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Paravaginal Repair

Paravaginal repair is a surgical procedure that reattaches the detached lateral vaginal wall (pubocervical fascia) to its normal insertion on the arcus tendineus fascia pelvis (ATFP, "white line") on the pelvic sidewall, correcting anterior vaginal wall prolapse caused by lateral support defects.[1][2][3] It can be performed via transvaginal, open abdominal, laparoscopic, or robotic approaches.

For the central-defect repair, see Anterior Colporrhaphy.

Historical Background and Anatomic Rationale​

The concept of the paravaginal defect was popularized by George White (1909) and refined by A. Cullen Richardson (1976, 1981), who proposed that some cystourethroceles reflect discrete breaks in the endopelvic fascia rather than generalized tissue attenuation.[3][4] In Richardson's historical series of 233 procedures for stress urinary incontinence associated with cystourethrocele, a paravaginal break was the most frequently encountered defect; the authors reported > 95% functionally satisfactory results at 2–8 yr follow-up.[4]

Reported paravaginal-defect prevalence depends on the population and diagnostic method; two clinical-versus-operative comparison studies found defects at surgery in up to 47% of women with anterior prolapse.[6] The concept is grounded in DeLancey's Level II vaginal support: the lateral attachment of the mid-vagina to the ATFP and underlying levator ani muscles.[6][7]

Anatomy of the Paravaginal Defect​

Support of the anterior vaginal wall involves the levator ani, ATFP, pubocervical fascia, and uterosacral and cardinal ligaments.[6] A paravaginal defect describes loss of lateral vaginal support near the ATFP. In a 30-case/30-control stress-MRI study, apical location, paravaginal location and hiatus size formed a highly correlated "collinear triad" explaining up to 83% of variation in cystocele size within that model.[7]

Paravaginal support repairOriginal schematic · v2026-09-20 · Clinical review pending

Conceptual lateral-support schematic in axial view. It is not a complete model of anterior prolapse. (1) A lateral attachment defect allows sulcal descent; (2) the illustrated sutures reattach lateral vaginal support toward the arcus tendineus fascia pelvis ("white line"). Suture number and concomitant midline/apical repair vary by technique and patient. Contrast anterior colporrhaphy. (Original WARWIKI schematic)

A classification system describes paravaginal defects as:[8]

Defect typeDescription
Fascial defectsPartial or complete tears in the paravaginal visceral pelvic fascia
Muscular defectsLevator ani tears of varying location
Combined fascial + muscularBoth lesions in the same patient

All of these can produce the same clinical finding: descent of the lateral vaginal sulcus.[8]

Diagnosis​

Diagnosing paravaginal defects remains challenging:[6][9]

ModalityNotes
Physical examinationCommonly used; operative-comparison studies report inconsistent sensitivity and specificity. Loss of lateral sulci or reduction with lateral support can suggest a defect, but neither proves a discrete fascial tear.
MRIA descriptive 12-woman pre/postoperative series reported displaced lateral walls and "saddlebags" (Level II) or "mustache" (Level III) signs. In a later 46-woman cohort, missing-H correlated with pubococcygeus injury rather than a demonstrated fascial paravaginal defect.[10][11]
UltrasoundTranslabial and other approaches can depict support relationships, but criteria and specificity for a discrete fascial defect remain unsettled. Older transabdominal bladder-base signs alone are unreliable.[6][9]
Intraoperative assessmentDirect inspection of the lateral attachment is possible when the retropubic space is exposed; it is an anatomic reference in operative-comparison studies.[6][12]

Surgical Technique​

Transvaginal Approach[1][2][13]​

  1. Midline anterior vaginal wall incision
  2. Sharp dissection of the vagina from bladder fascia continues laterally until the pelvic sidewall is identified
  3. The retropubic space is entered under the inferior pubic ramus
  4. The ATFP (white line) is identified on the pelvic sidewall
  5. Permanent or delayed-absorbable sutures are placed from the lateral vaginal wall or pubocervical fascia to the ATFP on each side (1–6 Gore-Tex CV-0 sutures per side in the Young series). When the white line is detached from the sidewall or does not seem durable, the obturator-internus fascia is a described alternative anchor; one illustrated technique places three to six held sutures along the white line from near the ischial spine toward the urethrovesical junction, then matches them with sutures through the lateral vaginal muscularis and endopelvic tissue, creating a three-point closure while preserving tissue for the vaginal closure and avoiding a suture bridge.[30]
  6. Tying these sutures elevates the lateral vaginal sulci
  7. A midline plication (standard anterior colporrhaphy) is typically performed concurrently
  8. Excess vaginal skin is trimmed and the vaginal wall is closed

