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] While historically important, it has been largely supplanted by midurethral slings and Burch colposuspension due to inferior long-term continence outcomes.[1][3]
This page is the canonical 04g Prolapse Repair entry for the Kelly plication. For modern anti-incontinence procedures with superior 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][4]
- Midline incision in the anterior vaginal wall overlying the bladder and urethra
- The vaginal mucosa is dissected off the underlying periurethral tissue and pubocervical fascia, extending from below the urethra to just anterior to the cervix
- One to three sutures ("Kelly sutures") are placed in the periurethral tissue and pubocervical fascia to support and elevate the bladder neck
- The fascia is plicated in the midline, narrowing the bladder neck and proximal urethra
- 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][5]
Mechanism of Action
The Kelly plication works by buttressing the bladder neck and increasing 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.[6] However, the Kelly plication does not reposition the bladder neck into a high, supported retropubic position — a key limitation that contributes to its higher failure rate compared with retropubic procedures.[5]
Variations
| Variant | Description |
|---|---|
| Kelly-Kennedy plication | Most commonly referenced variant |
| Marion Kelly technique | Historical modification |
| Bologna procedure | Vaginal-to-suprapubic suspension variant |
| Diaphragmplasty | Broader fascial-imbrication variant |
| Modified Kelly with vaginal retropubic urethropexy | Beck et al. — adding a vaginal retropubic urethropexy increased cure from 75% to 94% for genuine SUI[7] |
Efficacy — Short-Term
In randomized trials, the Kelly plication demonstrates moderate short-term continence rates of 66–75%:[2]
| Study | n | Outcome |
|---|---|---|
| Park & Miller 1988[8] | 680 | Kelly 69% continence at 1 yr, comparable to MMK (66%) and superior to original Pereyra. Both Kelly and MMK superior to Pereyra at all time points. |
| Beck 1991[7] | 519 | Standard Kelly-Kennedy 75% cure for genuine SUI; modified technique with vaginal retropubic urethropexy 94%. |
Efficacy — Long-Term
Long-term outcomes reveal the central weakness of the Kelly plication — progressive decline in continence rates:[6][8]
Bergman & Elia 1995, 5-year RCT — objective success at 5 yr:
| Procedure | 5-yr objective success | Drop from yr 1 → yr 5 |
|---|---|---|
| Kelly plication | 37% | −26% |
| Pereyra needle suspension | 43% | −22% |
| Burch colposuspension | 82% | −7% |
At the same 5-yr mark, only 30% of Kelly plication patients had a negative cotton-swab test (indicating adequate bladder-neck support), compared with 46% for Pereyra and 91% for Burch — confirming inferior anatomic suspension.[6] Park & Miller's 10-year follow-up showed that all procedures declined steadily, with Kelly and MMK showing similar long-term efficacy (~ 66%) beyond 3 years.[8]
Kelly Plication vs. Other Anti-Incontinence Procedures
| Procedure | Short-term cure | Long-term cure (5+ yr) | Key advantages | Key disadvantages |
|---|---|---|---|---|
| Kelly plication | 66–75% | 37–66% | Transvaginal, low morbidity, simultaneous prolapse repair | Progressive decline; poor anatomic support |
| Burch colposuspension | 85–89% | 82% | Durable; excellent anatomic support | Abdominal approach; longer recovery |
| Midurethral sling (RMUS) | 77–98% | 72–85% | Minimally invasive; outpatient ~30 min | Mesh-related complications (~ 1% exposure) |
| Autologous fascial PVS | 66% (composite) | Durable | Native tissue; no mesh | Donor-site morbidity; voiding dysfunction |
| Needle suspension (Pereyra) | 43–69% | 43% | Transvaginal | Poor durability; intravesical-suture complications |
Cochrane Review Evidence
The Cochrane review on anterior vaginal repair for urinary incontinence (Glazener 2017; 10 trials, 1,012 women) concluded:[1]
- Anterior vaginal repair (including Kelly plication) was significantly less effective than open abdominal retropubic suspension (Burch): failure 38% vs. 17% at 1–5 yr (RR 2.29, 95% CI 1.70–3.08)
- This inferiority persisted beyond 5 yr: 38% vs. 21% failure (RR 2.02, 95% CI 1.36–3.01)
- Repeat incontinence surgery dramatically more frequent after anterior repair: 23% vs. 2% (RR 8.87, 95% CI 3.28–23.94)
- Fewer women had prolapse after anterior repair (RR 0.24), but this did not translate into fewer prolapse operations
The Cochrane authors concluded that anterior vaginal repair "did not seem to be better than any of the comparison interventions, and seemed worse than open abdominal retropubic suspension," recommending that its use for urinary incontinence should be restricted to women deemed unsuitable for alternative treatment.[1]
Network Meta-Analysis Ranking
A BMJ network meta-analysis of 175 RCTs / 21,598 women (Imamura 2019) ranked surgical procedures for SUI by cure rate (SUCRA):[3]
- Traditional sling — 89.4%
- Retropubic midurethral sling — 89.1%
- Open colposuspension — 76.7%
- Transobturator MUS — 64.1%
Anterior vaginal repair / Kelly plication was not among the top-ranked procedures, consistent with its inferior long-term outcomes.
