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Kelly Plication

The Kelly plication (also called the Kelly-Kennedy plication or Kelly suture) is one of the oldest surgical procedures for stress urinary incontinence (SUI), first described by Howard A. Kelly in the early 20th century. It is the bladder-neck-buttressing component of the anterior colporrhaphy and involves placing sutures in the periurethral tissue and pubocervical fascia to support and elevate the bladder neck.[1][2] It has largely been supplanted by midurethral slings and Burch colposuspension. Randomized comparisons in the cited review favored open abdominal retropubic suspension for long-term patient-reported continence, while that review had no direct trial against a suburethral sling.[1][3]

For modern anti-incontinence procedures with better long-term outcomes, see the Female SUI database, particularly Burch colposuspension, retropubic midurethral sling, and autologous fascial pubovaginal sling.

Definition and Technique​

The Kelly plication is performed transvaginally as part of or alongside an anterior colporrhaphy:[1]

  1. Midline incision in the anterior vaginal wall overlying the bladder and urethra
  2. The vaginal mucosa is dissected off the underlying periurethral tissue and pubocervical fascia, extending from below the urethra to just anterior to the cervix
  3. One to three sutures ("Kelly sutures") are placed in the periurethral tissue and pubocervical fascia to support and elevate the bladder neck
  4. The fascia is plicated in the midline, narrowing the bladder neck and proximal urethra
  5. Excess vaginal tissue may be trimmed, and the vaginal mucosa is closed

The procedure aims to lift and support the urethrovesical junction to restore the anatomic position needed for continence.[1][4]

Mechanism of Action​

The Kelly plication is intended to buttress the bladder neck and increase abdominal pressure transmission to the urethra. When successful, all three classic procedures (Kelly, Burch, Pereyra) significantly increase abdominal pressure transmission to the urethra on urodynamic testing.[5] However, the Kelly plication does not reposition the bladder neck into a high, supported retropubic position, a limitation that contributes to its higher failure rate compared with retropubic procedures.[4]

Variations​

VariantDescription
Kelly-Kennedy plicationMost commonly referenced variant
Marion Kelly techniqueHistorical modification
Bologna procedureVaginal-to-suprapubic suspension variant
DiaphragmplastyBroader fascial-imbrication variant
Modified Kelly with vaginal retropubic urethropexyBeck et al.'s historical series reported 75% cure with a Kelly-Kennedy-type technique versus 94% when it was modified to include vaginal retropubic urethropexy, for genuine SUI in a 194-patient subgroup[6]

Historical Comparative Series​

The following observational reports used different populations and follow-up intervals.[6][7]

StudynOutcome
Park & Miller 1988[7]680 women across three procedures, observed annually for up to 10 yrMore than 3 yr after surgery, Kelly 69% and Marshall–Marchetti–Krantz (MMK) 66% corrective; both exceeded original Pereyra in this cohort. MMK was most effective in the immediate postoperative period.
Beck 1991[6]519 anterior colporrhaphies over 25 yr; 194 patients treated for genuine SUIA Kelly-Kennedy-type technique was associated with 75% cure versus 94% when modified with vaginal retropubic urethropexy in the genuine-SUI subgroup.

Efficacy — Long-Term​

Continence rates after Kelly plication declined with longer follow-up in both studies below:[5][7]

Bergman & Elia 1995, 5-year prospective randomized study. 127 consecutive women were allocated to a procedure, 107 evaluated at 1 year and 93 at 5 years. Objective success among those evaluated at 5 years was:[5]

Procedure5-yr objective successDrop from yr 1 → yr 5
Kelly plication37%−26 percentage points
Pereyra needle suspension43%−22 percentage points
Burch colposuspension82%−7 percentage points

At 5 years in this trial, 30% of the evaluated Kelly group, 46% of the Pereyra group and 91% of the Burch group had a negative cotton-swab test, an anatomic outcome.[5] In Park & Miller's separate observational cohort, success declined with longer observation; more than 3 years after surgery the Kelly and MMK figures were 69% and 66%, respectively.[7]

Kelly Plication vs. Other Anti-Incontinence Procedures​

A small direct RCT in women with SUI and stage I–II cystocele compared anterior colporrhaphy with Kelly plication against transobturator tape: absence of incontinence at 1 year was 20/30 (66.7%) versus 24/30 (80%), respectively (p = 0.22).[16] One Kelly recipient had urinary retention after discharge and four reported dyspareunia, persistent in three.[16] In SISTEr, autologous PVS achieved 66% SUI-specific success but 47% strict overall success at 24 months; the Burch estimates were 49% and 38%.[12] Compare the dedicated Burch, MUS and PVS pages for population, endpoint, durability and complications.

