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BJOG: an International Journal of Obstetrics and Gynaecology December 2004, Vol. 111, Supplement 1, pp. 67– 72 Management of prolapse of the anterior compartment Mark Slack HISTORICAL ASPECTS A wide range of techniques have been attempted to repair the prolapsing anterior vaginal wall. Geradin tried denudation of vaginal mucosa for the management of prolapse in 1823 on a cadaver. This was first performed on a living patient in 1830. By 1866 J.M. Simm had performed a series of denudation operations very similar to a modern anterior repair.1 The majority of historical papers describing the aetiology of, and treatment for, the cystocoele regard the condition as analogous to a herniation of the anterior abdominal wall. Consequently all the surgical techniques concentrate on excision of the redundant vaginal tissue with plication of the cut ends of the fascia in the midline.2,3 George White in 1909 wrote of his frustration with the suboptimal outcome of operations for the repair of the cystocoele.4 He believed that the practice of removing part of the anterior wall before suturing the cut ends together was irrational and destined for failure. In this paper he made the first reference to the lateral supports of the anterior wall. He proposed that injuries at parturition produced tears in the fibres of the white line allowing the anterior wall to dislocate from its attachments and present as a cystocoele. His proposed solution was a vaginal technique allowing attachment of the lateral sulci of the vagina to the white line using absorbable sutures (the technique described is not dissimilar to the current abdominal paravaginal repair described by Richardson1). Nineteen cases with no recurrence at 3 years were described. White appreciated that the operation, in addition to correcting the prolapse, did not compromise the capacity of the vagina. The prevailing belief at the time was that a cystocoele represented a central herniation of the bladder through the anterior fascia and therefore would not be served by an operative procedure, which only approached the lateral supports. As a consequence the procedure was largely ignored until its resurrection by Richardson in 1981. In the interim surgeons concentrated their efforts on improving the outcome of the midline procedures. Attention was given to correction of midline ‘fascial’ defects by ‘lapping’ techniques.6,7 The abdominal approach was introduced in 1939 and underwent subsequent modifications.8 – 11 Macer concluded that the procedure was superior to the vaginal approach.12 Various techniques originally described for the management of stress incontinence have been tried for anterior wall defects13,14 but have failed to make any real impact; the condition continues to be managed by vaginal plication by most surgeons. However, with the re-introduction of the paravaginal repair by Shull15 and Richardson5 it seems as if the management of the problem has gone ‘full circle’. Most surgeons are less than satisfied with the outcome of operations for prolapse. Richard TeLinde wrote Every surgeon of extensive and long experience will have to admit that he is not entirely and absolutely satisfied with the long-term results of all his operations for prolapse and allied conditions. A more assertive patient population has expectations of effective therapy and is more likely to return for assessment if the original operation has been unsuccessful. It is extremely important therefore to ensure that the patient is well counselled prior to the original surgery and has a good understanding of the aims of the operation, its limitations and the associated success and failure rates. Failure could result from the recurrence of the original problem or arise because of the development of new symptoms such as urinary incontinence. Surgical management of pelvic organ prolapse is common. In the USA the lifetime risk of having an operation for prolapse or incontinence by age 80 was 11.1%.16 A staggering 30% of these patients required a second operation for the same problem. MacLennan and colleagues showed that 46.2% of women aged 15 –97 had pelvic floor dysfunction with 23% of them having had a previous repair.17 Recent estimates suggest that demand for prolapse surgery will increase by 45% in the next 30 years.18 If so, urgent attention will need to be given to the development of new operations for prolapse or else there could be a major increase in cases needing repeat surgery. ANATOMY OF THE ANTERIOR VAGINAL WALL Hinchingbrooke and Addenbrooke’s Hospitals, Cambridge, UK Correspondence: Dr M. Slack, Hinchingbrooke and Addenbrooke’s