- Email: [email protected]
Histologic examination of “fascia” used in colporrhaphy
Histologic Examination of “Fascia” Used in Colporrhaphy Scott A. Farrell, MD, Tina Dempsey, MD, and Laurette Geldenhuys, MD OBJECTIVE: To perform a histologic examination of tissue identified as fascia and used during colporrhaphy. 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. (Obstet Gynecol 2001;98:794 – 8. © 2001 by the American College of Obstetricians and Gynecologists.)
Many gynecologic surgeons believe that the identification and use of tissue referred to as “fascia” is essential to From the Departments of Obstetrics and Gynaecology, and Anatomical Pathology, Dalhousie University, Halifax, Nova Scotia, Canada. This study was supported by a grant from the Atlee Foundation of the Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada.
794
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. MATERIALS AND METHODS Women who were scheduled to undergo a primary surgical correction of pelvic organ prolapse, which included both an anterior and posterior colporrhaphy, were enrolled in this study. The protocol was approved by the institutional ethical review board. All women were encouraged to use a vaginal estrogen cream preoperatively. Women who underwent previous pelvic prolapse surgery, other than a vaginal hysterectomy, were excluded. If necessary, a vaginal hysterectomy was performed before colporrhaphy. The vaginal wall was opened anteriorly and posteriorly in the same fashion using scissors tips to dissect the underlying bladder and rectum from the overlying vaginal wall by blunt dissection.12 Blunt dissection was followed by a sharp
VOL. 98, NO. 5, PART 1, NOVEMBER 2001 © 2001 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
0029-7844/01/$20.00 PII S0029-7844(01)01533-2
Figure 1. Photomicrograph (⫻200 original magnification) of vaginal wall biopsy. Farrell. Histology of Gynecologic Fascia. Obstet Gynecol 2001.
vertical midline incision. The vaginal walls on each side were grasped by T-clamps, and sharp dissection using scissors was carried laterally from the midline to separate the bladder and rectum from the vaginal wall. When the vaginal wall was dissected satisfactorily from the underlying organs, hemostasis was achieved by cautery, and the area was washed with normal saline. Three surgically distinct tissues were identified: the vaginal wall, the surgical fascia, and areolar tissue in both the anterior and posterior dissections. Two biopsies of each of these tissues were taken in both the anterior and posterior compartments for a total of 12 biopsies from each patient. Photographs were taken of the biopsy sites. The biopsies were placed on a small square of telfa and preserved in formalin. Each biopsy was identified only by a letter and number, ensuring that the pathologist was blinded as to the surgical diagnosis. Biopsies were stained using hematoxylin-eosin, Masson trichrome for collagen, Movat for elastin, and immunoperoxidase for actin in smooth muscle. The specimens were examined microscopically for histologic content as well as for the presence of collagen, smooth muscle, and elastin. The results of the histologic examination were then compared with the surgical diagnosis for accuracy using the histologic appearance as the “gold standard.” RESULTS A total of 60 biopsies were taken from five patients. Specimens from two patients were subsequently disqual-
VOL. 98, NO. 5, PART 1, NOVEMBER 2001
ified: the first because the woman had undergone a previous anterior colporrhaphy, and the second because the specimens were not properly labeled. These specimens, although excluded, were consistent histologically with the specimens included in the analysis. The pathologist identified three tissue types based upon the hematoxylin-eosin–stained specimens: type I, vaginal mucosa and underlying dense connective tissue, which was composed of large amounts of collagen, smooth muscle, and elastin (Figure 1); 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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Histology of Gynecologic Fascia
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Figure 2. Photomicrograph (⫻200 original magnification) of vaginal “fascia.” Farrell. Histology of Gynecologic Fascia. Obstet Gynecol 2001.
DISCUSSION In this study, surgical “fascia” had the histologic appearance of moderately dense connective tissue. This tissue was indistinguishable from the deep layer of the vaginal wall using the criteria of cellular components as well as
the criteria of distribution of collagen, smooth muscle, and elastin. These findings confirm eloquent work done by previous authors who clearly demonstrated that there is no distinct layer of fascia lying between either the bladder or the rectum and the vaginal wall. Goff et al
Figure 3. Photomicrograph (⫻200 original magnification) of areolar tissue. Farrell. Histology of Gynecologic Fascia. Obstet Gynecol 2001.