Cochrane Review Evidence​

The Cochrane review on anterior vaginal repair for urinary incontinence (Glazener 2017; 10 trials, 1,012 women; register searched to 2009) reported:[1]

  • Anterior vaginal repair (including Kelly plication) was less effective than open abdominal retropubic suspension (mostly Burch, not exclusively): patient-reported failure 97/259 (38%) versus 57/327 (17%) at 1–5 yr (RR 2.29, 95% CI 1.70–3.08)[1]
  • The difference persisted beyond 5 yr: 49/128 (38%) versus 31/145 (21%) failure (RR 2.02, 95% CI 1.36–3.01)[1]
  • Repeat incontinence surgery was more frequent after anterior repair in three trials: 25/107 (23%) versus 4/164 (2%) (RR 8.87, 95% CI 3.28–23.94)[1]
  • Fewer women had prolapse after anterior repair (RR 0.24), but this did not translate into fewer prolapse operations[1]

This review found no evidence that anterior repair was better than its comparators for SUI, and favored open retropubic suspension on the reported continence endpoints. The authors suggested restricting anterior repair for SUI to women unsuitable for alternatives; current NICE guidance is more explicit against offering anterior colporrhaphy as SUI treatment.[1][13]

Network Meta-Analysis Ranking​

A BMJ network meta-analysis of 175 RCTs with 21,598 women (Imamura 2019) reported relative rankings for the cure outcome using SUCRA.[3]

  1. Traditional sling: 89.4%[3]
  2. Retropubic midurethral sling: 89.1%[3]
  3. Open colposuspension: 76.7%[3]
  4. Transobturator MUS: 64.1%[3]

Anterior vaginal repair or Kelly plication was not among the top-ranked procedures in the abstract, and the authors note that long-term data were limited.

Complications and Morbidity​

Historical anterior-colporrhaphy series reported the following harms. These series lack comparisons with contemporary injectables, retropubic procedures or slings:[6][7]

ComplicationRate
Significant morbidity (excluding incontinence)1% in 25-yr / 519-case series[6]
New-onset detrusor instability6% across surgeries in Beck's series; higher after incontinence than prolapse surgery[6]
De novo incontinence after prolapse surgery11% in one subgroup of Beck's series, not the entire 519-case cohort[6]
Repeat operationsMore likely to fail than primary repairs
Voiding dysfunction or outlet obstructionRecognized after Kelly-Kennedy repair. In a selected series of women referred with postoperative obstructive symptoms, 176 had undergone Kelly-Kennedy operations.[15]
Mesh-related complicationsNone (native-tissue procedure)

Current Role and Indications​

The Kelly plication is no longer considered a first-line anti-incontinence procedure. Evidence reviews and current guidelines frame its role as follows:[1][3][8][13][14]

  • Midurethral slings are the most commonly performed and most extensively studied anti-incontinence procedure, with documented short- and long-term efficacy[8][9]
  • Burch colposuspension and autologous fascial pubovaginal slings are the primary mesh-free alternatives[8][10]
  • NICE NG123 recommends against anterior colporrhaphy as a treatment for SUI (1.5.14). This is distinct from an anterior repair performed for symptomatic prolapse.[13] The AUA/SUFU 2023 SUI guideline excluded anterior colporrhaphy and Kelly plication from its review and makes no recommendation on them.[14]

Emerging Alternatives — Pubourethral Ligament Plication (PLP)​

Pubourethral ligament plication (PLP) is a distinct operation, not a modern Kelly plication. A 2026 prospective, nonrandomized cohort compared 48 PLP recipients with 92 transobturator-tape (TOT) recipients at 6 months. Pad-count-defined objective success was 77.1% for PLP versus 88.0% for TOT (p > 0.05); preoperative symptoms were more severe in the TOT group. PLP took less operative time, and the report found no mesh-related complications with PLP versus an 8.7% complication rate with TOT.[11]

