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ORIGINAL RESEARCH |
From the Departments of Obstetrics and Gynaecology, and Anatomical Pathology, Dalhousie University, Halifax, Nova Scotia, Canada.
Address reprint requests to: Scott A. Farrell, MD, Department of Obstetrics and Gynaecology, Dalhousie University, 5980 University Avenue, Room 6039, Halifax, Nova Scotia B3J 3G9, Canada; E-mail: scott.farrell{at}iwk.nshealth.ca.
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ABSTRACT |
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METHODS: In patients undergoing primary anterior and posterior colporrhaphy, biopsies were taken from three surgically distinct vaginal tissues types: the wall, the "fascia," and areolar tissue. The biopsies were placed in formalin, identified numerically, and sent to pathology for staining with hematoxylin-eosin, Masson trichrome for collagen, Movat for elastin, and immunoperoxidase stain for actin in smooth muscle. Simultaneous photographs were taken of the biopsy sites. The histologic diagnosis was compared with the surgical diagnosis.
RESULTS: A total of 60 samples were taken from five women. The specimens from two of these patients were disqualified. The pathologist made the following histologic diagnosis for each type of surgical specimen: vaginal wall, mucosa and underlying connective tissue; fascia, moderately dense connective tissue with smooth muscle; areolar tissue, loose connective tissue. The histologic appearance of the "fascia" was indistinguishable from the deeper aspects of the vaginal wall. It was composed of the same proportions of smooth muscle, elastin, and collagen. Using the histologic appearance as the "gold standard," the accuracy of the surgical diagnosis was: "vaginal wall," 12 of 12 (100%); "fascia," seven of 12 (58%); and "areolar tissue," eight of 12 (67%).
CONCLUSIONS: The surgical "fascia" used during colporrhaphy consists of moderately dense connective tissue with smooth muscle similar to the deep aspects of the vaginal wall, is the same in both the anterior and posterior compartments, and is an artifact of the surgical dissection used to separate the vaginal wall from the underlying organs.
Many gynecologic surgeons believe that the identification and use of tissue referred to as "fascia" is essential to achieving effective anterior and posterior colporrhaphy. Controversy about the histologic components, location, and proper use of this "fascia" is evident in gynecologic literature spanning more than 100 years.1–4 Authors who have conducted studies involving gross anatomic dissections support the existence of an identifiable layer of tissue that lies between the surrounding organs and the vaginal wall both anteriorly and posteriorly.4–5 The layer between the bladder and the vagina is often referred to as the pubocervical fascia. The layer between the rectum and the vagina is called Denonvillier’s fascia or the rectovaginal septum. Authors who have conducted histologic studies of the vagina and adjacent organs have found only a loose areolar tissue separating the bladder from the anterior vaginal wall and the rectum from the posterior vaginal wall.2,3,6–8 Although the use of so-called surgical fascia is described,9,10 only one author has examined the histology of this surgical fascia.11 They admitted that this "fascia" may have resulted from splitting the vaginal wall.
This study had three purposes: first, to examine histology of surgical "fascia" used during colporrhaphy; second, to see if the so-called pubocervical fascia differed histologically from the so-called Denonvillier’s fascia; and third, to determine the consistency with which this tissue is diagnosed surgically.
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MATERIALS AND METHODS |
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RESULTS |
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); type II, moderately dense connective tissue composed of collagen, smooth muscle, and elastin (Figure 2); and type III, loose connective tissue composed of fat cells and loose bundles of smooth muscle and perivascular collagen (Figure 3). Using the histologic diagnosis as the "gold standard," the surgical diagnosis correlated as follows: vaginal wall, 12 of 12 (100%) of these specimens were histologic type I; fascia, seven of 12 (58%) of these specimens were histologic type II; and areolar tissue, eight of 12 (67%) of these specimens were histologic type III. Five of the surgical fascia specimens were histologic type III, loose connective tissue. Four of the surgical areolar tissue specimens were histologic type II, moderately dense connective tissue. Specimens of the moderately dense connective tissue were indistinguishable histologically from the deeper layers of the vaginal wall. The histologic appearance and makeup of specimens taken from the anterior dissection was the same as those taken from the posterior dissection.