Hospitals, Cambridge, UK. D RCOG 2004 BJOG: an International Journal of Obstetrics and Gynaecology In order to understand the various operations that have been proposed to correct cystocoele, it is necessary to have a three-dimensional understanding of the anatomy of the anterior vaginal wall. The mechanisms by which the uterus and vagina are supported have been investigated in cadaveric www.blackwellpublishing.com/bjog 68 M. SLACK dissections and our knowledge in this area is mainly due to the work of John Delancey, which has brought a mechanical framework to the landmarks described in anatomy textbooks. These concepts, which had been suggested by Victor Bonney in 1934,19 have received fresh attention as a result of his work20 and have altered surgical approaches in prolapse as a result. The following paragraphs attempt to summarise Delancey’s ideas about supporting structures in the pelvis. The concept of three levels or forms of support that can be analysed for any organ in the pelvis has been proposed. Support is provided mainly by the endo-pelvic fascia that invests each organ and that forms condensations or (named) ligaments. In addition to endo-pelvic fascia, the muscles of levator ani provide indirect support by closing the genital hiatus and providing a platform against which rises in abdominal pressure compress the pelvic organs. Delancey described level I support as vertical suspension of the uterus, cervix and vagina, level II support as lateral attachment to the side-walls of the pelvis and level III support as the fusion of the lower end of the organ to the cloacal area. Failure of any of these supports can lead to organ prolapse and/or incontinence. In the case of the uterus and vagina, the suspensory supports (level I) are provided by the cardinal and uterosacral ligaments, while level II support of the vagina is provided by connective tissue (called paracolpium by Delancey) which connects the vagina to the arcus tendineus fascia pelvis or ‘white line’. This is a fibrous condensation running along the pelvic side-wall from about 1 cm lateral to the pubic symphysis to the ischial spine, which forms part of the origin of the levator ani muscles. As well as fixing the vagina laterally, the paracolpium forms a supportive layer under the bladder anteriorly, which is called the pubocervical fascia. The posterior aspect of the paracolpium is similarly attached to the superior fascia of the levator ani muscles, forming the rectovaginal septum or Denonvilliers fascia. Level III support of the lower third of the vagina is provided by fusion of the vaginal connective tissue posteriorly to the perineal body and anteriorly to the urethra. The main support of the bladder and bladder neck is the ‘hammock-like’ anterior vaginal wall and the condensation of pubocervical fascia around the vagina, which extends laterally to the arcus tendineus fascia pelvis and fuses to the levator ani muscles beneath. As the distal urethra passes through the perineal membrane the fascia surrounding it fuses densely with the pubic bone. The indirect lateral attachments to the levator ani muscles (specifically the pubococcygeus portion) provide a base against which the urethra is compressed during rises in intra-abdominal pressure, closing the urethral lumen. When the levator ani muscles are voluntarily contracted, they are able to provide compression that can interrupt the urinary stream. Cystocoeles can arise in a number of different ways. Defects in the endo-pelvic fascia in the midline lead to a central cystocoele while detachment of the pubocervical fascia from the white line gives rise to lateral prolapse of the anterior vaginal wall. In addition, superior transverse defects have been described in the endo-pelvic fascia where the pub-cervical fascia attaches to the cervix, merging with the uterosacral and cardinal ligament complex, leading to a high central cystocoele.21 At the bladder neck, failure of the supporting structures can give rise to stress incontinence. The type of fascial defects present need to be carefully assessed in the individual patient in order to repair and support the affected structures. In addition at least 35% of women will have new onset (occult) stress incontinence postoperatively which needs to be assessed by urodynamic investigations preoperatively with and without reduction of the prolapse.22 SURGICAL APPROACHES TO ANTERIOR VAGINAL WALL PROLAPSE In this review, only operations designed to correct anterior vaginal prolapse will be described. In the case of bladder neck descent leading to stress incontinence, or combined prolapse and stress incontinence, the various operations may be