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Anterior Colporrhaphy

Anterior colporrhaphy is an established native-tissue transvaginal repair for anterior vaginal wall prolapse (cystocele). The FDA ordered manufacturers to stop selling transvaginal mesh devices for pelvic organ prolapse (POP) in the US in April 2019; this did not prohibit native-tissue repair, SUI slings or transabdominal POP mesh.[1][2][3][19]

Definition and Indications​

Anterior colporrhaphy addresses prolapse of the bladder (cystocele) or urethra into the anterior vaginal wall. The indication is bothersome prolapse with shared treatment choice, not a fixed POP-Q stage or a requirement to fail every nonsurgical option. NICE NG123 offers surgery when nonsurgical treatment has not helped or has been declined, with discussion of pessary, pelvic-floor training and other relevant choices.[20] NICE recommends anterior repair without mesh for anterior vaginal wall prolapse.[20] Assess the apex and other compartments before choosing an isolated anterior repair.[12]

Surgical Technique​

The procedure can be performed under regional or general anesthesia:[1][3]

  1. Midline incision in the vaginal mucosa overlying the bladder and urethra
  2. Dissection in a plane directly below the vagina exposes the damaged pubocervical (fibromuscular) layer supporting the bladder
  3. The fascia is plicated in the midline with delayed-absorbable or permanent sutures
  4. Excessive vaginal skin may be trimmed
  5. The vaginal skin is closed
  6. Other sites of prolapse are repaired as required
  7. Perform cystoscopy to inspect the bladder and confirm efflux from both ureteral orifices after the repair; evaluate absent efflux or a suspected bladder suture before completing the operation.[29]

The distal extent of the incision and the plication construct vary by surgeon. Tarsi and colleagues describe extending the incision to about 1.5 cm proximal to the urethral meatus, stopping at least 3 cm proximal to the meatus when a concomitant midurethral sling is planned, to leave room for the separate sling incision.[23] The vaginal wall is dissected directly off the pubocervical fascia along its glistening surface; in a repeat anterior colporrhaphy, scarring can obscure this plane and increase bleeding risk.[24] For the midline plication itself, Hendrickson and Barber describe starting at the urethrovesical junction with 2-0 or 0 delayed-absorbable suture tied without excessive tension, using one or two plication rows or a purse-string followed by plication depending on the defect; they and Tarsi and colleagues both caution that bites should stay shallow and tension-free to avoid incorporating the bladder, and that one or two additional urethral-support sutures may contribute to postoperative voiding difficulty.[23][25]

Positioning and Room Setup​

Dorsal lithotomy with boot or candy-cane stirrups is the standard position for anterior colporrhaphy. Steep or prolonged lithotomy is a recognized cause of lower-extremity compartment syndrome; a German survey of gynecologic departments found all reported cases occurred in lithotomy, most after operations lasting more than 4 hours, and found no consensus prevention protocol across institutions.[21] Repositioning, padding and avoiding excessive hip flexion for a long combined-compartment case are reasonable precautions.[21] A urethral (Foley) catheter is commonly used intraoperatively to decompress the bladder and help define the dissection plane; it is not necessarily left in place afterward. In a randomized trial of vaginal prolapse surgery, 55% (17 women) assigned immediate postoperative catheter removal needed no postoperative catheterization, and immediate removal reduced symptomatic bacteriuria and length of stay compared with a suprapubic catheter left until a 48-hour voiding trial.[22] No anterior-colporrhaphy-specific VTE recommendation exists; treat it as reconstructive pelvic surgery and apply the general risk framework (age, obesity, prior VTE, malignancy, prolonged operation or immobility) on the VTE Prophylaxis page.

