Skip to main content

Anterior Colporrhaphy

Anterior colporrhaphy is the most commonly performed native-tissue surgical repair for anterior vaginal wall prolapse (cystocele) and remains the standard transvaginal approach, particularly since the FDA ordered all transvaginal mesh products for POP off the U.S. market in April 2019.[1][2][3]

Definition and Indications​

Anterior colporrhaphy addresses prolapse of the bladder (cystocele) or urethra into the anterior vaginal wall. It is indicated for symptomatic anterior compartment prolapse — typically POP-Q stage ≥ II — that has failed or is not amenable to conservative management (prolapse pessary, PFMT, lifestyle modifications).[1][3] The anterior compartment is the most commonly affected segment in pelvic organ prolapse.[4]

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

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)

Outcomes and Success Rates​

Success rates vary substantially depending on the definition used:

DefinitionSuccess rate
Clinically relevant (no prolapse beyond the hymen + absence of bulge symptoms + no retreatment)88% at 1 year[5]
Strict anatomic (POP-Q stage 0 or 1)13–34% at long-term follow-up[7][8]
Subjective success (absence of bulge symptoms)69% at mean 74 mo[7]
Patient satisfaction98.5%, even among those with anatomic recurrence — 66% of patients with objective recurrence had no prolapse symptoms[7]

The double-layered technique (DAC) reported an 81.7% anatomic cure rate (prolapse ≤ stage I).[6]

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 graftNative tissue repair likely increases recurrent anterior prolapse (RR 1.53, 95% CI 1.19–1.97); little to no difference in prolapse awareness, repeat surgery, or dyspareunia
vs. transvaginal permanent meshNative tissue repair → more prolapse awareness (RR 1.77), more recurrence (RR 3.21), more repeat surgery for prolapse (RR 2.17); similar dyspareunia and fewer bladder injuries

The clinical significance of these anatomic-recurrence differences is debated — many recurrences are asymptomatic and do not require retreatment.[5][7]

Suture Type​

Whether suture type affects outcomes is an active area of investigation. A multicenter RCT protocol is comparing non-absorbable vs. absorbable sutures for anterior colporrhaphy, hypothesizing that absorbable sutures may not retain adequate strength during fascial remodeling, potentially contributing to recurrence.[9]

Complications​

Anterior colporrhaphy has a favorable safety profile compared with mesh-augmented repairs:[8][10]

ComplicationRate
Intraoperative bladder injury0.2–0.5%
Rectal injury0.2%
Urinary tract infection7.8%
Post-void residual / voiding difficulty5.5%
Postoperative hemorrhage requiring reoperation0.9%
De novo SUI~6.3% (vs. 12.3% with mesh)
De novo urgency / detrusor overactivityReported but uncommon[11]
Clavien-Dindo grade III (requiring surgical intervention)1.8%

No grade IV or V complications were reported in a systematic assessment of 438 cases.[10]

Anterior Colporrhaphy vs. Transvaginal Mesh — Regulatory Context​

The landmark Altman et al. NEJM 2011 trial demonstrated that transvaginal mesh achieved higher composite success (60.8% vs. 34.5%) but at the cost of:[8]

  • Longer operative times
  • More hemorrhage
  • Higher bladder perforation (3.5% vs. 0.5%)
  • More de novo SUI (12.3% vs. 6.3%)
  • 3.2% mesh exposure requiring reintervention

"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 all transvaginal mesh for POP off the U.S. market in April 2019, determining that manufacturers failed to demonstrate an acceptable benefit-risk profile compared with native tissue repair.[2][3] This order does NOT apply to transvaginal mesh for SUI or transabdominal mesh (sacrocolpopexy).[2] ACOG and AUGS note that some surgeons may still offer transvaginal mesh for select high-risk patients (e.g., recurrent prolapse), but this should be limited.[2][12]

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​

One of the most important surgical principles is that many women with anterior wall prolapse also have apical prolapse, and failure to address the apex is a major contributor to recurrence. ACOG recommends that surgery should correct apical prolapse concurrently with anterior wall repair, as resupport of the vaginal apex reduces the risk of recurrent POP surgery.[2]

A Medicare analysis of 2,756 women followed for 10 years demonstrated:[13]

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

Despite this evidence, apical suspension remains underutilized — only 24% of hysterectomies for POP included a colpopexy in one statewide analysis.[14]

Concomitant Anti-Incontinence Surgery​

Approximately 40% of continent women develop de novo stress urinary incontinence after prolapse repair (occult SUI unmasked by correction of urethral kinking).[15] The OPUS trial (Wei 2012) demonstrated that prophylactic midurethral sling placement at the time of vaginal prolapse surgery reduced postoperative SUI from 49% to 24%.[16] The AUA / SUFU guideline supports consideration of a concomitant anti-incontinence procedure, though this should be a shared decision given the higher complication rates (bladder perforation, tape exposure) with combined surgery.[17]

Long-Term Outcomes​

At long-term follow-up (> 5 yr), anterior colporrhaphy shows durable patient satisfaction despite modest anatomic outcomes. A comparison of colporrhaphy, xenograft, and mesh at a mean of 95 months found no significant difference in objective or subjective outcomes, while mesh was associated with higher complication rates.[18] The 5-year objective cure rate for native tissue repair with sacrospinous fixation was 64.4% vs. 89.1% for anterior-apical mesh, though both groups had low retreatment rates.[19]

Summary of Key Comparisons​

ComparisonProlapse awarenessAnatomic recurrenceRepeat surgeryDyspareuniaKey complications
AC vs. Biological GraftNo difference (RR 1.20)[4]Higher with AC (RR 1.53)[4]No difference (RR 0.99)No differenceSimilar safety profiles
AC vs. Transvaginal MeshHigher with AC (RR 1.77)[4]Higher with AC (RR 3.21)[4]Higher with AC (RR 2.17)No differenceMesh: bladder injury, exposure (~12%), de novo SUI[8]
AC + Apical Suspension vs. AC AloneNot reportedLower with apical suspension11.6% vs. 20.2% at 10 yr[13]Not reportedSlightly higher perioperative complications

Current Practice Recommendations​

Per ACOG and AUGS:[2]

  • Anterior colporrhaphy is an effective first-line treatment for anterior vaginal wall prolapse
  • Concomitant apical support should be performed when apical prolapse coexists
  • Biologic grafts provide minimal additional benefit over native tissue repair
  • Transvaginal mesh is no longer FDA-approved for POP in the U.S.; its use should be limited to select high-risk patients
  • Preoperative evaluation for occult SUI should be performed, with shared decision-making regarding concomitant anti-incontinence procedures

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. American Urogynecologic Society Best Practice Statement. "Pelvic Organ Prolapse." Female Pelvic Med Reconstr Surg. 2019;25(6):397-408. doi:10.1097/SPV.0000000000000794

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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