combined with procedures to support the bladder neck, such as a Burch colposuspension or the sling procedure, which are outside the scope of this review. Anterior colporraphy A large number of variations have been described: in the main, the operation involves a midline incision of the vaginal mucosa with dissection of mucosal flaps to expose the bladder and proximal urethra. Absorbable mattress sutures are placed into paravesical fascia laterally in order to support the bladder in the midline. The excess vaginal mucosa is excised and closed in the midline with further absorbable sutures. As a result of the anatomical concepts described above, it is now thought that only a central fascial defect will respond to anterior colporrhaphy: any evidence of displacement of the vaginal wall from the white line laterally (lateral defect) will require reattachment of the vaginal wall back onto the white line (i.e. a paravaginal repair). However, this hypothesis has yet to be tested. Results of anterior colporrhaphy The numerous retrospective studies of anterior colporrhaphy as a treatment for prolapse have been reviewed by Weber and Walters.23 A randomised trial of different variations in repair method has been performed. This failed to demonstrate a difference in outcome.24 The majority of studies had recurrent cystocoele rates of between 3% and 20% after 2 – 8 years’ follow-up, but as these were all retrospective studies it is unclear what assessment of lateral D RCOG 2004 BJOG: an International Journal of Obstetrics and Gynaecology 111 (Suppl. 1), pp. 67 – 72 MANAGEMENT OF PROLAPSE OF THE ANTERIOR COMPARTMENT defects was carried out prior to surgery. Porges and Smilen carried out a retrospective analysis of their case load of 486 prolapse procedures over 23 years.25 For primary anterior repairs they had a recurrence rate of 1.4% for mild prolapse and 3.8% for severe prolapse; in the recurrent surgery group, recurrences of 2.9% –4.5% are quoted. No complications of the surgery are reported but there were two deaths, one due to medical problems and one due to pelvic sepsis in a diabetic. Stanton et al.26 noted a recurrence rate of 15% after 2 years for anterior colporrhaphy performed for prolapse, although the study concentrated on the preand postoperative urodynamic findings. Weber’s group demonstrated a recurrence rate of 40% at 1 year.24 Abdominal cystocoele repair Several techniques of abdominal repair of cystocoele have been described at the time of hysterectomy, although these have fallen out of favour.8 – 12 The basis of the technique is to dissect the bladder at abdominal hysterectomy much more fully than usual, exposing vaginal mucosa at the level of the urethra and removing a diamond-shaped portion of vaginal mucosa in the midline. The repair is oversewn using absorbable sutures. In 1978, Macer published his 20 years’ experience of the technique: subjective assessment of 76 patients showed an overall recurrence of cystocoele occurred in 7.9% of cases, which he compared with a recurrence rate of 22% in his anterior colporrhaphy cases over the same period.10 Unfortunately, there was no indication in these papers of any independent assessment of the patients nor of any indication of any complications resulting from the surgery. Abdominal paravaginal repair Paravaginal repair of lateral wall defects aims to reapproximate the vaginal wall to the arcus tendineus fascia pelvis/white line. The most widely used surgical approach has been an abdominal one, via the retropubic space, although the same structures can also be approached vaginally. The procedure is similar to that employed in a Burch colposuspension. After exposure of the lateral vagina by medial dissection of the bladder base, between four and six permanent sutures are placed through the vagina along its length, and then via the arcus tendineus fascia pelvis rather than the ilio-pectineal ligament, in order to restore lateral vaginal support. Vaginal paravaginal repair Initially described by White in 1909,4 this operation can be performed through a midline vaginal incision or through bilateral vaginal incisions. The bladder is dissected medially 69 from the vagina and the pelvic side-walls, exposing the ischial spines. Permanent sutures are placed from the iliococcygeus fascia anterior to the ischial spine and then through the vagina (leaving the epithelium intact), suspending the vagina bilaterally using the same technique as for sacrospinous fixation. Further sutures are then placed through the arcus tendineus fascia and through the lateral vaginal wall to reattach the vagina on both sides to the white line. Any central defects can be repaired