Variations​

VariationDescription
Ultralateral colporrhaphyPlication extended laterally for broader fascial coverage
Double-layered anterior colporrhaphy (DAC)Continuous suture followed by traditional interrupted sutures[6]
Paravaginal repairReattachment of lateral vaginal fascia to the arcus tendineus fascia pelvis (white line)
Transverse defect repairFor a transverse support defect, the redundant transverse fascial edge is sutured superiorly to the cervical stroma, as in a cervicopexy, before midline plication; described as a defect-specific variant, not shown to outperform standard plication[26]

Outcomes and Success Rates​

Success rates vary substantially depending on the definition used:

DefinitionSuccess rate
Clinically relevant (no prolapse beyond the hymen, no bulge symptoms and no retreatment)88% (66/75 evaluable women) at 1 year, from a 114-person trial of three anterior-repair techniques including a polyglactin-mesh arm[5]
Strict anatomic (POP-Q stage 0 or 1)13.2% at mean 74.1 mo among 68 analyzed women (50 anterior colporrhaphy alone; 18 with concurrent posterior colporrhaphy; 70 of 137 invited attended)[7]
Subjective success (absence of bulge symptoms)68.7% at mean 74.1 mo among 68 analyzed women (50 anterior colporrhaphy alone; 18 with concurrent posterior colporrhaphy)[7]
Patient satisfaction98.5% of 68 analyzed women (50 anterior colporrhaphy alone; 18 with concurrent posterior colporrhaphy) were satisfied; 66.1% of women with objective recurrence had no prolapse symptoms at mean 74.1 mo[7]

In a retrospective series of double-layered anterior colporrhaphy with concomitant vaginal hysterectomy and apical fixation, 49 of the 60 women examined (81.7%) had anatomic cure (prolapse below stage 2) at a median of 19.3 months.[6] In the Altman randomized trial, the composite of POP-Q stage 0 or 1 and no bulge symptoms was met by 34.5% of women after colporrhaphy at 1 year.[8]

Recurrence — The Central Challenge​

Recurrence is the primary limitation of anterior colporrhaphy. A 2026 Cochrane review of 41 RCTs (4,531 women) found:[4]

ComparatorRecurrence outcome
vs. biological graftAt 1–2 years, native tissue repair likely increases recurrent anterior prolapse (RR 1.53, 95% CI 1.19–1.97; moderate certainty); little to no difference in prolapse awareness, repeat surgery, or dyspareunia
vs. transvaginal permanent meshAt 1–2 years, native tissue repair is followed by more prolapse awareness (RR 1.77, moderate certainty), more recurrence (RR 3.21, low certainty) and more repeat surgery for prolapse (RR 2.17, moderate certainty); dyspareunia is similar and bladder injuries are fewer

Anatomic recurrence, prolapse awareness and repeat surgery are different endpoints.[4][19]

Suture Type​

Whether suture type meaningfully changes patient outcomes remains uncertain.[9] A published multicenter RCT protocol compares non-absorbable with absorbable sutures.[9]

Complications​

Safety estimates depend on what other procedures were done. Mothes et al. studied 438 women who all had both anterior and posterior colporrhaphy; many also had apical fixation or hysterectomy.[10] The Altman randomized comparison separately informs selected mesh-versus-native-tissue events.[8]

ComplicationReported source and scope
Intraoperative bladder or rectal injuryOne bladder lesion (0.23%) and one rectal lesion (0.23%) in the combined anterior/posterior repair cohort; the Altman anterior-repair arm reported 0.5% bladder perforation[10][8]
Urinary tract infection requiring antibiotics7.8% in the combined-repair cohort[10]
Postoperative postvoid residual requiring medical treatment5.5% in the combined-repair cohort[10]
Hemorrhage requiring reoperation0.9% in the combined-repair cohort[10]
New stress urinary incontinenceIn Altman's trial, 6.3% in the native-tissue arm versus 12.3% in the mesh arm[8]
Clavien-Dindo grade III1.8% in the combined-repair cohort[10]
Anterior-repair suture findings on cystoscopySeven of 346 anterior colporrhaphies (2.0%) in a cystoscopy series had previously unsuspected findings caused by anterior colporrhaphy sutures that required an intraoperative management change; the report identifies anterior colporrhaphy as its most common cause of unrecognized ureteral compromise[27]