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Farrell et al
Histology of Gynecologic Fascia
OBSTETRICS & GYNECOLOGY
studied a nulliparous woman aged 27 years by taking cross sections through the anterior and posterior vagina and adjacent organs.4 He found only a thin layer of fascia of the areolar type and concluded that successful prolapse surgery must use the tissues of the vaginal wall rather than this “fragile areolar fascia.” Ricci et al conducted an extensive examination of the histologic makeup of cross sections taken through the bladder, vagina, and rectum in cadaver specimens ranging in age from a 4-month-old fetus to a 72-year-old multiparous woman.3 He concluded that “there is no microscopic evidence whatsoever to substantiate belief in the existence of a so-called ‘fascia’ between the urethra and the vagina, between the bladder and the vagina, between the rectum and the vagina, predicated on the basic concept that a fascia is a connective tissue sheet of variable thickness that possesses tensile strength. Such designations as urethrovaginal, vesicovaginal, pubocervical, pubovesical cervical, uteropubic, and rectovaginal fascias are gynecologic misconceptions.” Other authors conducting similar—though less extensive—studies have drawn the same conclusions.6 – 8 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
VOL. 98, NO. 5, PART 1, NOVEMBER 2001
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
Farrell et al
Histology of Gynecologic Fascia
797
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. REFERENCES 1. Emmet TA. A study of the etiology of perineal laceration with a new method for its proper repair. Trans Am Gynecol Soc 1883;8:210 –5. 2. Uhlenhuth E, Day EC, Smith RD, Middleton EB. The visceral endopelvic fascia and the hypogastric sheath. Surg Gynecol Obstet 1948;86:9 –28. 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. 6. Goff BH. The surgical anatomy of cystocele and urethrocele with special reference to the pubocervical fascia. Surg Gynecol Obstet 1948;87:725–34.
798
Farrell et al
Histology of Gynecologic Fascia
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. 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. 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. 15. Richardson AC, Lyons JB, Williams NL. A new look at pelvic relaxation. Am J Obstet Gynecol 1976;126:568 –73. 16. Ricci JV, Thom CH, Kron WL. Cleavage planes in reconstructive vaginal surgery. Am J Surg 1948;76:354 – 63. 17. Weber AM, Walters MD. Anterior vaginal prolapse: Review of anatomy and techniques of surgical repair. Obstet Gynecol 1997;89:311– 8. 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: [email protected]. Received February 27, 2001. Received in revised form June 12, 2001. Accepted June 21, 2001.
OBSTETRICS & GYNECOLOGY
Many gynecologic surgeons believe that the identification and use of tissue referred to as “fascia” is essential to From the Departments of Obstetrics and Gynaecology, and Anatomical Pathology, Dalhousie University, Halifax, Nova Scotia, Canada. This study was supported by a grant from the Atlee Foundation of the Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada.
794
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. MATERIALS AND METHODS Women who were scheduled to undergo a primary surgical correction of pelvic organ prolapse, which included both an anterior and posterior colporrhaphy, were enrolled in this study. The protocol was approved by the institutional ethical review board. All women were encouraged to use a vaginal estrogen cream preoperatively. Women who underwent previous pelvic prolapse surgery, other than a vaginal hysterectomy, were excluded. If necessary, a vaginal hysterectomy was performed before colporrhaphy. The vaginal wall was opened anteriorly and posteriorly in the same fashion using scissors tips to dissect the underlying bladder and rectum from the overlying vaginal wall by blunt dissection.12 Blunt dissection was followed by a sharp
VOL. 98, NO. 5, PART 1, NOVEMBER 2001 © 2001 by The American College of Obstetricians and Gynecologists. Published by Elsevier Science Inc.
0029-7844/01/$20.00 PII S0029-7844(01)01533-2
Figure 1. Photomicrograph (⫻200 original magnification) of vaginal wall biopsy. Farrell. Histology of Gynecologic Fascia. Obstet Gynecol 2001.