by an anterior colporrhaphy: the lateral wall sutures are only tied to elevate the anterior wall after the vaginal mucosa has been closed. A modification of the technique described by Scotti et al.26 is the use of ischial periosteum anterior to the ischial spine or the obturator membrane as an anchoring tissue rather than the arcus tendineus fascia. In a prospective study of 40 patients, 75% of whom also had urodynamic stress incontinence, only one patient had a recurrent paravaginal defect during the follow up period (mean 39 months, range 7 – 52 months). However, a high proportion of patients had other procedures performed concomitantly, which ranged from abdominal sacrocolpopexy to suburethral sling procedures, so the results are difficult to interpret. RESULTS OF PARAVAGINAL REPAIR (ABDOMINAL AND VAGINAL) Shull et al.15 reported on 62 women with bilateral paravaginal defects, leading to severe cystocoele (87% beyond hymen) operated on vaginally and followed up for a mean of 1.6 years; 69% had had previous pelvic surgery, including anterior or posterior repair in 34 patients. As well as bilateral paravaginal repairs, additional procedures were carried out in a proportion of patients, with 73% having a form of culdoplasty and all patients also having a perineorraphy and posterior repair. Thirty-three per cent developed recurrent anterior vault prolapse, none of which was as severe as the preoperative state and none of which had required further surgery, although the follow up data and its method of assessment was unclear. Benson et al.27 carried out a randomised study of patients with primarily uterine or vault prolapse associated with relaxation of the anterior vaginal wall, up to or beyond the hymen, with a paravaginal defect present. Women with central cystocoeles were excluded. Eightyeight women were operated on after careful assessment, including subtracted dual channel cystometry and 48 women were randomised to a vaginal approach which included bilateral sacrospinous fixation and vaginal paravaginal repair, using permanent monofilament sutures. In addition, however, vaginal hysterectomy, Pereya urethropexy or sling, McCall culdoplasty or anterior colporrhaphy were also undertaken at the surgeon’s discretion. The other 40 women underwent an abdominal surgical approach, with the main part of the procedure being sacrocolpopexy and abdominal paravaginal repair, also with permanent D RCOG 2004 BJOG: an International Journal of Obstetrics and Gynaecology 111 (Suppl. 1), pp. 67 – 72 70 M. SLACK monofilament sutures. In addition, in this arm of the study patients underwent abdominal hysterectomy, Burch or sling procedures, culdoplasty or a Macer abdominal anterior wedge repair as well. Of the abdominal group 30% required a vaginal anterior colporrhaphy, and in 50% of the abdominal group and 67% of the vaginal group, posterior repairs were also performed. Patients were followed up at 6 months and annually for 5 years by an independent coauthor (not the surgeon). Patients operated on vaginally had significantly shorter operating times and operative costs, but longer duration of catheter use (greater than 5 days in 75% compared with 48% of the abdominal group) and twice the rate of postoperative urinary incontinence. Mean time to recurrence of prolapse was 11.2 months (F11.5) in the vaginal group and 22.2 (F16.2) in the abdominal group, which was significant. Re-operation for cystocoele was required in 29% of the vaginal group and only 10.5% of the abdominal group. Despite the confounding differences in the other surgical procedures performed, this study does indicate some possible advantages for the abdominal route, especially in terms of the longevity of the repair. Monga28 described the results of paravaginal repair for cystourethrocoele as ‘cure’ in between 76% and 97% of patients; however, he noted that the patient groups were often mixed, and definitions of ‘cure’ varied. ABDOMINOPERINEAL PROCEDURES: FOUR CORNER REPAIR An abdominoperineal procedure was suggested by Raz in 1989 for the correction of anterior vaginal wall laxity. The initial description was for a group of patients with grade II to III cystocele.29 A significant number of these patients had coexistent stress incontinence. The procedure is based on the same principles as the Raz long needle colpsuspension. In addition to two paraurethral sutures another two sutures are placed more proximally and through the entire vaginal wall. The four sets of sutures are transferred to the abdomen with a double pronged needle through a suprapubic incision. The degree of elevation of the bladder neck is estimated cystoscopically, then the prolene