No grade IV or V complications were reported in that 438-person combined-procedure assessment.[10] Counsel about bleeding, infection, bladder injury, voiding dysfunction, pain, dyspareunia and recurrent prolapse according to the individual's planned operations.[10]

Anterior Colporrhaphy vs. Transvaginal Mesh — Regulatory Context​

In the Altman et al. NEJM 2011 randomized trial (389 women), transvaginal mesh had higher composite success at 1 year (60.8% versus 34.5%), with:[8]

  • Longer operative times
  • More hemorrhage (mean estimated blood loss 84.7 ± 163.5 mL with mesh versus 35.4 ± 35.4 mL with colporrhaphy, p < 0.001; clinically significant intraoperative blood loss in 5 of 389 women (1.3%), all in the mesh group, including one EBL over 1000 mL with a subsequent retropubic hematoma)[8]
  • Higher bladder perforation (3.5% versus 0.5%, p = 0.07)[8]
  • More new SUI (12.3% versus 6.3%, p = 0.05)[8]
  • Surgical reintervention for mesh exposure in 3.2% of 186 mesh patients[8]

"As compared with anterior colporrhaphy, use of a standardized, trocar-guided mesh kit for cystocele repair resulted in higher short-term rates of successful treatment but also in higher rates of surgical complications and postoperative adverse events." — Altman D, et al. NEJM 2011

Subsequently, the FDA ordered manufacturers to stop selling transvaginal mesh for POP in the US in April 2019 because they had not shown a reasonable assurance of safety and effectiveness. No such device is currently marketed in the US. The order does not apply to SUI slings or transabdominal mesh (sacrocolpopexy).[19][30]

For deeper coverage of mesh-augmented repair indications, complications, and the regulatory timeline, see Mesh & Graft-Augmented Prolapse Repair.

The Critical Role of Concomitant Apical Support​

Many women with anterior wall prolapse also have apical descent. Evaluate both; repair a clinically relevant apical defect. A large Medicare analysis associated concomitant apical support with less later prolapse surgery.[12]

In a 2,756-woman Medicare vaginal-repair cohort that included anterior-only, posterior-only and combined repairs, the anterior-only subgroups had these cumulative ten-year reoperation rates:[12]

GroupCumulative reoperation rate at 10 years
Isolated anterior repair20.2%
Anterior repair + concomitant apical suspension11.6% (p < 0.01)

A separate statewide hysterectomy analysis reported colpopexy in 24% of POP hysterectomies. That is a different population and denominator from the Medicare cohort.[13]

Concomitant Anti-Incontinence Surgery​

The OPUS trial randomized 337 women without stress-incontinence symptoms undergoing vaginal prolapse surgery. At 3 months, urinary incontinence or treatment occurred in 23.6% with a prophylactic sling versus 49.4% with sham.[15] At 12 months, urinary incontinence allowing for subsequent treatment was 27.3% versus 43.0%, respectively.[15] Bladder perforation, urinary tract infection, bleeding and incomplete emptying were more frequent with a sling.[15] NICE NG123 advises against surgery to prevent incontinence in women having surgery for prolapse who do not have incontinence (1.8.3).[20] For patients with prolapse and SUI, AUA/SUFU 2023 states that clinicians may perform a concomitant incontinence procedure after shared decision-making.[20][16]

Characterize baseline stress, urgency and mixed symptoms before that decision; a general incontinence evaluation is distinct from predicting postoperative SUI for this repair.[14] Burch retropubic colposuspension is a separate anti-incontinence operation.[11][16]

Placing plicating sutures at the urethrovesical junction during midline cystocele repair, as some authors recommend in most cases with the stated hope of reducing de novo SUI, is a different maneuver from a prophylactic sling.[28]

