outcomes of Laparoscopic Repair of Paravaginal Defects. Arch Women Heal Gyn: AWHG-103. Received Date: 31 March, 2020; Accepted Date: 03 April, 2020; Published Date: 08 April, 2020 Abstract In the era of minimally invasive surgeries, laparoscopic approach has been adopted in many surgical procedures as a successful alternative. Laparoscopic paravaginal repair is a good approach for surgical treatment of lateral type cystoceles. This prospective study was done to investigate whether laparoscopic paravaginal repair might be a reasonable alternative to open or vaginal routes in terms of success rate, operative and postoperative outcomes. Fifty patients with clinically diagnosed paravaginal defect were included in this study. The overall success rate in our study was 88 % after one year according to prolapse staging. This is nearly comparable to the results of most studies. Dividing the overall outcome into favorable and unfavorable, we reported that the unfavorable outcome was 22%. Unfavorable outcome includes cases of recurrence, persistent symptoms or appearance of new complaints. Conclusion: Although laparoscopic paravaginal repair offers an alternative method with shorter hospital stay, less postoperative pain and quicker recovery, but it still has its drawbacks. It needs long learning curve and has prolonged operative time. Introduction Laparoscopic paravaginal defect repair ( P.VdR) regains the normal lateral support of the puboceirvical fascia to the Anterior colporrhaphy has been the standard surgical archus tendineus fascia pelvis (ATFP) of the pelvic sidewall option for anterior vaginal wall prolapse. However, it is and gives good anatomical repair of the fascial defect associated with a 50% recurrence rate. This is because the cystocele [5]. classical anterior colporrhaphy primarily focuses on central defect, while paravaginal repair targets fascial Aim of the Work defects. Since the central defect alone is rare [1]. Evaluation of use of laproscopy as a method in repair of The other concern with the vaginal approach to prolapse anterior vaginal wall prolapse due to paravaginal defect repair is that it produces scars and distortion of the vagina, regarding operative and postoperative short-term results. potentially leading to sexual unsatisfaction, especially in younger women [2]. Patients and method Permanent mesh kits have been introduced in an attempt Fifty patients complaining of lateral type of anterior vaginal to increase success rates, but their use has been limited by wall prolapse or paravaginal defect were enrolled in this complications and long-term sequelae related to the study that was carried out from January 2018 to December techniques and materials used [3]. 2019 at the Obstetrics and Gynecology Department, Benha University. Egypt patients were selected from those Paravaginal repair was initially done as a vaginal route, attending the Obstetrics and Gynecology and Urology subsequent it has been performed abdominally and lastly Outpatient Clinics. All patients had given a written as a laparoscopic procedure. Vaginal paravaginal repair informed consent to share in the study. (v.PVR) has a success rate ranging from 67.1% to 100% but higher complication are reported (including intraoperative Inclusion criteria bleeding, hematoma, abscess, severe postoperative blood loss, and bilateral ureteric occlusion) [4]. Cases of anterior vaginal wall prolapse proved clinically as displacement type ( paravaginal defect) by: Arch Women Heal Gyn: 2020 Issue 1 Page:1|8 Citation: Tawfik W (2020) Clinical Outcomes of Laparoscopic Repair of Paravaginal Defects. Arch Women Heal Gyn: AWHG- 103. a. Inspection of anterior vaginal wall while the patient is 5. Informed written consent before procedure was straining in a lithotomy position and with separation of obtained. labia, reveals presence of anterior vaginal wall sulci and preserved mucosal rugae of the vagina over the (B) Operative procedure: prolapsed part. b. Elevation of the anterior vaginal wall by Sim’s Anesthesia: A general anesthesia was used. speculum while the patient is straining in a lithotomy Position: The patient’s legs were placed in the lithotomy position, fails to correct the prolapse. position in adjustable stirrups with the arms are tuckd to c. Elevation of the lateral aspects of the anterior vaginal the patient's sides, and Foley catheter was placed in the wall by curved ring forceps while the patient bears bladder. down in lithotomy position, corrects the prolapse completely. Room setup: The patient should be in low dorsal lithotomy position Exclusion criteria Steps of procedure: 1- Cases of anterior vaginal wall prolapsed proved clinically as distension type (central defect). • Creation of pneumoperitoneum: 2- Patients with stress urinary incontinence. • Trocar placement: infraumbilical 10 mm trocar was 3- Patients with associated uterine prolapse. passed into the abdomen through the umbilical 4- Previous surgery in retropubic space. aponeurosis. 