sutures are tied abdominally across the rectus sheath. Both in this series and in a second series30 on patients with grade IV cystocoele a cure rate of greater than 90% was reported (for cystocoele). A more modest success rate was achieved for the cure of urodynamic stress incontinence. Using the same technique in a smaller series, Miyazaki and Miyazaki had excellent results at 6 weeks but this had dropped to 59% by 4 years.31 Kohli32 retrospectively compared two groups of patients, 27 undergoing anterior colporrhaphy alone and 40 who underwent four corner repair for anterior wall prolapse and concomitant genuine stress incontinence. The patients were a mixed group with 28 of the 67 patients having had previous pelvic floor surgery, including seven who had had previous bladder neck surgery. The authors aimed to assess the degree of anterior wall descent in the two groups postoperatively. After mean follow up in both groups of 13 months (range 4– 38 months), 7% of the anterior repair group had a recurrent cystocoele compared with 33% of the four corner repair group. This was a statistically significant difference and indicated that the needle suspension did not add further support to the anterior repair. It does not appear that this procedure has any real advantages over anterior colporrhaphy. SYNTHETIC PROSTHESES Dissatisfaction with the outcome of operations for the management of anterior wall prolapse have encouraged surgeons to experiment with a variety of natural and synthetic grafts. A report on the use of Tantalum mesh was published in 1955.33 Ten patients had Tantalum mesh grafts inserted for the repair of large symptomatic cystoceles. Follow-up was very short (6–18 months) and was completed on nine of the patients. Five had a complete resolution of the symptoms but in four the mesh was exposed and required trimming. Friedman in 1970 reported on the use of a collagen mesh prosthesis in the management of four patients with a variety of pelvic floor defects.34 In one patient with a uterine and anterior wall prolapse the mesh was placed below the epithelium of the anterior wall. No objective or long-term (greater than 10 years) results are available. Rosing described fibrin sealant placed in the Cave of Retzius.35 In a group of nine patients with anterior wall defects and a high body mass index he successfully corrected the prolapse. No details of type or length of follow up are available. A descriptive paper on the use of a free full-thickness epithelial graft for the correction of prolapse was made by Zacharin.36 Again no results are available. More recently Julian used Marlex mesh in a randomised prospective study.37 Twenty-four patients were randomised into control and treatment groups. All patients underwent an anterior colporrhaphy, paravaginal repair and urethral suspension. In the treatment group a Marlex polypropylene mesh was placed under the anterior vaginal wall before closure. There were only four failures which all occurred in the control group. Three patients suffered vaginal erosions but these were successfully treated conservatively. Data on the use of synthetic prostheses are limited but following the success of the tension-free vaginal tape for the treatment of urinary incontinence there will no doubt be renewed interest.38 Polypropylene is probably one of the ideal biocompatible materials. It is strong and both chemically and physically inert. It is not carcinogenic and is easy to produce. It is possible that the characteristics of the weave impart specific properties to the mesh and thus not all forms of polypropylene are identical. The behaviour of different D RCOG 2004 BJOG: an International Journal of Obstetrics and Gynaecology 111 (Suppl. 1), pp. 67 – 72 MANAGEMENT OF PROLAPSE OF THE ANTERIOR COMPARTMENT forms of mesh in the suburethral position may be due as much to tissue reactivity as to operative technique. Experience with the complications of artificial slings in the suburethral position (e.g. erosion) should act as a warning to surgeons planning to use mesh for cystocele repair. Although the use of mesh is very tempting, widespread introduction should be preceded by careful clinical trials. COMPLICATIONS OF ANTERIOR WALL SURGERY Direct complications with these procedures remain rare. An injury rate of 0.5% –2.0% of cases has been reported.39 Obviously damage to the bladder and urethra at the time of operation has been described. These are easily corrected surgically and apart from the need for continuous urinary drainage for 10 days are unlikely to have any long-term consequences. The use of nonabsorbable suture material is uncommon, which should minimise