Complications and Morbidity
The Kelly plication has a favorable safety profile — its morbidity falls between that of injectable agents and retropubic / sling procedures:[2][7][8]
| Complication | Rate |
|---|---|
| Significant morbidity (excluding incontinence) | 1% in 25-yr / 519-case series[7] |
| New-onset detrusor instability | 6% (higher after incontinence surgery than prolapse alone) |
| De novo incontinence after prolapse surgery (no preoperative SUI) | 11%[7] |
| Repeat operations | More likely to fail than primary repairs |
| Mesh-related complications | None (native-tissue procedure) |
Current Role and Indications
The Kelly plication is no longer considered a first-line anti-incontinence procedure. Current guidelines and expert consensus position it as follows:[1][3][9]
- Midurethral slings are the most commonly performed and most extensively studied anti-incontinence procedure, with documented short- and long-term efficacy[9][10]
- Burch colposuspension and autologous fascial pubovaginal slings are the primary mesh-free alternatives[9][11]
- The Kelly plication may still have a role in:
- Women undergoing anterior colporrhaphy for prolapse who also have mild SUI — the plication can be added with minimal additional morbidity
- Poor candidates for more invasive procedures (elderly, frail)
- Settings where mesh avoidance is strongly desired and Burch / autologous PVS are not feasible
- Low-resource settings where midurethral slings are unavailable
Emerging Alternatives — Pubourethral Ligament Plication (PLP)
A recent 2026 study compared a modern plication technique — pubourethral ligament plication (PLP) — with transobturator tape (TOT) in 140 women. PLP achieved 77.1% objective success (vs. 88.0% for TOT, p > 0.05) with significantly shorter operative time and no mesh-related complications (vs. 8.7% for TOT). Plication-based, mesh-free approaches continue to evolve as alternatives for selected patients.[12]
Historical Significance
The Kelly plication holds an important place in the history of urogynecology as one of the first described surgical treatments for female SUI. It established the principle that bladder-neck support is critical for continence and paved the way for the development of retropubic suspensions, needle suspensions, and ultimately midurethral slings. While its role has diminished, the concept of periurethral tissue plication remains embedded in modern anterior colporrhaphy technique.[1][2]
See Also
- Anterior Colporrhaphy
- Burch Colposuspension
- Retropubic Midurethral Sling
- Autologous Fascial Pubovaginal Sling
- Female SUI database
- Principles of Prolapse Repair
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. 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
5. 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
6. 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
7. Beck RP, McCormick S, Nordstrom L. "A 25-Year Experience With 519 Anterior Colporrhaphy Procedures." Obstet Gynecol. 1991;78(6):1011-8. PMID 1945202
8. Park GS, Miller EJ. "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 3281007
9. Wu JM. "Stress Incontinence in Women." N Engl J Med. 2021;384(25):2428-2436. doi:10.1056/NEJMcp1914037
10. 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
11. 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
12. İncebıyık M, Adak İH, Be. "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. doi:10.1007/s00192-026-06552-4