Anterior vaginal repair


Dear Sir

Thank you for the interesting, beautifully illustrated practical paper by Reid and Smith regarding anterior vaginal repair.[1]

With respect to the paragraphs of ‘types of repair’ and ‘removal of skin’ the suggestion is made that removal or retention of skin is a matter of opinion. On this point may I draw attention to my previously published contention elsewhere[2, 3] that not only should a diamond-shaped area of skin be left attached, covering the bladder anteriorly (or if working posteriorly a triangular area of skin over the rectum) and certainly is better not excised. This patch, which I tend to call a ‘vascularised pedicle graft’ acts as a natural support avoiding any mesh, free graft[4] or foreign material[5] that lately is being introduced.

I agree that the all important fascial layer is in this way beautifully retained, blood loss is minimised, haematoma, infection and raw area is reduced as is sharp damage to the bladder (or rectum). Closing the residual, mobilised lateral skin flaps over the described retained area, then offers an excellent and strongly supported vaginal repair.

Authors' reply

Dear Sir

We are grateful for Dr Jotkowitz's interest and comments. The comments, with attached references, highlight the need for robust studies to determine the optimal technique for vaginal prolapse repair. The Health Technology Assessment-funded, multicentre, randomised, controlled trial of different types of vaginal prolapse repair, including the use of absorbable and non-absorbable mesh (PROSPECT) should give us some additional insight into this question but it will not report until 2014.

In the meantime, we must all audit the results of our surgery employing tools such as the British Society of Urogynaecology database to learn which technique produces the best results with the minimum of complications.