Long-Term Outcomes​

In one cohort followed to a mean of 74 months, patient satisfaction was high despite a low anatomic success rate.[7] A retrospective comparison of colporrhaphy, xenograft and mesh at a mean of 95 months (109 women) found no significant difference in objective or subjective outcomes, and mesh was associated with more complications.[17] In a retrospective study of 181 women, 5-year objective cure was 64.4% after anterior colporrhaphy with sacrospinous fixation versus 89.1% after anterior-apical mesh (Surelift), with minor complications in both groups.[18]

Summary of Key Comparisons​

ComparisonProlapse awarenessAnatomic recurrenceRepeat surgeryDyspareuniaKey complications
AC vs. Biological GraftLittle to no difference (RR 1.20)[4]Higher with AC (RR 1.53)[4]Little to no difference (RR 0.99)[4]Little to no difference in reported dyspareunia (RR 0.87; 2 RCTs, 151 women)[4]—
AC vs. historical transvaginal permanent meshHigher with AC (RR 1.77)[4]Higher with AC (RR 3.21)[4]Higher with AC (RR 2.17)[4]No clear differencePOP mesh is not marketed in the US[19]
AC + apical suspension vs. AC alone (Medicare observational)Not reportedNot established by this claim11.6% vs. 20.2% at 10 yr (observational association)[12]Not reported—

Current Practice Recommendations​

Practice points:

  • Offer surgery for bothersome prolapse when nonsurgical treatment has not helped or is declined, after discussing alternatives, goals and operative risk (NICE NG123 1.8.1, 1.8.2).[20]
  • Offer a review 6 months after prolapse surgery with a vaginal examination, and ensure access to further referral for recurrent symptoms or suspected complications (NICE NG123 1.8.24–1.8.25).[20]
  • Assess apical support and address a coexisting clinically relevant defect; the Medicare association is observational.[12]
  • Discuss symptom, retreatment and anatomic outcomes separately; biological grafts and historical vaginal mesh show different trade-offs in the anterior Cochrane review.[4]
  • Discuss occult or de novo SUI and a concomitant anti-incontinence procedure using actual trial endpoints, harms, patient preference and the relevant local guideline; avoid routine prophylactic-sling language.[15][16][20] The 2026 Cochrane review found that adding a midurethral sling to vaginal prolapse surgery probably reduced postoperative subjective SUI in women with occult SUI (RR 0.38, 95% CI 0.26–0.55; five RCTs, 369 women; moderate certainty), but found probably no difference among women classified as stress-continent (RR 0.69, 95% CI 0.47–1.00; one RCT, 220 women; moderate certainty).[1]

See Also​

Videos​

Anterior Colporrhaphy with Deep Dissection Technique
DrHappyVagina (2025)
Cystocele Repair: Anterior Colporrhaphy
Urogynecology for Beginners (2022)

References​

1. Baessler K, Christmann-Schmid C, Haya N, et al. "Surgery for Women With Pelvic Organ Prolapse With or Without Stress Urinary Incontinence." Cochrane Database Syst Rev. 2026;2:CD013108. doi:10.1002/14651858.CD013108.pub2

2. Committee on Practice Bulletins—Gynecology and American Urogynecologic Society. "Pelvic Organ Prolapse: ACOG Practice Bulletin, Number 214." Obstet Gynecol. 2019;134(5):e126-e142. doi:10.1097/AOG.0000000000003519

3. Yeung E, Baessler K, Christmann-Schmid C, et al. "Transvaginal Mesh or Grafts or Native Tissue Repair for Vaginal Prolapse." Cochrane Database Syst Rev. 2024;3:CD012079. doi:10.1002/14651858.CD012079.pub2

4. Christmann-Schmid C, Baessler K, Yeung E, et al. "Surgery for Women With Anterior Compartment Prolapse." Cochrane Database Syst Rev. 2026;4:CD004014. doi:10.1002/14651858.CD004014.pub7