Open Abdominal Approach[5][14]​

  1. Pfannenstiel or low midline incision
  2. The retropubic space (space of Retzius) is entered
  3. The ATFP is identified bilaterally
  4. Sutures are placed from the lateral vaginal wall to the ATFP. One described open technique takes a full-thickness vaginal bite, excluding epithelium, into the ATFP about 3–4 cm below the obturator fossa for the first suture, then places two to four further sutures at roughly 1-cm intervals toward the pubic bone, beginning at the ischial spine.[31] Cadaveric studies found variable pudendal neurovascular proximity to the posterior ATFP near the ischial spine; identify the relevant anatomy and avoid a blind posterior needle pass.[38][39]
  5. Often combined with Burch colposuspension or sacrocolpopexy. When both are planned, one author's preference is to complete the paravaginal repair first, because exposure of the lateral defects decreases once the Burch sutures are tied.[31]

For bleeding encountered while placing a retropubic paravaginal suture, one described bailout is a figure-of-eight stitch placed in the vagina, with its attached needle then passed into the pelvic sidewall to obtain hemostasis; this is an author-described maneuver without linked comparative outcome evidence.[32]

Laparoscopic / Robotic Approach[5][15][16][17]​

  1. Transperitoneal access to the space of Retzius
  2. Identification of the ATFP and paravaginal defects under magnified visualization
  3. Suture placement from lateral vagina to ATFP (an average of 6 sutures for the paravaginal repair in Miklos and Kohli's series)
  4. Often combined with sacrocolpopexy, Burch colposuspension, or both
  5. In Miklos and Kohli's retropubic laparoscopic technique, cystoscopy checks lower urinary tract integrity after suturing.[16]

The 2018 AUGS consensus recommends cystoscopy after anterior prolapse reconstruction by any route, with inspection of the urethra and bladder and confirmation of bilateral ureteral efflux.[43]

One described unit variant anchors laterally to Cooper's ligament rather than the ATFP: after filling the bladder with 200–300 mL saline to define its dome and entering the Retzius space 2–4 cm cephalad to it, a double bite through the pubocervical fibromuscular tissue at the urethrovesical junction is anchored to the ipsilateral Cooper's ligament, usually with two to four sutures per side placed alternately to preserve symmetry, limiting tension so about 2 cm remains between fascia and ligament.[33] Excessive tension is described as a possible contributor to postoperative voiding difficulty.[33][44] The same unit routinely places bilateral ureteric catheters before peritoneal entry for visualization and injury recognition.[33]

Variations​

VariationDescriptionReference
Trans-obturator native-tissue paravaginal repairAvoids complex retropubic dissection[18]
Modified cross-stitch paravaginal repair (Huang 2022)Reverse bridge repair + cross-stitching of bilateral sutures; reported success was 93/98 (94.9%) at 12 mo, 61/71 (91.0%) at 24 mo, and 16/21 (76.2%) at 48 mo. The later percentages reflect substantial follow-up attrition.[19]
Ischial periosteum / obturator membrane fixation (Scotti 1998)Sutures pass through ATFP, obturator fascia, obturator membrane, and ischial periosteum; comparative suspension benefit was not tested[20]
Paravaginal lattice technique (Rude 2021)See the dedicated subsection below. Hybrid native-tissue repair intertwining midline colporrhaphy sutures with lateral ATFP / obturator-fascia sutures into a lattice scaffold[29]
Historical mesh-augmented transvaginal paravaginal repair with distal urethral sling (Rodríguez 2005; no FDA-approved transvaginal POP mesh is currently marketed in the United States)[42]Every patient first had a distal urethral polypropylene sling. After central-defect repair, a 5 × 5 cm soft polypropylene mesh was fixed proximally to the sacrouterine/cardinal ligament complex, distally to the bladder neck and laterally to the infralevator obturator fascia. In 98 women with grade III–IV cystocele (mean age 65 years; 94% also had rectocele repair, 45% enterocele repair and 26% vaginal hysterectomy), postoperative anterior-wall POP-Q stage was 0–I in 85%, II in 13% and III in 2%; no patient had urinary retention, 3 had de novo SUI and 2 had de novo urgency incontinence; one had transient ureteral obstruction from a bladder-wall hematoma, and one required repair of a recurrent enterocele.[35]

