to describe a new technique of paravaginal repair , utilizing prolene mesh and a hernia stapler . we conducted a retrospective case series review of 12 patients who underwent laparoscopic bladder neck suspension , who were clinically diagnosed with cystocele caused by paravaginal defects . all procedures were completed without incident . no additional blood loss or other morbidity has been identified . this procedure is potentially an alternative method for performing the paravaginal repair by a minimally invasive route . we feel that this makes the procedure potentially safer , quicker , and more accessible to laparoscopic surgeons but with equal effectiveness . larger series with more rigorous analysis are required before the procedure can be evaluated adequately and recommended for general use . the history of laparoscopic surgery comprises examples of surgeons applying minimally invasive techniques to standard procedures . first , the standard laparotomy technique is used , adapted as little as possible to the constraints of laparoscopy . then effort and ingenuity are applied to finding ways to make the procedure easier and more accessible , frequently by using innovative instrumentation or equipment . white first described the paravaginal repair as an anatomically correct procedure to repair cystocele caused by detachment of the vesicovaginal fascia from the arcus tendineus . the procedure has been described being done by laparotomy , by a vaginal approach and by laparoscopy . the standard procedure involves placing sutures from the lateral margins of the vagina to the ipsilateral arcus tendineus . the procedure is frequently awkward or technically difficult because of the angles involved in placing sutures into the depths of the space of retzius . five years ago , we began doing bladder neck suspensions , using a laparoscopic mesh and staple method described by ou et al . eleven patients who were scheduled for laparoscopic bladder neck suspension based on physical examination and cystometrogram were found to have first degree cystocele or worse . a pelvic organ prolapse quantitation examination was performed , and point aa ( the relationship of the point 3 cm from the hymeneal meatus to the hymeneal ring while straining ) was at -2 or below in all patients . informed consent was obtained , and the patients had paravaginal repairs done at the same time as their bladder neck suspensions . see figure 1 . the laparoscope is placed through the umbilicus in a 10-mm optivue sheath ( ethicon endo - surgery , cincinnati , oh ) . a second 10-mm optivue sheath is placed in the left lateral position , and a 5-mm step expanding sheath is used in the right lateral position ( autosuture step , tyco healthcare , norwalk , ct ) . dissection is done with disposable laparoscopic scissors and a harmonic scalpel ( ultracision , ethicon endo - surgery , cincinnati , oh ) . bipolar cautery is used for hemostasis . after the hysterectomy and any cul de sac repairs are completed , the space of retzius is entered by making a transverse incision about 2 inches above the pubic symphisis . the incision extends from 1 obliterated umbilical artery to the other and is placed cephalad to the dome of the bladder . the bladder neck repair is accomplished using 24-cm rectangles of prolene mesh stapled on either side of the bladder neck and suspended to cooper 's ligament . two pieces of prolene hernia mesh , cut in a semitrapezoidal shape with the apex 1-cm across and the base 5-cm , are used . the front edge of each piece of mesh is vertical , and the rear edge angles down to the base . the lateral vagina is supported by the fingers of the operator 's left hand , while the wide edge of the mesh is stapled to the vaginal margin with the helical tacker . the upper edge is tacked to cooper 's ligament next to the bladder neck repair . the vertical height of the mesh is about 4 cm so that this leaves a suspension gap and avoids over elevating the vagina . after the repair the peritoneum is reapproximated either with the stapler or with a continuous suture of vicryl . the cystoscopies showed no staples perforating from the repair , and no instance was noted of ureteral compromise . space of retzius showing the placement of mesh and staples relative to the bladder neck and paravaginal defects . see figure 1 . the laparoscope is placed through the umbilicus in a 10-mm optivue sheath ( ethicon endo - surgery , cincinnati , oh ) . a second 10-mm optivue sheath is placed in the left lateral position , and a 5-mm step expanding sheath is used in the right lateral position ( autosuture step , tyco healthcare , norwalk , ct ) . dissection is done with disposable laparoscopic scissors and a harmonic scalpel ( ultracision , ethicon endo - surgery , cincinnati , oh ) . bipolar cautery is used for hemostasis . after the hysterectomy and any cul de sac repairs are completed , the space of retzius is entered by