complications secondary to suture placement into the lumen of the bladder. Recurrent urinary tract infections secondary to penetration of the bladder wall with chromic suture material have been reported. Diagnosis with the help of ultrasound or at the time of cystoscopy is easily achieved. Removal at the time of cystoscopy should be straightforward.40 In an assessment of urinary function after colporrhaphy Stanton et al.41 demonstrated a reduction in the symptoms of urge, stress and a resolution of the presenting symptoms. These patients had no alteration in flow rate, maximum voiding pressure or residual urine and no increase in detrusor instability. However, in an earlier report from a tertiary practice, Delaere et al.42 reviewed a series of 85 women referred after having developed complications as a result of anterior vaginal repair. Iatrogenic or persistent urinary stress incontinence occurred in 72%. In addition 40% had bladder outlet obstruction and 25% had detrusor instability. Of this entire group 23% were troubled by recurrent urinary tract infections. One can assume that the paravaginal repairs will mirror the complications of their abdominal and vaginal counterparts. On purely theoretical grounds the abdominal approach could cause denervation injury to the bladder, which might produce detrusor overactivity. It would seem that because of a paucity of information about the true complication rates and reluctance on the part of the patients to complain we might be underestimating the size of the problem. There is a need for national registers to report complications in the same way as the ‘Yellow card’ system for drug therapy. The anatomical alterations that lead to vaginal prolapse are starting to be better understood and applied by surgeons. A number of different operations have been described in the past to repair the anterior vaginal wall, the most common of which is still the anterior colporrhaphy. As a result of the anatomical studies described above, the role 71 of the paravaginal repair has increased in prominence in the last 15 years. It is not established whether anterior wall defects occur alone or possibly always in combination with a level I defect. If this is the case the standard approach may be to combine the operation with a vault supporting procedure. Unfortunately, the patient groups that are included in most of the available reports are so diverse in terms of previous surgery, the presence or absence of incontinence and the number of repair procedures performed concurrently, that any comparison of different surgical approaches is impossible. There is a need for a properly randomised study of anterior repair alone vs anterior repair with paravaginal repair and paravaginal repair alone. All the new techniques using mesh will also need a similar level of scrutiny. Hopefully grant-awarding bodies such as the Medical Research Council will show renewed interest in clinical studies that address surgical issues such as the management of the anterior wall. Proper funding will allow us to find better ways to manage this condition. References 1. Emge LA, Durfee RB. Pelvic organ prolapse: Four thousand years of treatment. Clin Obstet Gynecol 1966;9:997 – 1032. 2. Kreutzmann HJ. The uniform principle in performing operations for lacerated perineum, cystocele rectocele and prolapse. Am J Obstet Gynecol 1902;45:359 – 365. 3. Hurd RA. Observations and conclusions on plastic operations in gynaecology. Am J Obstet Gynecol 1929;19:633 – 640. 4. White GR. Cystocoele, a radical cure by suturing lateral sulci of vagina to white line of pelvic fascia. JAMA 1909;21:1707 – 1710. 5. Richardson AC, Edmonds PB, Williams NL. Treatment of stress urinary incontinence due to paravaginal fascial defect. Obstet Gynecol 1981;57:357 – 363. 6. Weinstein M, Roberts M. Simultaneous repair of cystocoele and high rectal prolapse during total hysterectomy. West J Surg Obstet Gynec 1949:34 – 37. 7. Bissel D. A vaginal hysterectomy technique for the cure of prolapse of the uterus when the removal of the uterus is necessitated. Surg Gynecol Obstet 1918;28:138 – 145. 8. Masters WH. The abdominal approach to cystourethrocele repair. Am J Obstet Gynecol 1954:67. 9. Spiers RE. The abdominal approach for repair of a cystocele. Surg Obstet Gynecol 1956;102:245 – 247. 10. Macer GA. Transabdominal repair of cystocele. West J Surg Obstet Gynec 1961;69:182 – 184. 11. Weinberg MS, Stone ML. Abdominal cystocele repair. Obstet Gynecol 1963;21:117 – 121. 12. Macer transabdominal repair of cystocele, a 20 year experience compared with the traditional vaginal approach. Am J Obstet Gynecol 1978;131:203 – 207. 