This video will outline the technique of robotic-assisted retropubic paravaginal defect repair. The basic surgical concept of the paravaginal defect and its repair was first elucidated by George R. White in 1912. While the procedure remained obscure for most of the 20th century, it was revitalized and popularized in the 1980s and 1990s through the work of Drs. Cullen Richardson and Bobby Scholl. Laparoscopic paravaginal repair was first described by Ross in 1997, but has not achieved significant popularity. Regardless of the route of surgical access, paravaginal repair has been found to be effective in providing long-term support to the anterior compartment, with rates of success ranging from 92 to 97% for up to 8 years post-operatively. While paravaginal repair is not as effective in the cure of stress incontinence as the Birch, Marshall-Marchetti, Kranz, or transvaginal sling procedures, these can easily be added to the paravaginal repair as the retropubic dissections are similar. The relevant retropubic anatomy is delineated superiorly by Cooper's ligaments, shown here as white lines. The bladder and urethrovesical junction, demonstrated here by the presence of the Foley balloon and catheter, outlined in yellow. The white line of the arcus tendineus fascia pelvis, marked here with a red line. The pubocervical fascia, which can be seen caudal to the bladder and urethrovesical junction, and marked here with blue triangles. Bilateral paravaginal defects are seen here, marked with green arrows, with clear separation of the pubocervical fascia from the arcus. The goal of the procedure is to close this defect while avoiding the bladder medially and the obturator neurovascular bundle posterolaterally, as demonstrated by the parallel red and blue lines. The procedure is begun by filling the bladder with approximately 150 cc's of sterile saline. An incision is made in the anterior peritoneum superior to the bladder. This incision is carried bilaterally, at least to the obliterated umbilical vessel remnants. The space of rhetsia is then entered, and the dissection carried caudally to the level of the arcus on the lateral border, the pubocervical fascia medially, the obturator bundle posteriorly, and the urethra anteriorly. Hemostasis is via monopolar and bipolar caudary, although the typically looser rail or tissue in the space of rhetsia is generally quite hemostatic. This dissection is then repeated on the contralateral side. A stitch is taken through the pubocervical fascia with a permanent suture. Zeroethabond is used here, and then through the arcus and tied. Subsequent sutures are used to close the defect, working from posterior to anterior. We prefer to alternate sides when closing bilateral defects. Typically four or five sutures are required on each side to close the defect. When the defect is closed, a birch culpo suspension may be performed if stress urinary incontinence is present. At the completion of the procedure, the space of rhetsia is then filled with pledges of uncompressed gel foam. We typically add a layer of thrombin-based tissue sealant as well. The peritoneum is closed with a 90-day delayed absorbable barbed suture. Cystoscopy is performed routinely to identify urineral patency, cystotomy, and or stitch perforation of the bladder. To date, we have not encountered any of these untoward events. A Foley catheter is left in place overnight, and a voiding trial performed on the morning of postoperative day number one. To date, no patients have failed this voiding trial with post-void residuals all below 120 cc. In our first ten patients undergoing this procedure, mean console time for the procedure has been 36 minutes, with a range from 28 to 44 minutes. The pre- and post-op anterior compartment OPQ measurements are as shown. We believe that the robotic-assisted paravaginal repair offers a long-term, non-mesh-based alternative for selected patients with anterior compartment prolapse, and that it is worthy of further study. Thank you.

robotic-assisted retropubic paravaginal defect repair

George R. White

Cullen Richardson

Bobby Scholl

anterior compartment support