vertical midline incision. The vaginal walls on each side were grasped by T-clamps, and sharp dissection using scissors was carried laterally from the midline to separate the bladder and rectum from the vaginal wall. When the vaginal wall was dissected satisfactorily from the underlying organs, hemostasis was achieved by cautery, and the area was washed with normal saline. Three surgically distinct tissues were identified: the vaginal wall, the surgical fascia, and areolar tissue in both the anterior and posterior dissections. Two biopsies of each of these tissues were taken in both the anterior and posterior compartments for a total of 12 biopsies from each patient. Photographs were taken of the biopsy sites. The biopsies were placed on a small square of telfa and preserved in formalin. Each biopsy was identified only by a letter and number, ensuring that the pathologist was blinded as to the surgical diagnosis. Biopsies were stained using hematoxylin-eosin, Masson trichrome for collagen, Movat for elastin, and immunoperoxidase for actin in smooth muscle. The specimens were examined microscopically for histologic content as well as for the presence of collagen, smooth muscle, and elastin. The results of the histologic examination were then compared with the surgical diagnosis for accuracy using the histologic appearance as the “gold standard.” RESULTS A total of 60 biopsies were taken from five patients. Specimens from two patients were subsequently disqual-
VOL. 98, NO. 5, PART 1, NOVEMBER 2001
ified: the first because the woman had undergone a previous anterior colporrhaphy, and the second because the specimens were not properly labeled. These specimens, although excluded, were consistent histologically with the specimens included in the analysis. The pathologist identified three tissue types based upon the hematoxylin-eosin–stained specimens: type I, vaginal mucosa and underlying dense connective tissue, which was composed of large amounts of collagen, smooth muscle, and elastin (Figure 1); 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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Histology of Gynecologic Fascia
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Figure 2. Photomicrograph (⫻200 original magnification) of vaginal “fascia.” Farrell. Histology of Gynecologic Fascia. Obstet Gynecol 2001.
DISCUSSION In this study, surgical “fascia” had the histologic appearance of moderately dense connective tissue. This tissue was indistinguishable from the deep layer of the vaginal wall using the criteria of cellular components as well as
the criteria of distribution of collagen, smooth muscle, and elastin. These findings confirm eloquent work done by previous authors who clearly demonstrated that there is no distinct layer of fascia lying between either the bladder or the rectum and the vaginal wall. Goff et al
Figure 3. Photomicrograph (⫻200 original magnification) of areolar tissue. Farrell. Histology of Gynecologic Fascia. Obstet Gynecol 2001.
796
Farrell et al
Histology of Gynecologic Fascia
OBSTETRICS & GYNECOLOGY
studied a nulliparous woman aged 27 years by taking cross sections through the anterior and posterior vagina and adjacent organs.4 He found only a thin layer of fascia of the areolar type and concluded that successful prolapse surgery must use the tissues of the vaginal wall rather than this “fragile areolar fascia.” Ricci et al conducted an extensive examination of the histologic makeup of cross sections taken through the bladder, vagina, and rectum in cadaver specimens ranging in age from a 4-month-old fetus to a 72-year-old multiparous woman.3 He concluded that “there is no microscopic evidence whatsoever to substantiate belief in the existence of a so-called ‘fascia’ between the urethra and the vagina, between the bladder and the vagina, between the rectum and the vagina, predicated on the basic concept that a fascia is a connective tissue sheet of variable thickness that possesses tensile strength. Such designations as urethrovaginal, vesicovaginal, pubocervical, pubovesical cervical, uteropubic, and rectovaginal fascias are gynecologic misconceptions.” Other authors conducting similar—though less extensive—studies have drawn the same conclusions.6 – 8 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
VOL. 98, NO. 5, PART 1, NOVEMBER 2001
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
Farrell et al
Histology of Gynecologic Fascia
797
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. REFERENCES 1. Emmet TA. A study of the etiology of perineal laceration with a new method for its proper repair. Trans Am Gynecol Soc 1883;8:210 –5. 2. Uhlenhuth E, Day EC, Smith RD, Middleton EB. The visceral endopelvic fascia and the hypogastric sheath. Surg Gynecol Obstet 1948;86:9 –28. 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. 6. Goff BH. The surgical anatomy of cystocele and urethrocele with special reference to the pubocervical fascia. Surg Gynecol Obstet 1948;87:725–34.
798
Farrell et al
Histology of Gynecologic Fascia
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. 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. 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. 15. Richardson AC, Lyons JB, Williams NL. A new look at pelvic relaxation. Am J Obstet Gynecol 1976;126:568 –73. 16. Ricci JV, Thom CH, Kron WL. Cleavage planes in reconstructive vaginal surgery. Am J Surg 1948;76:354 – 63. 17. Weber AM, Walters MD. Anterior vaginal prolapse: Review of anatomy and techniques of surgical repair. Obstet Gynecol 1997;89:311– 8. 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: [email protected]. Received February 27, 2001. Received in revised form June 12, 2001. Accepted June 21, 2001.
OBSTETRICS & GYNECOLOGY