Paravaginal Lattice Technique (Rude 2021)​

The paravaginal lattice technique is a native-tissue technique described by Rude et al. (2021) in the period after transvaginal mesh withdrawal. It combines midline anterior colporrhaphy with lateral paravaginal sutures intertwined into a lattice-work configuration and is designed to address central and lateral defects through a single transvaginal incision without mesh.[29]

Concept​

The technique attempts to create a suture-based scaffold that mimics the broad support previously provided by mesh, using absorbable PDS sutures to connect native-tissue fixation points without a mesh implant.[29] The distinguishing step is intertwining the midline plication sutures with the lateral ATFP or obturator-fascia sutures so the two sets of sutures form a unified support structure rather than independent repairs.

Step-by-Step​

  1. Standard midline anterior vaginal wall incision and dissection
  2. Lateral sutures. 2-0 PDS placed at the level of the obturator fascia or ATFP: one distally and one proximally on each side (4 lateral sutures total)
  3. Midline sutures. Standard midline anterior colporrhaphy with 4 separate 2-0 PDS sutures through the pubocervical fascia
  4. Lattice formation. Midline colporrhaphy sutures are intertwined with the lateral obturator or ATFP sutures and tied, creating a cross-hatch pattern
  5. The lattice configuration elevates the central repair laterally while anchoring the construct to the pelvic sidewall

Outcomes (Rude 2021 prospective cohort, n = 109, mean follow-up 12 mo)[29]​

OutcomeResult
Anatomic recurrence (POP-Q Ba ≥ −1)11% (12 / 109)
Mean time to recurrence13.9 mo
Intraoperative complications0%
Transient urinary retention19% (all self-resolved with conservative management)
De novo SUI4%
Recurrence association with concomitant apical / posterior repairNone

Comparison with Adjacent Techniques​

FeatureLattice (Rude 2021)Standard ACStandard paravaginalModified cross-stitch (Huang 2022)
Defects addressedCentral + lateralCentral onlyLateral onlyLateral with cross-stitch reinforcement
Suture material2-0 PDS (absorbable)VariablePermanent or delayed-absorbableNot specified
Lateral fixationObturator fascia / ATFPNoneATFPATFP with cross-stitching
Outcome evidenceSingle-surgeon cohort, 109 patients; 11% met POP-Q Ba ≥ −1 recurrence, mean follow-up 12 mo; 19% transient retention[29]Native-tissue evidence spans different populations and definitions; see anterior colporrhaphyIsolated and combined repairs are both reported; central recurrence may remain after lateral-only repairRetrospective series with shrinking denominators: 93/98 at 12 mo, 61/71 at 24 mo, 16/21 at 48 mo[19]

Caveats​

  • Single-surgeon, single-center prospective cohort. Generalizability is uncertain
  • Short follow-up (mean 12 mo). Long-term durability of this technique is unknown.[29]
  • Absorbable PDS. Ethicon reports about 60% breaking-strength retention at six weeks for size 2-0 PDS II, with essentially complete absorption at 182–238 days.[41] Whether the lattice maintains support as suture strength declines remains unknown from Rude’s short-term cohort.[29]
  • 19% transient urinary retention occurred in this cohort.[29]
  • No randomized comparison with AC, paravaginal, or mesh-augmented repair

The Rude lattice technique has been described in one short-term prospective series. The series reported 11% POP-Q Ba recurrence and 19% transient retention.[29] Long-term durability and comparative benefit remain unproven.

Outcomes by Approach​

These figures come from different studies with different definitions of success, follow-up and concomitant procedures.

