Paravaginal repair of lateral vaginal wall defects by fixation to the ischial periosteum and obturator membrane

OBJECTIVE: The aim of the study was to evaluate the anatomic basis, efficacy, and safety of a technique for correcting lateral wall vaginal defects. STUDY DESIGN: Phase I was cadaveric dissection carried out to ascertain the strength and position of structures likely to support lateral vaginal wall defects. The ischial periosteum just anterior to the ischial spine was found to be strong tissue, relatively free of nerves and vessels. In phase II, paravaginal defects were repaired by placing sutures through the arcus tendineus and underlying obturator fascia, obturator membrane, and ischial periosteum. Other defects and urinary incontinence were corrected within the same surgical setting. Forty patients were followed up for an average of 39 months (range 7-52 months). Preoperative evaluation consisted of an extensive history, cough stress test, spontaneous uroflowmetry, postvoid residual urine determination, urethral axis determination, site- specific pelvic floor defect evaluation; and multichannel urodynamic studies. After the operation patients underwent evaluations at 3 months, at 6 months, and then annually. RESULTS: Objective site-specific re-examination of the 40 patients revealed the following recurrences: lateral wall in 1 of 40 procedures, anterior wall in 3 of 35 procedures, posterior wall in 1 of 36 procedures, and apical wall in 1 of 27 procedures. Thirty-four of 36 women (94.4%) with urodynamically confirmed genuine stress incontinence or potential incontinence achieved cure (P < .001). CONCLUSIONS: (1) The ischial periosteum and obturator membrane are consistently strong reattachment sites. (2) Repair of paravaginal defects with these tissues is effective and safe. (3) Urodynamic parameters were unchanged after the operation except for measures of incontinence, which were improved (P < .001). (4) Performing other pelvic procedures did not negatively alter the success rates of paravaginal repair. (5) The urethral axis was favorably altered after the operation (P< .01).