Repair of severe anterior vaginal wall prolapse (grade IV cystourethrocele).

The classical approach for the repair of severe anterior vaginal wall prolapse is the use of transvaginal colporrhaphy or, more recently, an abdominal paravaginal repair. Severe cystoceles develop from weaknesses of the levator sling and pubocervical fasciae resulting in 2 main anatomical changes: a central defect between the pubocervical fasciae, and a sliding herniation of the bladder and urethra (paravaginal defect). We developed a new transvaginal technique for the repair of large cystoceles (grade IV) extending outside of the introitus at rest, which includes repair of the central defect by anterior colporrhaphy, and repair of the paravaginal herniation of the bladder base and bladder neck by a needle suspension of these structures. We report our experience within a 5-year period in the treatment of 51 cases of severe bladder prolapse (grade IV cystoceles), 46 of which required this combined procedure regardless of preoperative stress urinary incontinence status. Five patients underwent anterior colporrhaphy as the only procedure, since they were continent and demonstrated a well supported bladder neck from a previous suspension operation. Other vaginal abnormalities should be repaired simultaneously to provide adequate pelvic floor support.