ApproachSuccess rate (prolapse)SUI cure rateKey advantagesKey disadvantages
TransvaginalYoung series: 98/100 met the grade-0 lateral-sulcus definition at mean 10.6 mo (55 followed at least 1 yr; 530 concomitant procedures); 22/100 had recurrent midline cystocele[13]; Huang modified-technique series: 93/98 (94.9%) success at 12 mo and 16/21 (76.2%) among those evaluated at 48 mo72% no-pad/no-leakage cure at mean 17 mo among 25 women without a sling (other prolapse defects could be repaired concurrently); 84% counted cure or improvement to at most one pad/day[26]Single incision; no abdominal entryTechnically demanding; hemorrhage risk; limited visualization[1][2][3][19]
Open abdominal60% free of objective stage-≥II anterior prolapse at 2 yr in the Minassian RCT; the 3–14% failure range in Weber’s older paravaginal case-series review was not open-specificColombo RCT: 61% objective and 72% subjective SUI cure after abdominal paravaginal repair (1–3 yr follow-up)Direct visualization; can combine with BurchLonger recovery; abdominal incision[5][14][21]
Laparoscopic76% at mean 14.2 mo after laparoscopic repair; 84% after 18 of 23 women with residual central defects underwent secondary graft-reinforced anterior colporrhaphyVariableMinimally invasive; magnified viewSteep learning curve; one comparative trial abandoned approach due to poor outcomes[5][17]
RoboticWith concomitant sacrocolpopexy: POP-Q Ba improved from 2.1 to −2.0 at 12 mo in 43 women (uncontrolled); PGI-I 1–2 in 65.1% and 1–3 in 81.4%Not primary indicationMagnified visualization; ergonomicCost; limited long-term data[15][22]

Paravaginal Repair vs. Anterior Colporrhaphy​

The two procedures address different anatomic defects: lateral (paravaginal) versus central (midline plication).[3]

TrialnOutcome
Weber & Walters 1997 review[3]—Reported failure 0–20% for AC and 3–14% for paravaginal repair in case series; no controlled comparison available at the time
Menefee 2011 RCT[23]99 randomized; 78 completed ≥2 yr2-yr anatomic failure: AC 58% / porcine-graft paravaginal 46% / polypropylene-mesh paravaginal 18% (p = 0.002 mesh vs AC). Composite (bulge symptoms and anatomic failure) was 13% / 12% / 4%, without a significant between-group difference; mesh erosion was 14%. The polypropylene transvaginal POP mesh arm is historical, not a currently marketed US option.
Minassian 2014 RCT[14]702-yr objective failure: vaginal AC + absorbable polyglactin mesh 32% vs abdominal paravaginal repair 40% (p = 0.56); satisfaction 88% vs 73% (p = 0.11). Concurrent hysterectomy differed (71% vs 42%).
Cai 2025 RCT[24]102In women aged 40–70 with symptomatic SUI and stage 2–3 anterior prolapse, combined paravaginal + pubocervical fascia plication had higher 12-mo patient-reported improvement (94.1% vs 78.4%), objective SUI cure (90.2% vs 74.5%), and anatomic success (92.2% vs 80.4%) than standard AC. The selected combined SUI/POP population limits generalization.

Vaginal vs. Abdominal Approach​

A prospective comparative study of 45 patients found no significant difference in subjective and objective outcomes between abdominal and vaginal paravaginal repair at 12 months. The laparoscopic arm was abandoned after 5 patients due to inferior outcomes.[5] In the 2016 Cochrane review, vaginal anterior colporrhaphy was compared with abdominal paravaginal repair/Burch combinations: one RCT found no clear difference in POP-Q point Ba (n = 50), and one found total vaginal length 3.20 cm longer after the vaginal approach (n = 68; 95% CI 2.58–3.82).[25]

Effect on Stress Urinary Incontinence​

In a selected 52-woman series with SUI, bladder-neck hypermobility and lateral-defect cystocele, the authors attributed postoperative continence improvement to restoration of lateral support; 25 women had paravaginal repair alone and 27 also had a rectus sling.[26] A 36-patient randomized trial found lower objective SUI cure with paravaginal repair than with Burch colposuspension at 1–3 yr (61% vs 100%).[21]

TrialFinding
Colombo 1996 RCT (n = 36)[21]Burch 100% vs paravaginal 61% objective cure (p = 0.004); negative cotton-swab 100% vs 33% (p = 0.01). Authors concluded paravaginal repair is not recommended for SUI.
Bruce 1999 (n = 52; 25 without sling, 27 with rectus sling)[26]No-pad/no-leakage SUI cure at mean 17 mo: 72% without sling and 85% with rectus muscle sling for ISD
Scotti 1998 (n = 40)[20]34/36 (94.4%) with genuine or potential urodynamic SUI achieved cure at mean 39 mo in the 40-woman cohort; paravaginal fixation used ischial periosteum and obturator membrane, with other pelvic procedures in the same setting