5- Contraindications of laparoscopy as cardiopulmonary • Developing the retropubic space: diseases, more than previous two laparotomies, history suggesting peritonitis or pelvic endometriosis and Body Identification of loose areolar tissue confirms dissection in Mass Index (BMI) > 35 kg/m2. the correct plane . The loose areolar tissue and fat in this space were swept away until we reach the pubic bone. As Methods small vessels encountered, they were coagulated. Once we reach the pubic bone , the overlying loose tissue was bluntly (A) Preoperative evaluation: dissected away to expose the bone and Cooper’s ligament. Blunt dissection is continued until the retropubic anatomy All patients had a standardized pre-operative asessment is visualized. The anterior wall of the vagina and its points that include: of lateral attachments from their origins at the symphysis 1- Detailed Taking of history pubis to their insertions in the ischeal spine can be viewed. II- Physical examination: All points except the tVL were recorded with the patients Sutures placement performing maximal Valsalva maneuver, patients were then assigned a POPQ stage: The first stictch is placed nearly in the apex of the vaginal wall through the paravesecal part of the pubocervecal • Stage (0): prolapse is not demonstrated fasciae. The needle must pass through the same sided • Stage (I): The most dista part of the prolapse is more obturatour internal muscle and fasciae around the archus than 1 centimeter above hymenal ring. tendineous fasciae at teh origin one to two cm distl to the • Stage (2): The most distl part of prolapse isles or equal ischeal spine . to 1 centimeter proximl or distl to the hymenal ring. • Stage (3): The most distl part of the prolapse is more • Closure of parietal peritoneum: than 1 centimeter below plane hymenal ring but bulges no more than two centimeters less than the tVL. We remove all the trocars under vision. CO2 allowed to escape gradually, then the last trocar was removed under • Stage (4): complete eversion of the whole lower vision. Lastly, we close the skin using silk suture which is genital canal is observed. removed after 7 days. III- Investigations: • Laboratory studies in the form of urine analysis and culture, renal and liver function tests, complete blood picture, coagulation profile and blood grouping. • Electrocardiography to exclude any cardiac problem. • Pelvic ultrasound to exclude any pelvic pathology. IV- Preoperative preparations: 1. Treatment of any associated urinary tract infection. 2. Treatment of any associated genital infection. 3. Treatment of precipitating factors. 4. Patients were evaluated by anesthesiologist. Figure 1: Parietal peritoneum incision. Arch Women Heal Gyn: 2020 Issue 1 Page:2|8 Citation: Tawfik W (2020) Clinical Outcomes of Laparoscopic Repair of Paravaginal Defects. Arch Women Heal Gyn: AWHG- 103. Figure 2: Enterance of retropubic space as an access to Figure 4: Closure of the peritoneum. paravaginal defect. (C) Post operative Care: All cases received Diclofenac potassium 100 mg and meperidine hydrochloride 50 mg intramuscular with anaesthesia recovery and 12 hours later second dose of diclofenac potassium was given. Thromboprophylaxis in the form of 40-60 mg Enoxaparin (Clexane) is given 6-12 hours postoperatively as SC injections. Foley’s catheter was removed 6 hours postoperative except in complicated cases with bladder injury, removed 5-7 days after operation. Figure 3: Suture placement in ATFP and obturator muscle Discharge of patients once they could withstand post- and fascia. operative pain and were tolerating regular diet and walk independently. (D) Outcome measures: A- The primary outcomes: includes 1- Operative outcomes A) Operative time. B) Blood loss: The amount of blood loss was estimated by the amount in the suction container after subtracting the amount of fluid used for washing. C) Operative morbidity: as bladder injury, intestinal or vascular injuries, anesthetic complications. Figure 4: Approximation of the defect edges. 2- Post-operative outcomes: A) Hospital stays. B) Post-operative pain was