Cystocele and functional anatomy of the pelvic floor: review and update of the various theories.
OBJECTIVE
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.
Département de Chirurgie Urogynécologique, Hôpital Femme Mère Enfant, Université Claude Bernard Lyon 1, Villeurbanne, France. gery.lamblin@chu-lyon.fr.|Faculté de Médecine Henri Warembourg, Université Lille 2, 42 Rue Paul Duez, 59000, Lille, France. gery.lamblin@chu-lyon.fr.|Department of Urogynecology, Femme Mère Enfant University Hospital, 59 Boulevard Pinel, 69677, Lyon-Bron, France. gery.lamblin@chu-lyon.fr.
Géry
G
Lamblin
Service de Chirurgie Urologique, Hôpital Privé Sainte Marie, 4 Allée Saint Jean des Vignes, 71100, Chalon-sur-Saône, France.
Emmanuel
E
Delorme
Faculté de Médecine Henri Warembourg, Université Lille 2, 42 Rue Paul Duez, 59000, Lille, France.|Clinique de Chirurgie Gynécologique, Hôpital Jeanne de Flandre, Université Lille 2, Avenue E Avinée, 59037, Lille Cedex, France.
Michel
M
Cosson
Faculté de Médecine Henri Warembourg, Université Lille 2, 42 Rue Paul Duez, 59000, Lille, France.|Clinique de Chirurgie Gynécologique, Hôpital Jeanne de Flandre, Université Lille 2, Avenue E Avinée, 59037, Lille Cedex, France.
Chrystèle
C
Rubod
D052858:Cystocele / Q000000981:diagnostic imaging / Q000503:physiopathology*; D005205:Fascia / Q000033:anatomy & histology / Q000000981:diagnostic imaging / Q000503:physiopathology; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008953:Models, Anatomic; D017773:Pelvic Floor / Q000033:anatomy & histology / Q000000981:diagnostic imaging / Q000503:physiopathology*; D014621:Vagina / Q000033:anatomy & histology / Q000000981:diagnostic imaging / Q000503:physiopathology*
Anatomy; Connective tissue; Cystocele; Endopelvic fascia; Pelvic floor; Pelvic mobility