Complications​

Complications vary by approach and concomitant surgery; the counts below come from separate series without an anterior-colporrhaphy comparator.[12][13][17]

ComplicationRate
HemorrhageYoung et al. reported 3 major intraoperative hemorrhagic events in 100 vaginal paravaginal repairs; one repair was converted to anterior colporrhaphy.[13]
Transfusion — vaginal approach16% in the same 100-woman Young et al. series, which included concomitant procedures; the authors suggested their low transfusion threshold may partly explain the rate[13]
Bladder injury / cystotomy4/171 (2.3%) cystotomies in a mixed laparoscopic Burch/paravaginal cohort (130 combined, 23 Burch alone, 18 paravaginal alone)[16]
Voiding dysfunction (prolonged retention)Prolonged retention, defined as postvoid residual >100 mL by postoperative day 7 necessitating catheterization, was the most common minor complication (10.4%) in the 212-woman laparoscopic cohort[17]
Lower-extremity neuropathy2% (long-term) in one series[13]
Recurrent midline (central) cystocele after vaginal paravaginal repair with concomitant procedures22/100 at 3–11 mo in Young et al.; the cohort also had 530 concomitant procedures[13]
Recurrent prolapse including grade III enterocele after vaginal paravaginal repair5/100 in Young et al.[13]
Major complications — laparoscopic approach4.2% (9 / 212)[17]

Recurrence and Risk Factors​

Recurrence and objective failure vary by approach, definition and follow-up duration:

Time horizonRecurrence
Early follow-upYoung: 2/100 residual or recurrent paravaginal defects at mean 10.6 mo (55 followed ≥1 yr); Shull: 4/56 (7.1%) anterior-segment defects to/through the hymen at mean 1.6 yr, not specifically lateral recurrence[12][13]
At 2 yrMinassian's abdominal paravaginal RCT arm had 40% objective stage-≥II failure; Huang's modified-technique series reported 61/71 (91.0%) success among those evaluated at 24 mo.[14][19]
At 4 yrHuang reported 16/21 (76.2%) success among the much smaller subset evaluated at 48 mo.[19]

Long-term laparoscopic follow-up. In a separate prospective cohort of 223 women who underwent laparoscopic paravaginal repair with treatment of associated conditions, median follow-up was 5.2 years (range 1–12; 63% followed at least 5 years). By that follow-up, 79% had developed prolapse of at least POP-Q stage 2 in one or more compartments and 58% had become symptomatic again; 48% underwent further prolapse surgery of any kind, 30% eventually had a further cystocele repair, and 24% had anterior prolapse recurrence beyond the hymen. The authors concluded that cystoceles are difficult to repair successfully over the long term.[34] This is a single-center cohort without a comparison arm.[34]

MRI-associated recurrence findings. In Arenholt's prospective cohort, 46 women completed 6-month follow-up, 20 after paravaginal repair alone and 26 with concomitant surgery. The full cohort had a 39% recurrence rate. Recurrence was more frequent among women with major pubococcygeus defects and a missing vaginal H configuration.[11]

Concomitant apical support should also be assessed; anterior descent often reflects more than one support defect.[6][7]

Concomitant Procedures​

Paravaginal repair is frequently combined with other procedures:[13][15][16]

  • Sacrocolpopexy. In an uncontrolled series of 43 women, robotic paravaginal repair with sacrocolpopexy improved POP-Q Ba (from 2.1 to −2.0) and C (from 0.3 to −4.3); PGI-I scores of 1–3 were reported by 81.4% at 12 mo[15]
  • Burch colposuspension. Historical retropubic series combined Burch with paravaginal repair.[16] Document symptomatic SUI and consider stress testing with prolapse reduction when occult SUI would affect the plan.[37] For prolapse repair with SUI, the amended AUA/SUFU guideline allows a concomitant midurethral or pubovaginal sling or Burch colposuspension .[37] Discuss concurrent versus staged continence surgery and the balance of continence benefit and added morbidity.[2][37]
  • Posterior colporrhaphy and enterocele repair. Multicompartment prolapse is common
  • Hysterectomy or uterine preservation. When uterine prolapse coexists, discuss hysterectomy-based and uterine-preserving apical repairs with eligible patients, including benefits, risks, contraindications, and patient preferences.[40]