5. Chmielewski L, Walters MD, Weber AM, Barber MD. "Reanalysis of a Randomized Trial of 3 Techniques of Anterior Colporrhaphy Using Clinically Relevant Definitions of Success." Am J Obstet Gynecol. 2011;205(1):69.e1-8. doi:10.1016/j.ajog.2011.03.027

6. Graefe F, Schwab F, Tunn R. "Double-Layered Anterior Colporrhaphy (DAC) — Video and Mid-Term Follow-Up of 60 Patients." Int Urogynecol J. 2023;34(1):297-300. doi:10.1007/s00192-022-05216-3

7. Šumak R, Serdinšek T, But I. "Long-Term Follow-Up of Native Tissue Anterior Vaginal Wall Repair: Does the POP-Q Stage Really Reflect Patients' Satisfaction Rate?" Int Urogynecol J. 2020;31(10):2081-2088. doi:10.1007/s00192-020-04353-x

8. Altman D, Väyrynen T, Engh ME, et al. "Anterior Colporrhaphy versus Transvaginal Mesh for Pelvic-Organ Prolapse." N Engl J Med. 2011;364(19):1826-36. doi:10.1056/NEJMoa1009521

9. Jeon MJ, Suh DH, Kim CH, et al. "Non-Absorbable Versus Absorbable Sutures for Anterior Colporrhaphy: Study Protocol for a Randomised Controlled Trial in South Korea." BMJ Open. 2020;10(6):e034218. doi:10.1136/bmjopen-2019-034218

10. Mothes AR, Mothes HK, Radosa MP, Runnebaum IB. "Systematic Assessment of Surgical Complications in 438 Cases of Vaginal Native Tissue Repair for Pelvic Organ Prolapse Adopting Clavien-Dindo Classification." Arch Gynecol Obstet. 2015;291(6):1297-301. doi:10.1007/s00404-014-3549-1

11. Lapitan MCM, Cody JD, Mashayekhi A. "Open Retropubic Colposuspension for Urinary Incontinence in Women." Cochrane Database Syst Rev. 2017;7:CD002912. doi:10.1002/14651858.CD002912.pub7

12. Eilber KS, Alperin M, Khan A, et al. "Outcomes of Vaginal Prolapse Surgery Among Female Medicare Beneficiaries: The Role of Apical Support." Obstet Gynecol. 2013;122(5):981-987. doi:10.1097/AOG.0b013e3182a8a5e4

13. Fairchild PS, Kamdar NS, Berger MB, Morgan DM. "Rates of Colpopexy and Colporrhaphy at the Time of Hysterectomy for Prolapse." Am J Obstet Gynecol. 2016;214(2):262.e1-262.e7. doi:10.1016/j.ajog.2015.08.053

14. Committee on Practice Bulletins—Gynecology and the American Urogynecologic Society. "ACOG Practice Bulletin No. 155: Urinary Incontinence in Women." Obstet Gynecol. 2015;126(5):e66-e81. doi:10.1097/AOG.0000000000001148

15. Wei JT, Nygaard I, Richter HE, et al. "A Midurethral Sling to Reduce Incontinence after Vaginal Prolapse Repair." N Engl J Med. 2012;366(25):2358-67. doi:10.1056/NEJMoa1111967

16. Kobashi KC, Vasavada S, Bloschichak A, et al. "Updates to Surgical Treatment of Female Stress Urinary Incontinence (SUI): AUA / SUFU Guideline (2023)." J Urol. 2023;209(6):1091-1098. doi:10.1097/JU.0000000000003435

17. Balzarro M, Rubilotta E, Porcaro AB, et al. "Long-Term Follow-Up of Anterior Vaginal Repair: A Comparison Among Colporrhaphy, Colporrhaphy With Reinforcement by Xenograft, and Mesh." Neurourol Urodyn. 2018;37(1):278-283. doi:10.1002/nau.23288