making a transverse incision about 2 inches above the pubic symphisis . the incision extends from 1 obliterated umbilical artery to the other and is placed cephalad to the dome of the bladder . the bladder neck repair is accomplished using 24-cm rectangles of prolene mesh stapled on either side of the bladder neck and suspended to cooper 's ligament . two pieces of prolene hernia mesh , cut in a semitrapezoidal shape with the apex 1-cm across and the base 5-cm , are used . the front edge of each piece of mesh is vertical , and the rear edge angles down to the base . the lateral vagina is supported by the fingers of the operator 's left hand , while the wide edge of the mesh is stapled to the vaginal margin with the helical tacker . the upper edge is tacked to cooper 's ligament next to the bladder neck repair . the vertical height of the mesh is about 4 cm so that this leaves a suspension gap and avoids over elevating the vagina . after the repair the peritoneum is reapproximated either with the stapler or with a continuous suture of vicryl . the cystoscopies showed no staples perforating from the repair , and no instance was noted of ureteral compromise . space of retzius showing the placement of mesh and staples relative to the bladder neck and paravaginal defects . we have done 12 of these repairs over the last 3 years with good short - term results ( table 1 ) . subjective success is defined as a positive answer to the question  is your bladder well supported ? objective success is defined by the number ba ( ba is defined as the difference between point ba , the point of greatest descensus on the anterior vaginal wall related to the hymeneal ring , preoperatively and postoperatively ) . adverse effects are defined as a positive answer to the question  do you have urge incontinence , dyspareunia , bladder , or vaginal pain ? she had the feeling that her bladder was dropping but did not have stress urinary incontinence . no increase in blood loss was encountered , and the increase in operating time was estimated at 15 minutes . ba is defined as the difference between point ba , the point of greatest descensus on the anterior vaginal wall related to the hymeneal ring , preoperatively and postoperatively . we feel that this technique may provide a good alternative to the standard laparoscopic suture paravaginal repair and is technically easier to perform . using staples and mesh for both the bladder neck suspension and the paravaginal repair makes placement of the support to the bladder neck and vagina easier to accomplish laparoscopically , and we feel that it makes for a more secure and reliable repair . we hypothesize that the mesh provides a framework for reparative fibrosis to reinforce the repair so that it will become sturdier as time passes , although this is yet to be proven . use of sutures requires greater time and dexterity for adequate placement of support and , we feel , is more likely to be inconsistent , less reproducible , and less reliable . the risk of bladder perforation and the possibility of hemorrhage should be no greater for the staple technique than for the standard technique . so far , in our hands , the operation causes minimal morbidity and appears to be safe and effective in our small series with short follow - up . our short - term results have been promising , though it is obvious that longer - term follow - up and a larger series will be required before the procedure can become part of the mainstream surgical armamentarium . we hope that in the future a larger series with sufficient numbers , controls , and randomization will be undertaken .
objective : to describe a new technique of paravaginal repair , utilizing prolene mesh and a hernia stapler.methods:we conducted a retrospective case series review of 12 patients who underwent laparoscopic bladder neck suspension , who were clinically diagnosed with cystocele caused by paravaginal defects . 
 the patients had paravaginal repair performed utilizing mesh and staples . 
 prolene mesh was stapled to the vaginal margin and suspended from cooper 's ligament . 
 the technique is described and demonstrated in a line drawing.results:all procedures were completed without incident . 
 no additional blood loss or other morbidity has been identified . 
 results were evaluated by history and examination . 
 subjective improvement was noted in 10 of 11 patients . 
 objective improvement was found in 9 of 11 . 
 adverse effects were not identified . 
 one patient was lost to follow-up.conclusion:this procedure is potentially an alternative method for performing the paravaginal repair by a minimally invasive route . 
 we feel that this makes the procedure potentially safer , quicker , and more accessible to laparoscopic surgeons but with equal effectiveness . 
 larger series with more rigorous analysis are required before the procedure can be evaluated adequately and recommended for general use .