Current Role and Guideline Positioning​

Paravaginal repair occupies a niche role in the surgical management of anterior vaginal wall prolapse:[27][28]

  • Rationale. The operation addresses the specific anatomic defect (lateral detachment) rather than midline plication
  • Reliable preoperative diagnosis of isolated paravaginal defects remains difficult, limiting targeted application[6][9]
  • Most surgeons perform standard anterior colporrhaphy (which addresses central defects) as the primary transvaginal native-tissue repair, sometimes incorporating lateral sutures as an "ultralateral" modification
  • Paravaginal repair may be performed abdominally or robotically with sacrocolpopexy when lateral defects are identified; vaginal native-tissue approaches are also described. In a retrospective sacrocolpopexy cohort, three-month PGI-I was 1.2 in 21 women with added robotic paravaginal repair and 1.5 in 102 without it (p = 0.128); surgeon selection and worse baseline prolapse in the added-repair group limit inference.[22] In a 160-woman randomized trial of modified paravaginal repair plus sacrospinous suspension versus laparoscopic sacrocolpopexy, 12-month composite success (no bothersome bulge, no prolapse beyond the hymen, and no additional prolapse treatment) was 73/75 versus 75/76 among completers; neuromuscular pain occurred in 13 versus 3 women (p = 0.008).[36]
  • ACOG and AUGS describe paravaginal defects as lateral detachments whose diagnosis by examination is unreliable; when a paravaginal defect is suspected there is usually loss of apical support, and apical procedures may address most anterior defects, including paravaginal ones[27]

Summary — Paravaginal Repair vs. Anterior Colporrhaphy​

FeatureParavaginal repairAnterior colporrhaphy
Defect addressedLateral (Level II)Central (midline)
Anatomic goalReattach vagina to ATFPPlicate midline fascia
Outcome interpretationIsolated and combined approaches differ; use the source-specific cohorts and endpoints aboveNative-tissue, graft-augmented, and concomitant repairs must be distinguished; see anterior colporrhaphy
SUI effect—Neither a standard anterior repair nor a Kelly plication is an established stand-alone SUI treatment
Key complicationHemorrhage; central recurrenceRecurrence; de novo SUI
Diagnostic challengeDifficult to confirm preoperativelyNot defect-specific

See Also​

References​

1. 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

2. 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

3. Weber AM, Walters MD. "Anterior Vaginal Prolapse: Review of Anatomy and Techniques of Surgical Repair." Obstet Gynecol. 1997;89(2):311-8. doi:10.1016/S0029-7844(96)00322-5

4. Richardson AC, Edmonds PB, Williams NL. "Treatment of Stress Urinary Incontinence Due to Paravaginal Fascial Defect." Obstet Gynecol. 1981;57(3):357-62. PMID 7465150

5. Hosni MM, El-Feky AE, Agur WI, Khater EM. "Evaluation of Three Different Surgical Approaches in Repairing Paravaginal Support Defects: A Comparative Trial." Arch Gynecol Obstet. 2013;288(6):1341-8. doi:10.1007/s00404-013-2927-4

6. Arenholt LTS, Pedersen BG, Glavind K, Glavind-Kristensen M, DeLancey JOL. "Paravaginal Defect: Anatomy, Clinical Findings, and Imaging." Int Urogynecol J. 2017;28(5):661-673. doi:10.1007/s00192-016-3096-3

7. Chen L, Lisse S, Larson K, et al. "Structural Failure Sites in Anterior Vaginal Wall Prolapse: Identification of a Collinear Triad." Obstet Gynecol. 2016;128(4):853-862. doi:10.1097/AOG.0000000000001652

8. Otcenasek M, Gauruder-Burmester A, Haak LA, et al. "Paravaginal Defect: A New Classification of Fascial and Muscle Tears in the Paravaginal Region." Clin Anat. 2016;29(4):524-9. doi:10.1002/ca.22694

9. Nguyen JK. "Current Concepts in the Diagnosis and Surgical Repair of Anterior Vaginal Prolapse Due to Paravaginal Defects." Obstet Gynecol Surv. 2001;56(4):239-46. doi:10.1097/00006254-200104000-00025