18. Lo TS, Rellora LE, Rom E, et al. "Long-Term Outcome of Anterior-Apical Mesh (Surelift) Versus Anterior Colporrhaphy and Sacrospinous Ligament Fixation in Advanced Pelvic Organ Prolapse Surgery." Int Urogynecol J. 2025;36(4):857-866. doi:10.1007/s00192-025-06105-1

19. US Food and Drug Administration. Urogynecologic Surgical Mesh Implants. Current FDA device-use and 2019 POP-mesh stop-sale overview. Accessed September 20, 2026.

20. National Institute for Health and Care Excellence. Urinary Incontinence and Pelvic Organ Prolapse in Women: Management (NG123), Recommendations. Current online recommendations, sections 1.7–1.9. Accessed September 20, 2026.

21. Bauer EC, Koch N, Erichsen CJ, et al. "Survey of Compartment Syndrome of the Lower Extremity After Gynecological Operations." Langenbecks Arch Surg. 2014;399(3):343-8. doi:10.1007/s00423-014-1172-z

22. Bray R, Cartwright R, Digesu A, et al. "A Randomised Controlled Trial Comparing Immediate Versus Delayed Catheter Removal Following Vaginal Prolapse Surgery." Eur J Obstet Gynecol Reprod Biol. 2017;210:314-318. doi:10.1016/j.ejogrb.2017.01.015

23. Tarsi EJ, Winters JC, Rourke E, Krlin RM. Anterior Pelvic Organ Prolapse Repair. In: Smith JA Jr, Dmochowski RR, Thomas JC, Preminger GM, eds. Hinman's Atlas of Urologic Surgery. 5th ed. Elsevier; 2025:692-699.

24. Krlin R, Hallner B Jr, Rourke E, Winters JC. Vaginal and Abdominal Reconstructive Surgery for Pelvic Organ Prolapse. In: Partin AW, Dmochowski RR, Kavoussi LR, Peters CA, eds. Campbell-Walsh-Wein Urology. 13th ed. Elsevier; 2025:2426-2459.

25. Hendrickson WK, Barber MD. Anterior Vaginal Wall Prolapse. In: Cardozo L, Staskin D, eds. Textbook of Female Urology and Urogynecology. Vol 2: Surgical Perspectives. 5th ed. CRC Press; 2023:889-901. doi:10.1201/9781003144243-90

26. Huffaker RK, Kuehl TJ, Muir TW, Yandell PM, Pierce LM, Shull BL. "Transverse Cystocele Repair With Uterine Preservation Using Native Tissue." Int Urogynecol J Pelvic Floor Dysfunct. 2008;19(9):1275-1281. doi:10.1007/s00192-008-0629-4

27. Kwon CH, Goldberg RP, Koduri S, Sand PK. "The Use of Intraoperative Cystoscopy in Major Vaginal and Urogynecologic Surgeries." Am J Obstet Gynecol. 2002;187(6):1466-1471. doi:10.1067/mob.2002.129157

28. Karram MM. Native Tissue Vaginal Repair of Cystocele, Rectocele, and Enterocele. In: Baggish MS, Karram MM, eds. Atlas of Pelvic Anatomy and Gynecologic Surgery. 5th ed. Elsevier; 2021:623-670.

29. Cohen SA, Carberry CL, Smilen SW. "American Urogynecologic Society Consensus Statement: Cystoscopy at the Time of Prolapse Repair." Female Pelvic Med Reconstr Surg. 2018;24(4):258-259. doi:10.1097/SPV.0000000000000529

30. American College of Obstetricians and Gynecologists and American Urogynecologic Society. "Pelvic Organ Prolapse" (joint publication of ACOG Practice Bulletin No. 214). Female Pelvic Med Reconstr Surg. 2019;25(6):397-408. doi:10.1097/SPV.0000000000000794