An Anterior Repair, or in medical jargon, an Anterior Colporrhaphy (coal-pour-ah-fee) is the surgical correction of a fallen bladder. It is a surgical procedure which corrects a cystocele or urethrocele. The procedure is performed in the operating room and is usually performed under general anesthesia, which means that you will be asleep during the surgery.
Technique: A speculum is inserted into your vagina to hold it open during the procedure. Next, an incision is made in the vaginal skin along the front wall of your vagina and the skin is peeled open, revealing your falling bladder above. The supporting tissue, called the fascia, is the thin layer between the vagina and bladder, and it is this layer which has given out, and is letting your bladder fall. Your physician will find the edges of your fascia and sew these back together in the midline, to provide support for your bladder. Any excess vaginal skin is trimmed off and the incision is closed with stitches.
Pictorially, the procedure is performed as follows:
Picture showing bulging anterior vaginal wall at the start of the surgery. An incision is being made along the vaginal skin (mucosa) overlying the fallen bladder. A catheter has been inserted into the urethra
The vaginal mucosa has been peeled back so that the bladder wall is now visible through the incision. The defective pubocervical fascia supporting layer is also visible. It is the weakened, broken, or stretched pubocervical fascia that gives rise to the cystocele.
The defective pubocervical fascia is sewn back together.
Once the fascial defect is closed, then the vaginal mucosa skin edges are sewn back together, thus completing the surgery.
An anterior repair seems like a simple enough surgery, but there are some issues with the procedure; the most striking being the failure rate, which is estimated between 25% and 52%.
So why should there be such a high failure rate? The answer is thought to be due to the fascia layer. Remember, the weakened fascia is the cause of the problem in the first place. With an anterior repair, the weakened fascia is being sewn back together so that it can again provide support. But what if the fascia is just too weak to provide long lasting real support? Then the surgical repair will fail and a new cystocele with again form. Not exactly the effect we were looking for.
So, to try and avoid a facial breakdown, leading to the re-development of another cystocele, we believe that you should consider adding additional support to your own fascial layer so that the bladder floor becomes significantly stronger. There are several ways of accomplishing this, however his preferred method is using a commercial product called a Repliform® Graft.
What is a Repliform® Graft? – The official name of this product is Repliform® Tissue Regeneration Matrix (LifeCell Corporation, Branchburg, NJ). This product is human tissue that was donated to a tissue bank that meets AATB standards in exactly the same way that organs are donated. The tissue is then put through a rigorous process to ensure that it is safe and is free from virus contamination. The Repliform® matrix replaces your damaged tissue with new healthy tissue and acts as a template for your own tissue to repopulate and grow. The Repliform® matrix also provides the collagen and elastin structure to provide natural form and function in addition to it's support capabilities.
The Repliform® graft matrix begins providing support for your fallen bladder and vaginal weakness very quickly after surgery. Usually, by 3 days after surgery your body’s supporting cells begin to move into the Repliform® graft template, thus adding support for your bladder. As your tissues heal, they will incorporate the Repliform® matrix into your own healthy tissue. You should be fully healed in 2 to 6 months, and once recovery is complete, you won’t be able to tell the Repliform® matrix was ever implanted.
So in summary, why use a graft material for cystocele repairs? The main reason that a bladder falls is because the supporting fascia layer has been damaged. This damage commonly occurs during childbirth, but can also occur due to a chronic cough, longstanding constipation, or simply due to an inherited weakness in one’s supporting tissues. Thus, if yor doctor uses only your tissue to strengthen the floor of your bladder, then it is possible that the problem may recur in the future as your supporting tissues weaken even more. In order to overcome your fascial weakness, your doctor can add the Repliform® graft matrix to greatly strengthen your bladder floor and help prevent your bladder from falling again.
A recent trial with Repliform® Matrix demonstrated that, within 12 weeks, typically, graft material can no longer be distinguished from your native skin borders. Histology confirmed robust, vital, and intact collagen with normal cell density at 12 months. Safety has been confirmed in 12 years of clinical experience with more than 750,000 grafts having been performed, with no reported disease transmissions. And equally, if not more important, not a single adverse outcome, erosion, graft exposure, or explant has been associated with the use of Repliform graft augmentation in studies to date and there have been no patient reactions to the grafts. Therefore, we believe that the benefits of the additional strength are great, and the risk is minimal.