10. Huddleston HT, Dunnihoo DR, Huddleston PM, Meyers PC. "Magnetic Resonance Imaging of Defects in DeLancey's Vaginal Support Levels I, II, and III." Am J Obstet Gynecol. 1995;172(6):1778-82. doi:10.1016/0002-9378(95)91411-0

11. Arenholt LTS, Pedersen BG, Glavind K, et al. "Prospective Evaluation of Paravaginal Defect Repair With and Without Apical Suspension: A 6-Month Postoperative Follow-Up With MRI, Clinical Examination, and Questionnaires." Int Urogynecol J. 2019;30(10):1725-1733. doi:10.1007/s00192-018-3807-z

12. Shull BL, Benn SJ, Kuehl TJ. "Surgical Management of Prolapse of the Anterior Vaginal Segment: An Analysis of Support Defects, Operative Morbidity, and Anatomic Outcome." Am J Obstet Gynecol. 1994;171(6):1429-36. doi:10.1016/0002-9378(94)90384-0

13. Young SB, Daman JJ, Bony LG. "Vaginal Paravaginal Repair: One-Year Outcomes." Am J Obstet Gynecol. 2001;185(6):1360-6. doi:10.1067/mob.2001.119073

14. Minassian VA, Parekh M, Poplawsky D, Gorman J, Litzy L. "Randomized Controlled Trial Comparing Two Procedures for Anterior Vaginal Wall Prolapse." Neurourol Urodyn. 2014;33(1):72-7. doi:10.1002/nau.22396

15. Kim WB, Lee SW, Lee KW, et al. "Robot-Assisted Laparoscopic Paravaginal Repair and Sacrocolpopexy in Patients With Pelvic Organ Prolapse." Urology. 2022;164:151-156. doi:10.1016/j.urology.2021.12.011

16. Miklos JR, Kohli N. "Laparoscopic Paravaginal Repair Plus Burch Colposuspension: Review and Descriptive Technique." Urology. 2000;56(6 Suppl 1):64-9. doi:10.1016/s0090-4295(00)00510-0

17. Behnia-Willison F, Seman EI, Cook JR, O'Shea RT, Keirse MJ. "Laparoscopic Paravaginal Repair of Anterior Compartment Prolapse." J Minim Invasive Gynecol. 2007;14(4):475-80. doi:10.1016/j.jmig.2006.12.002

18. Kalis V, Kovarova V, Rusavy Z, Ismail KM. "Trans-Obturator Cystocele Repair of Level 2 Paravaginal Defect." Int Urogynecol J. 2020;31(11):2435-2438. doi:10.1007/s00192-020-04337-x

19. Huang S, Lv Q, Li Y, Meng Q, Li M. "A Modified Technique for Paravaginal Repair of Cystocele With Paravaginal Defect: A Retrospective Study." Eur J Obstet Gynecol Reprod Biol. 2022;269:108-113. doi:10.1016/j.ejogrb.2021.12.028

20. Scotti RJ, Garely AD, Greston WM, Flora RF, Olson TR. "Paravaginal Repair of Lateral Vaginal Wall Defects by Fixation to the Ischial Periosteum and Obturator Membrane." Am J Obstet Gynecol. 1998;179(6 Pt 1):1436-45. doi:10.1016/s0002-9378(98)70007-9

21. Colombo M, Milani R, Vitobello D, Maggioni A. "A Randomized Comparison of Burch Colposuspension and Abdominal Paravaginal Defect Repair for Female Stress Urinary Incontinence." Am J Obstet Gynecol. 1996;175(1):78-84. doi:10.1016/s0002-9378(96)70254-5

22. Hoke TP, Goldstein H, Saks EK, Vakili B. "Surgical Outcomes of Paravaginal Repair After Robotic Sacrocolpopexy." J Minim Invasive Gynecol. 2018;25(5):892-895. doi:10.1016/j.jmig.2018.01.013

23. Menefee SA, Dyer KY, Lukacz ES, et al. "Colporrhaphy Compared With Mesh or Graft-Reinforced Vaginal Paravaginal Repair for Anterior Vaginal Wall Prolapse: A Randomized Controlled Trial." Obstet Gynecol. 2011;118(6):1337-1344. doi:10.1097/AOG.0b013e318237edc4

