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Cystocele and functional anatomy of the pelvic floor: review and update of the various theories

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Abstract

Introduction and hypothesis

We updated anatomic theories of pelvic organ support to determine pathophysiology in various forms of cystocele.

Methods

PubMed/MEDLINE, ScienceDirect, Cochrane Library, and Web of Science databases were searched using the terms pelvic floor, cystocele, anatomy, connective tissue, endopelvic fascia, and pelvic mobility. We retrieved 612 articles, of which 61 matched our topic and thus were selected. Anatomic structures of bladder support and their roles in cystocele onset were determined on the international anatomic classification; the various anatomic theories of pelvic organ support were reviewed and a synthesis was made of theories of cystocele pathophysiology.

Results

Anterior vaginal support structures comprise pubocervical fascia, tendinous arcs, endopelvic fascia, and levator ani muscle. DeLancey’s theory was based on anatomic models and, later, magnetic resonance imaging (MRI), establishing a three-level anatomopathologic definition of prolapse. Petros’s integral theory demonstrated interdependence between pelvic organ support systems, linking ligament–fascia lesions, and clinical expression. Apical cystocele is induced by failure of the pubocervical fascia and insertion of its cervical ring; lower cystocele is induced by pubocervical fascia (medial cystocele) or endopelvic fascia failure at its arcus tendineus fasciae pelvis attachment (lateral cystocele).

Conclusions

Improved anatomic knowledge of vaginal wall support mechanisms will improve understanding of cystocele pathophysiology, diagnosis of the various types, and surgical techniques. The two most relevant theories, DeLancey’s and Petros’s, are complementary, enriching knowledge of pelvic functional anatomy, but differ in mechanism. Three-dimensional digital models could integrate and assess the mechanical properties of each anatomic structure.

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Abbreviations

ATFP:

Arcus tendineus fasciae pelvis

ATLA:

Arcus tendineus levator ani

CL:

Cardinal ligament

EF:

Endopelvic fascia

LAM:

Levator ani muscle

PB:

Perineal body

PCF:

Pubocervical fascia

USL:

Uterosacral ligament

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Acknowledgments

Sincere thanks to Dr. Eric Voiglio, surgeon and Lyon Medical School anatomist, for the anatomic diagrams (Figs. 1 and 2).

Conflicts of interest

Chrystèle Rubod is a consultant for Olympus. Michel Cosson led training courses with Boston, AMS, and Olympus, and is also a consultant, accepting honoraria and payment for research from Allergan, Boston, and AMS.

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Authors and Affiliations

  1. Département de Chirurgie Urogynécologique, Hôpital Femme Mère Enfant, Université Claude Bernard Lyon 1, Villeurbanne, France

    Géry Lamblin

  2. Faculté de Médecine Henri Warembourg, Université Lille 2, 42 Rue Paul Duez, 59000, Lille, France

    Géry Lamblin, Michel Cosson & Chrystèle Rubod

  3. Service de Chirurgie Urologique, Hôpital Privé Sainte Marie, 4 Allée Saint Jean des Vignes, 71100, Chalon-sur-Saône, France

    Emmanuel Delorme

  4. Clinique de Chirurgie Gynécologique, Hôpital Jeanne de Flandre, Université Lille 2, Avenue E Avinée, 59037, Lille Cedex, France

    Michel Cosson & Chrystèle Rubod

  5. Department of Urogynecology, Femme Mère Enfant University Hospital, 59 Boulevard Pinel, 69677, Lyon-Bron, France

    Géry Lamblin

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  1. Géry Lamblin
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  2. Emmanuel Delorme
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  4. Chrystèle Rubod
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Correspondence to Géry Lamblin.

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Lamblin, G., Delorme, E., Cosson, M. et al. Cystocele and functional anatomy of the pelvic floor: review and update of the various theories. Int Urogynecol J 27, 1297–1305 (2016). https://doi.org/10.1007/s00192-015-2832-4

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  • DOI: https://doi.org/10.1007/s00192-015-2832-4

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