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DISCUSSION |
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The main proponents of the existence of surgical fascia have based their conclusions upon results of gross anatomical dissection of the pelvic organs. Denonvillier is widely quoted as being the first to describe the existence of a fascial layer extending from the vagina apex, where it takes off from the uterosacral ligament complex, down the full length of the posterior vaginal wall to attach to the perineal body.9 Tobin and Benjamin published an article on their study of Denonvillier’s fascia, which includes the original monograph by Denonvillier along with an English translation.13 It is clear that Denonvillier was describing a capsule of tissue surrounding the seminal vesicles in a male. He states that "the inferior surface [of this fascial capsule] which touches the rectum barely adheres to it by a very loose cellular tissue." His anatomic dissections did not involve a female cadaver, and the fascia he described did not extend below its rather tenuous attachment to the upper rectum. Tobin and Benjamin, who conducted extensive histologic and gross anatomic dissections, proposed that Denonvillier’s fascia be subdivided into an anterior layer that is derived from the fusion of the pelvic cul-de-sac peritoneum and a posterior layer that is the fascia around the rectal muscularis. This posterior fascia was composed primarily of adipose and areolar tissue.
Uhlenhuth et al conducted gross anatomic dissections in both males and females.2,5 His conclusions concerning the female pelvis were based primarily on his dissection of the cadaver of a 35-year-old black woman. Like Tobin, Uhlenhuth concluded that a rectogenital septum forms by the fusion of the peritoneum in the Pouch of Douglas. This membrane was attached cranially to the peritoneum at the bottom of the Pouch of Douglas and caudally to the "dorsal surface" of the vagina. He described this membrane as more adherent to the vagina than to the rectum. Its appearance "was glistening evenly membranous, of firm texture and sometimes faintly greenish in color." In most cases it did not extend the full length of the rectovaginal septum. He did not examine this membrane histologically. Milley et al, while claiming to have identified a rectovaginal septum, admitted that the histologic findings suggested that the vaginal connective tissue capsule had been split.11 The only distinct histologic feature of the septum was a longitudinal orientation of coarse elastic fibers.
Despite the fact that the bulk of research evidence supports the conclusion that no true fascia exists between the vagina and its adjacent organs, authors continue to describe the use of this fascia to achieve surgical cure of cystocele and rectocele.9,10,14,15 Our study has demonstrated that the surgical "fascia" identified and used to achieve a site-specific repair of cystocele or rectocele is composed of moderately dense connective tissue indistinguishable histologically from the deep layer of the vaginal wall. We conclude that this fascia is actually a surgical artifact of the technique used to separate the vaginal wall from the surrounding organs. Ricci et al have described a surgical approach to colporrhaphy that permits entry into an avascular space of loose areolar tissue.16 Once in this space, the surgeon is able to separate the bladder or rectum from the vagina by blunt dissection alone. Colporrhaphy is then completed by excision of the excess vaginal wall and reapproximation in the midline. We have used this surgical technique.
The gynecologic surgeon’s goal is to achieve a permanent repair of cystocele and rectocele. If we accept that fascia does not exist between the bladder and rectum and the vagina, then the use of artifactual "fascia" created by splitting the vaginal wall during colporrhaphy should be no more effective than a simple excision of redundant full-thickness vaginal wall and subsequent repair. Nichols describes three methods of anterior colporrhaphy, two of which are considered correct.12 One of the correct methods involves entry into the avascular space between the bladder and the vagina, excision of excess vaginal wall and midline closure. The second correct method involves splitting the vaginal wall into two layers after it has been separated from the bladder. Excess tissue is excised from both layers, and these layers are repaired separately in the midline. The second method, which involves a deliberate splitting of the vaginal wall into two layers, is a close approximation to "site-specific" repair of vaginal fascial defects. Although Nichols describes a variety of techniques for anterior colporrhaphy, he does not provide any data as to the effectiveness of the different surgical procedures. Weber and Walters, after an extensive review of literature on anterior vaginal wall prolapse, conclude that controlled studies of surgical techniques are essential to determine which methods are most effective.17 A prospective cohort study comparing a full-thickness with a split-thickness vaginal wall repair for colporrhaphy might resolve some of the controversy about "site-specific" surgical repairs.
