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The goal of repair is to restore pelvic anatomic support of the anterior vaginal wall. This is rarely an independent surgery. Often, surgery entails addressing incontinence as well as prolapse of the uterus and posterior compartment. The end result must restore anatomy and function by restoring normal vaginal axis and depth while preserving urinary, bowel, and sexual function. Treatment of cystocele must address all defects of the pelvic floor. In the anterior compartment, we must correct urethral hypermobility, weakness of lateral bladder support (paravaginal), perivesical fascia (central), and cardinal-sacrouterine ligament complex. Options for surgical treatment include abdominal, laparoscopic, or vaginalapproaches. This chapter focuses on the various vaginal techniques popularized to repair cystoceles and introduces our new technique that addresses all the defects of the anterior compartment.

The surgical management of pelvic organ prolapse is more challenging than that for stressurinary incontinence, and detection and correction of apical repairs can be the most difficult of all pelvic floor defects. One-third of procedures performed for pelvic organ prolapse are secondary procedures ( 1 ). The number of procedures performed in the United States to treat posthysterectomy vaginal vault prolapse increased dramatically from 1437 procedures in 1979 to 22,025 procedures in 1997 ( 2 ), while the overall number of procedures performed for pelvic organ prolapse declined from 226,000 in 1979 to 205,000 in 1997. Despite this apparent epidemic of apical prolapse, residency training for urologists and gynecologists alike favors repair of cystoceles and rectoceles. Moreover, defects of the anterior and posterior vaginal walls are more common and easier to detect than apical defects such as uterine prolapse and vaginal vault prolapse ( 3 ). For these reasons, correction of apical defects remains a surgical challenge for many surgeons.

An enterocele is a hernia of the peritoneumlined pouch of Douglas, and it may contain intraabdominal contents including small bowel and omentum. Most commonly the hernia is at the vaginal apex or the proximal posterior vaginal wall on the rectum. Rarely, it is seen at the apical anterior vaginal wall under the bladder. Before discussing the pathophysiology and treatment of enterocele, we will review the relevant normal pelvic anatomy.

Fecal incontinence is underreported by patients and underrecognized by providers. The true prevalence of fecal incontinence is unknown, but in the few published population-based studies, rates range from 0.5% to 13% and are six to eight times more common in women than men ( 1 ). Anal continence is maintained by a variety of mechanisms including normal stool delivery and consistency, intact sensation and motor enervation, an intact anal sphincter complex, and a functioning puborectalis muscle ( 2 , 3 ). Loss of anal continence may result from damage to a single part of the continence mechanism or may result from multiple insults over time. While the term anal incontinence includes the loss of gas, liquid stool, and solid stool and may be preferred by some clinicians and organizations, the term fecal incontinence is used in this chapter because of the surgical focus: incontinence to gas is unlikely to result in surgical management. The treatment of fecal incontinence includes behavioral and physical therapy, medications, as well as surgical therapy. Because of varied etiologies of anal incontinence, as well as poor long-term results of anal continence surgery, any approach to treatment of anal incontinence should include a trial of nonsurgical intervention.

After any failed surgery for incontinence, or after any vaginal surgery complicated by incontinence for that matter, it is essential to carry out a complete evaluation of the patient— both subjectively and objectively. Certainly recurrent incontinence after previous surgery can usually be treated successfully, but it requires precise patient evaluation because it is imperative that the exact functional derangement is defined and the precise etiological factors are identified. This is particularly important when there is more than one abnormality present, since incorrect treatment may aggravate symptoms rather than cure them. A careful balance should be struck between thetreatment modality to be chosen and the patient’s expectations. In addition to a clear history, a full examination—physical, urodynamic, and, where appropriate, imaging— should be performed. Although in some patients with a history of recurrent incontinence it may not be possible to demonstrate any significant abnormality, it is essential to exclude a significant abnormality.

Bladder outlet obstruction resulting in voiding dysfunction following anti-incontinence procedures can be a disappointing outcome for both patient and surgeon. When stress incontinence is replaced by lower urinary tract symptoms (LUTS) such as frequency, urgency or urge incontinence, difficulty voiding, or urinary retention, the patient may have more severe complaints than at initial presentation. It is a challenging task for the clinician to decide what if any action to take and when to take it and by what approach. Several considerations are the type of anti-incontinence procedure, postoperative physical findings, the patient’s degree of bother, and any addition testing that may be performed. Recent work has focused on clarifying the etiology and incidence of this condition, as well as providing new definitions on bladder-outlet obstruction in women. In addition, effective, less invasive ways of treating this condition have been described. The prevailing doctrine is not to make a bad situation worse and to find the simplest solution that produces the least anxiety for the patient. The vaginal approach to sling incision and urethrolysis is appealing for this reason. This chapter discusses the incidence and etiology of postsurgical obstruction, the diagnostic evaluation, and the current management and treatment for this condition, with specific emphasis on the vaginal approach.

After pelvic organ prolapse repair, nearly 30% of women undergo additional surgical intervention for prolapse recurrence ( 1 ). Despite this fact, there are few published reports specifically examining prolapse recurrence and its optimal surgical management. Furthermore, the definition of a surgical failure is not always clear, as there are cases in which organ dysfunction may persist, despite a technically sound outcome, whereas some asymptomatic patients may have a recurrent low-grade or-stage prolapse.

Approximately 70% of iatrogenic injuries to the genitourinary tract are not recognized at the time of operation ( 1 ). The long-term sequelae of these injuries include ureteral obstruction with loss of renal function and fistula formation. It is estimated that surgery for benign gynecologic conditions is responsible for 74% of genitourinary fistulas and over 90% of vesicovaginal fistulas in the United States ( 2 ). The vagina affords the urologist and urogynecologist an easily accessible, less morbid route for performing surgery to correct urinary incontinence and pelvic organ prolapse. But factors such as previous pelvic surgery, obesity, pelvic inflammatory disease, endometriosis, and pelvic irradiation can result in decreased organ mobility and impaired healing should an injury occur ( 3 ). The awareness of these risk factors for genitourinary injury, as well as the adoption of a few simple intraoperative precautions, can aid in their prevention and eventual recognition at the time of surgery. Early recognition of these injuries and proper postoperative management serve to decrease patient morbidity.

In developed countries, modern obstetric care has substantially limited the risk of vesicovaginal fistulas. In these areas, fistulas are usually the consequence of complications of gynecologic or other pelvic surgery with secondary etiologies such as inflammatory bowel disease and malignancy being responsible for a minority of cases. In developing countries, birth trauma accounts for the majority of fistulas ( 1 , 2 ). Necrosis of the bladder base and urethra is induced by prolonged labor, which results in tissue loss that is often marked ( 90 ).

Urethral diverticula may represent some of the more challenging diagnostic and reconstructive cases in urology. Women with lower urinary tract symptoms, pelvic pain, or vaginal masses are often referred to a urologist or gynecologist as diagnostic dilemmas. A portion of these patients are subsequently found to have urethral diverticula. However, urethral diverticula represent only one of several types of pathologic periurethral masses presenting in the female. Given the rather wide spectrum of lesions and conditions that present in this manner, proper characterization is necessary prior to formulating a therapeutic plan. Often, although not invariably, urethral diverticula and other periurethral masses are treated surgically. These cases are approached individually and a successful repair often may employ a variety of reconstructive maneuvers including flaps and grafts. The operating surgeon, therefore, should be prepared to be flexible and alter the operative plan accordingly with the findings at operation.