13. Goetsch C. Suprapubic vesicourethral suspension as a primary means of correcting stress incontinence and cystocele. West J Surg Obstet Gynec 1954;62:201 – 204. 14. Raz S, Little NA, Juma S, Sussmen EM. Repair of severe anterior vaginal wall prolapse. J Urol 1991;146:988 – 992. 15. Shull RL, 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: 1429 – 1439. D RCOG 2004 BJOG: an International Journal of Obstetrics and Gynaecology 111 (Suppl. 1), pp. 67 – 72 72 M. SLACK 16. Olsen AL, Smith VJ, Bergstrom JO, Colling JO, Clark AL. Epidemiology of surgically managed pelvic organ prolapse and urinary incontinence. Am J Obstet Gynecol 1997;89:501 – 505. 17. MacLennan AH, Taylor AW, Wilson DH, Wilson D. The prevalence of pelvic floor disorders and their relationship to gender, age, parity and mode of delivery. Br J Obstet Gynecol 2000;107:1460 – 1470. 18. Luber KM, Boero S, Choe JY. The demographics of pelvic floor disorders: current observations and future projections. Am J Obstet Gynecol 2001;184:1496 – 1501. 19. Bonney VJ. Obstet Gynaecol Br Emp 1934;41:669 – 683. 20. Delancey JOL. Anatomic aspects of vaginal eversion after hysterectomy. Am J Obstet Gynecol 1992;166:1717 – 1728. 21. Richardson AC, Lyons JB, Williams NL. A new look at pelvic relaxation. Am J Obstet Gynecol 1976;126:568 – 573. 22. Bergman A, Koonings PP, Ballard CA. Predicting postoperative urinary incontinence development in women undergoing operation for genitourinary prolapse. Am J Obstet Gynecol 1988;158:1171 – 1175. 23. Weber AM, Walters MD. Anterior vaginal prolapse: review of anatomy and techniques of surgical repair. Obstet Gynecol 1997; 89:311 – 318. 24. Weber AM, Walters M, Piedmonte M, Ballard LA. Anterior colporrhaphy. A randomised trial of three surgical techniques. Am J Obstet Gynecol 2001;185:1299 – 1306. 25. Porges RF, Smilen SW. Long-term analysis of the surgical management of pelvic support defects. Am J Obstet Gynecol 1994; 171:1518 – 1528. 26. 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; 179:1436 – 1445. 27. Benson JT, Lucente V, McClellan E. Vaginal versus abdominal reconstructive surgery for the treatment of pelvic support defects: a prospective randomised study with long-term outcome evaluation. Am J Obstet Gynecol 1996;175:1418 – 1422. 28. Monga A. Fascia: defects and repair. Curr Opinion Obstet Gynaecol 1996;8:366 – 371. 29. Raz S, Klutke CG, Golomb J. Four-corner bladder and urethral suspension for moderate cystocele. J Urol 1989;142:712 – 715. 30. Raz S, Little NA, Juma S, Sussmen EM. Repair of severe anterior vaginal wall prolapse. J Urol 1991;171:1429 – 1439. 31. Miyazaki FS, Miyazaki DW. Raz four-corner suspension for severe cystocoele: poor results. Int Urogynaecol J 1994;5:94 – 97. 32. Kohli N, Sze EHM, Todd WR, Karram MM. Incidence of recurrent cystocoele after anterior colporrhaphy with and without concomitant transvaginal needle suspension. Am J Obstet Gynecol 1996;175: 1476 – 1482. 33. Moore J, Armstrong JT, Wills SH. The use of tantalum mesh in cystocele with critical report of ten cases. Am J Obstet Gynecol 1955; 69:1127 – 1135. 34. Friedman EA, Meltzer RM. Collagen mesh prosthesis for repair of endopelvic fascial defects. Am J Obstet Gynecol 1970;106:430 – 433. 35. Rosing U, Fianu S, Larsson B. A new surgical technique for repairing cystocoele in hysterectomised women. J Gynec Surg 1990;6:281 – 285. 36. Zacharin RF. Free full-thickness vaginal epithelium graft in correction of recurrent genital prolapse. Aust NZ Obstet Gyneacol 1992;32: 146 – 148. 37. Julian TM. The efficacy of Marlex mesh in the repair of severe recurrent vaginal prolapse of the anterior midvaginal wall. Am J Obstet Gynecol 1996:1472 – 1475. 38. Ward KL, Hilton P, UK and Ireland TVT Trial Group . A prospective multicenter randomized trial of tension-free vaginal tape and colposuspension for primary urodynamic stress incontinence: two-year follow-up. Am J Obstet Gynecol 2002;190:324 – 331. 39. Spirnak JP, Resnick MI. Intraoperative consultation for the bladder. Urol Clin N Am 1985;12:439 – 446. 40. Neuman M, Alon H, Langer R, et al. Recurrent urinary tract infections in the presence of intravesical suture material after vaginal hysterectomy and anterior colporrhaphy. Aust NZ J Obstet Gynecol 1990;30:184 – 185. 41. Stanton SL, Norton C, Cardozo L. Clinical and urodynamic effects of anterior colporrhaphy and vaginal hysterectomy for prolapse with and without incontinence. Br J Obstet Gynecol 1982;89:459 – 463. 42. Delaere KPJ, Moonen WA, Debruyne FMJ, et al. Anterior vaginal repair: cause of troublesome voiding disorders? Eur Urol 1979;5: 190 – 194. D RCOG 2004 BJOG: an International Journal of Obstetrics and Gynaecology 111 (Suppl. 1), pp. 67 – 72