ABSTRACT

The support of the anterior vaginal wall, with its overlying bladder and urethra, is dependent

upon the inherent strength of the pubocervical fascia and its lateral attachment to the pelvic

sidewalls. Specifically, the pubocervical fascia is attached to the arcus tendineus fascia pelvis

(also termed “the white line”). The arcus tendineus fascia pelvis is a condensation of intervening

connective tissue overlying the obturator internus muscle (Fig. 1). Upon vaginal inspection the

anterior lateral vaginal sulcus shows excellent support when the pubocervical fascia and the

arcus tendineus are intact (Fig. 2). Loss of the lateral vaginal attachment to the pelvic sidewall

is called a paravaginal defect and usually results in a cystourethrocele, urethral hypermobility,

and/or stress urinary incontinence (Fig. 3). Vaginal inspection in patients with bilateral paravaginal defects reveals loss of anterior vaginal wall support with detachment of the

lateral sulci, resulting in a displacement cystocele (Fig. 4). White (1) first described the para-

vaginal repair in 1909, but it did not gain popularity until decades later, when Richardson

(2,3) and Shull (4,5) described their abdominal and vaginal approaches to this type of anterior

wall repair. Paravaginal defect repair has been described using not only vaginal and open

abdominal approaches but also, more recently, via a laparoscopic approach (6-8).