1. Cirurgia Vaginal Para Urologistas
Prof Paulo Palma
Titular Urologia Feminina
UNICAMP

2. Central Defect Anterior Vaginal Prolapse (AVP) Lateral Defect Uterus P
Tendineous Arc
Lateral Defect
Vagina

3. Possible fascial tearings
Davila, Guerette.IUGA 2004

4. Transverse defect

5. Anterior Vaginal Prolapse
repair

6. Paravaginal repair
Richardson, 1976

7. Anterior Vaginal Prolapse (AVP)
Uterus P
Meshing the anterior vaginal prolapse reinforces the damaged tissues and allows for the treatment of both defects and urethral hypermobility at the same time.
Vagina

8. Anterior Vaginal Prolapse
Mesh vs Anterior repair n T
(m)
Success
(%)
Complications
Julian
Marlex 12 24
100
25% erosion
Colp. Ant. 12 24 66 no
Sand
Poliglactina 73 12 75 no
Colp. Ant. 70 12 57 no
Weber
Poliglactina 26 23 42 n0
Colp. Ant. 57 23 37 no
Modified from Tayrac el al Int Urogyn J 2006, 17:100

9. Posterior vaginal wall prolapses
The past
Levator ani Miorraphy
The Present
Pericervical ring reconstruction
Posterior Slings

10. Pain, dypareunia, recurrency
Levator miorraphy
Anti anatomic
Pain, dypareunia, recurrency

11. Connective Tissue between the vagina and the rectum
Rectovaginal Fascia
Connective Tissue between the vagina and the rectum
Smooth Muscle fibers

12. Rectovaginal Fascia Preserve vaginal lengh and helps rectal function
Main supportive element of the posterior wall

13. Anatomical levels Support Lateral Fusion
Stenchever,Urogynecology and Reconstructive Pelvic Surgery, Vol. V

14. AT THE LEVEL OF THE ISCHIAL SPINES;
PERICERVICAL RING
ONE OF THE MOST IMPORTANT CONCEPTS FOR
RECONSTRUCTIVE VAGINAL SURGEONS;
AT THE LEVEL OF THE ISCHIAL SPINES;
COMPLEX REPRESENTED BY THE CONTINUITY OF THE CARDINAL-UTEROSACRAL LIGAMENTS WITH:
PUBOCERVICAL AND RECTOVAGINAL FASCIA.
Adapted from Netter, Atlas of Human Anatomy

15. CHILDBIRTH AND PVP
ON THE DESCEND AND EXTENSION OF THE FETAL HEAD, INTENSE PRESSURE IS EXERTED ON THE SUSPENSORY FUNCTION OF THE UTEROSACRAL LIGAMENTS;
CONTINUATION OF THIS PROCESS RESULTS IN A PROXIMAL TRANSVERSE SEPARATION OF THE RECTOVAGINAL SEPTUM FROM THE UTEROSACRAL LIGAMENT AND THE PERICERVICAL RING;
Adapted from Williams, Obstetrics

16. Pericervical Ring

17. Posterior Vaginal Prolapse (PVP)
Rectum
Uterus
Tendineous Arc P
Posterior
Defect
Regarding the posterior vaginal wall prolapses, we can mesh the defect and create a neo sacro uterine ligament.
Vagina
Levator ani

18. Pericervical Ring

19. Surgical Approach

20. Surgical Approach P
Arco tendineo
Reto
Utero
Vagina
Elevador ânus

21. Posterior Vaginal Prolapse Repair
Rectum
Uterus
Tendineous Arc P
Sacrospinal
Ligament
Vagina
Levator ani