24. Cai Y, Su K, Bian A. "Comparing Combined Paravaginal Repair With Pubocervical Fascia Plication Versus Standard Anterior Colporrhaphy for the Treatment of Stress Urinary Incontinence in Women With Anterior Vaginal Wall Prolapse: A Randomised Controlled Trial." Arch Gynecol Obstet. 2025;311(1):163-173. doi:10.1007/s00404-024-07864-w

25. Maher C, Feiner B, Baessler K, et al. "Surgery for Women With Anterior Compartment Prolapse." Cochrane Database Syst Rev. 2016;11:CD004014. doi:10.1002/14651858.CD004014.pub6

26. Bruce RG, El-Galley RE, Galloway NT. "Paravaginal Defect Repair in the Treatment of Female Stress Urinary Incontinence and Cystocele." Urology. 1999;54(4):647-51. doi:10.1016/s0090-4295(99)00225-3

27. 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

28. Jelovsek JE, Maher C, Barber MD. "Pelvic Organ Prolapse." Lancet. 2007;369(9566):1027-38. doi:10.1016/S0140-6736(07)60462-0

29. Rude T, Sanford M, Cai J, et al. "Transvaginal Paravaginal Native Tissue Anterior Repair Technique: Initial Outcomes." Urology. 2021;150:125-129. doi:10.1016/j.urology.2020.06.070

30. 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

31. Walters MD. Laparoscopic Surgery for Stress Urinary Incontinence (Burch Colposuspension). In: Baggish MS, Karram MM, eds. Atlas of Pelvic Anatomy and Gynecologic Surgery. 5th ed. Elsevier; 2021:1313-1316.

32. 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.

33. Thanatsis N, Izett-Kay ML, Vashisht A. Laparoscopic Paravaginal Repair. In: Martins FE, Holm HV, Sandhu JS, McCammon KA, eds. Female Genitourinary and Pelvic Floor Reconstruction. Springer; 2023:533-550.

34. Bedford ND, Seman EI, O'Shea RT, Keirse MJ. "Long-Term Outcomes of Laparoscopic Repair of Cystocoele." Aust N Z J Obstet Gynaecol. 2015;55(6):588-592. doi:10.1111/ajo.12388

35. Rodríguez LV, Bukkapatnam R, Shah SM, Raz S. "Transvaginal paravaginal repair of high-grade cystocele central and lateral defects with concomitant suburethral sling: report of early results, outcomes, and patient satisfaction with a new technique." Urology. 2005;66(5 Suppl):57-65. doi:10.1016/j.urology.2005.06.126

36. Huang S, Li H, Li Y, et al. "Modified paravaginal repair combined with sacrospinous ligament suspension for pelvic organ prolapse: a randomized controlled study." Int J Surg. 2026;112(1):973-980. doi:10.1097/JS9.0000000000003479

37. 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. Full amended guideline

38. Occelli B, Narducci F, Hautefeuille J, et al. "Anatomic study of arcus tendineus fasciae pelvis." Eur J Obstet Gynecol Reprod Biol. 2001;97(2):213-219. doi:10.1016/S0301-2115(00)00527-3

39. Ersoy M, Sagsoz N, Bozkurt MC, Apaydin N, Elhan A, Tekdemir I. "Important anatomical structures used in paravaginal defect repair: cadaveric study." Eur J Obstet Gynecol Reprod Biol. 2004;112(2):206-213. doi:10.1016/j.ejogrb.2003.06.015

40. Chang OH, Carter Ramirez A, Edwards A, et al. "The Role of Uterine Preservation at the Time of Pelvic Organ Prolapse Surgery." Urogynecology (Phila). 2025;31(5):482-495. doi:10.1097/SPV.0000000000001667

41. Johnson & Johnson Medical Limited. "Ethicon Suture Chart: Synthetic Absorbable Sutures." 2020. Product chart

42. U.S. Food and Drug Administration. "Urogynecologic Surgical Mesh Implants." FDA device information (accessed 2026-10-08).

43. 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

44. Merritt AJ, Crosbie EJ, Charova J, Achiampong J, Zommere I, Winter-Roach B, Slade RJ. "Prophylactic Pre-Operative Bilateral Ureteric Catheters for Major Gynaecological Surgery." Arch Gynecol Obstet. 2013;288(5):1061-1066. doi:10.1007/s00404-013-2853-5