Historical Significance​

The Kelly plication is one of the first described surgical treatments for female SUI. It introduced bladder-neck support as a treatment principle, and retropubic suspensions, needle suspensions and midurethral slings followed. Periurethral tissue plication remains part of anterior colporrhaphy technique.[1][2]

See Also​

References​

1. Glazener CM, Cooper K, Mashayekhi A. "Anterior Vaginal Repair for Urinary Incontinence in Women." Cochrane Database Syst Rev. 2017;7:CD001755. doi:10.1002/14651858.CD001755.pub2

2. Norton P, Brubaker L. "Urinary Incontinence in Women." Lancet. 2006;367(9504):57-67. doi:10.1016/S0140-6736(06)67925-7

3. Imamura M, Hudson J, Wallace SA, et al. "Surgical Interventions for Women With Stress Urinary Incontinence: Systematic Review and Network Meta-Analysis of Randomised Controlled Trials." BMJ. 2019;365:l1842. doi:10.1136/bmj.l1842

4. Raz S, Klutke CG, Golomb J. "Four-Corner Bladder and Urethral Suspension for Moderate Cystocele." J Urol. 1989;142(3):712-5. doi:10.1016/s0022-5347(17)38863-8

5. Bergman A, Elia G. "Three Surgical Procedures for Genuine Stress Incontinence: Five-Year Follow-Up of a Prospective Randomized Study." Am J Obstet Gynecol. 1995;173(1):66-71. doi:10.1016/0002-9378(95)90171-x

6. Beck RP, McCormick S, Nordstrom L. "A 25-Year Experience With 519 Anterior Colporrhaphy Procedures." Obstet Gynecol. 1991;78(6):1011-8. PMID 1945199

7. Park GS, Miller EJ Jr. "Surgical Treatment of Stress Urinary Incontinence: A Comparison of the Kelly Plication, Marshall-Marchetti-Krantz, and Pereyra Procedures." Obstet Gynecol. 1988;71(4):575-9. PMID 3353049

8. Wu JM. "Stress Incontinence in Women." N Engl J Med. 2021;384(25):2428-2436. doi:10.1056/NEJMcp1914037

9. Lukacz ES, Santiago-Lastra Y, Albo ME, Brubaker L. "Urinary Incontinence in Women: A Review." JAMA. 2017;318(16):1592-1604. doi:10.1001/jama.2017.12137

10. Caldwell L, White AB. "Stress Urinary Incontinence: Slings, Single-Incision Slings, and Nonmesh Approaches." Obstet Gynecol Clin North Am. 2021;48(3):449-466. doi:10.1016/j.ogc.2021.05.002

11. İncebıyık M, Adak İH. "Beyond the Mesh: Pubourethral Ligament Plication Versus Transobturator Tape at 6 Months and the Power of Preoperative ICIQ-SF for Risk Stratification." Int Urogynecol J. 2026;37(8):2407-2416. doi:10.1007/s00192-026-06552-4

12. Albo ME, Richter HE, Brubaker L, et al. Burch colposuspension versus fascial sling to reduce urinary stress incontinence. N Engl J Med. 2007;356:2143–2155. doi:10.1056/NEJMoa070416.

13. NICE. Urinary incontinence and pelvic organ prolapse in women: management. NG123, recommendation 1.5.14. Recommendations.

14. 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

15. Rodrigues P, Hering F, Dias EC. "Female obstruction after incontinence surgery may present different urodynamic patterns." Int Urogynecol J. 2013;24(2):331-336. doi:10.1007/s00192-012-1869-x

16. Sohbati S, Salari Z, Eftekhari N. "Comparison Between the Transobturator Tape Procedure and Anterior Colporrhaphy With the Kelly's Plication in the Treatment of Stress Urinary Incontinence: a Randomized Clinical Trial." Nephrourol Mon. 2015;7(5):e32046. doi:10.5812/numonthly.32046