The findings of this study support the conclusions of previous authors that there is no fascia between the vagina and its adjacent organs that can be used to achieve a more effective surgical colporrhaphy. Future controlled studies using standardized surgical techniques are necessary to determine the best method of colporrhaphy.
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Footnotes |
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Received February 27, 2001. Received in revised form June 12, 2001. Accepted June 21, 2001.
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REFERENCES |
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2. Uhlenhuth E, Day EC, Smith RD, Middleton EB. The visceral endopelvic fascia and the hypogastric sheath. Surg Gynecol Obstet 1948;86:9–28.[Medline]
3. Ricci JV, Lisa JR, Thom CH, Kron WL. The relationship of the vagina to adjacent organs in reconstructive surgery. A histologic study. Am J Surg 1947;74:387–410.
4. Goff BH. A histologic study of the perivaginal fascia in a nullipara. Surg Gynecol Obstet 1931;52:32–42.
5. Uhlenhuth E, Wolfe WM, Smith EM, Middleton EB. The rectogenital septum. Surg Gynecol Obstet 1948;86: 148–63.[Medline]
6. Goff BH. The surgical anatomy of cystocele and urethrocele with special reference to the pubocervical fascia. Surg Gynecol Obstet 1948;87:725–34.[Medline]
7. Krantz KE. The anatomy of the urethra and anterior vaginal wall. Am J Obstet Gynecol 1951:62:374–86.
8. Bissell D. Fascia lapping as applied to the tissues of the vaginal wall – a misnomer. Surg Gynecol Obstet 1929;48: 549–50.
9. Richardson AC. The rectovaginal septum revisited: Its relationship to rectocele and its importance in rectocele repair. Clin Obstet Gynecol 1993;36:976–83.[Medline]
10. Cundiff GW, Weidner AC, Visco AG, Addison WA, Bump RC. An anatomic and functional assessment of the discrete defect rectocele repair. Am J Obstet Gynecol 1998; 179:1451–7.[Medline]
11. Milley PS, Nichols DH. A correlative investigation of the human rectovaginal septum. Anat Rec 1968;163:443–52.
12. Nichols DH. Anterior colporrhaphy. In: Nichols DH, ed. Vaginal surgery. 4th ed. Baltimore: Williams and Wilkins 1996:218–56.
13. Tobin CE, Benjamin JA. Anatomical and surgical restudy of Denonvillier’s fascia. Surg Obstet Gynecol 1945;80: 373–88.
14. Monga A. Fascia – defects and repair. Curr Opin Obstet Gynecol 1996;8:366–71.[Medline]
15. Richardson AC, Lyons JB, Williams NL. A new look at pelvic relaxation. Am J Obstet Gynecol 1976;126:568–73.[Medline]
16. Ricci JV, Thom CH, Kron WL. Cleavage planes in reconstructive vaginal surgery. Am J Surg 1948;76:354–63.[Medline]
17. Weber AM, Walters MD. Anterior vaginal prolapse: Review of anatomy and techniques of surgical repair. Obstet Gynecol 1997;89:311–8.[Abstract]
This article has been cited by other articles:
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  G. R McCracken and G. Lefebvre Mesh-free anterior vaginal wall repair: history or best practice? Obstet Gynaecol (Lond), October 1, 2007; 9(4): 233 - 242. [Abstract] [Full Text] [PDF]
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