Anterior vaginal wall laxity (cystocele) is one of the most common forms of pelvic organ prolapse found in women. More than 20,000 cystocele repairs are performed each year in the United States; however, traditional surgeries often show low cure rates and/or inadequate anatomical outcomes. Successful treatment of anterior vaginal wall prolapse remains one of the most challenging and highly studied areas in reconstructive pelvic surgery. Our team has developed more advanced surgical techniques that provide excellent support for the anterior and posterior vaginal wall (e.g., rectocele), the vaginal apex (e.g., vaginal vault prolapse), as well as stress urinary incontinence, a problem affecting more than 1.5 million women in Greece.
Our team has developed, at MITERA Hospital, one of the first centers in the country to use grafts/meshes in cystocele repairs, achieving improvement rates above 92% with minimal complications. For many years, abdominal sacrocolpopexy, involving the placement of a mesh at the vaginal apex for vault prolapse, has been considered the most successful procedure available. Improvements in this procedure now allow us to offer patients a minimally invasive laparoscopic micro-surgical approach to sacrocolpopexy, with the same excellent success rates (>92%), hospital stays under 24 hours, and reduced complications. Despite these advancements, the anterior vaginal wall remains one of the most difficult areas in the vagina to achieve satisfactory anatomical results and high cure rates with traditional repairs—while at the same time avoiding issues such as sexual dysfunction, dyspareunia (pain during intercourse), defecatory problems (e.g., incontinence or persistence/frequency syndromes), or the outcome of a shortened or scarred vagina.
What we do today
Traditionally, cystocele has been repaired using the Anterior Colporrhaphy technique (also called Anterior Repair), which involves folding and suturing the fascia from one side to the other, from the top of the bladder to the top of the vagina. Even today, it remains the most commonly performed procedure for cystocele, despite failure rates reaching 30–50%. It is one of the oldest prolapse surgeries, and despite its low cure rates, it continues to be performed by most gynecologists and urologists for the treatment of cystocele. Many doctors even advise their patients to delay surgery until later in life, as the procedure often needs to be repeated due to eventual failure.
In addition to the high failure rates, the anatomical outcomes are often unsatisfactory. When tissues are brought together with midline plication, the vagina may become narrowed because the surgeon removes the excess vaginal skin. This can lead to pain during sexual intercourse (dyspareunia) or even the inability to have sexual intercourse if the vagina becomes too restricted or closed. While the bulge may be reduced, this approach is not considered a proper anatomical repair — it is merely a compensatory procedure that folds one weak tissue onto another weak tissue, which is likely to tear or stretch again under the same forces that caused the prolapse in the first place. It is also not uncommon for patients to experience difficulty with bowel movements after tightening the tissue beneath the bladder base. Another theory explaining the failure of these repairs is the presence of paravaginal defects in some patients (e.g., lateral detachments where support has separated from the pelvic sidewalls). In such cases, the surgeon pulls healthy fascia toward the midline, away from the pelvic sidewalls, folding it centrally rather than restoring natural lateral support.
Our laparoscopic technique provides patients with a microsurgical approach to cystocele repair, and for younger, sexually active women, this is our primary method of treatment. However, this laparoscopic approach is technically very demanding and requires highly advanced surgical skill, meaning that only a small number of gynecologists in our country are able to perform this procedure.
Use of Mesh and Grafts
Over the past five years, there has been growing interest and research in the use of mesh grafts for the surgical correction of prolapse and incontinence. The initial research originates from medical studies conducted many years ago, when researchers discovered that abdominal hernia repairs had higher success rates when mesh was used. This is entirely logical, and in recent years, we have seen increasing evidence supporting the use of mesh in pelvic organ prolapse surgery. With traditional repairs (for example, those performed without mesh reinforcement), we rely on suturing weak tissue to weak tissue, and the tissue is placed under tension — a principle that contradicts basic surgical foundations. It is no surprise, therefore, that cure rates are so low.
Today, very few abdominal wall hernias are repaired without mesh, and the same principle should now apply to prolapse surgeries. For many years, we have known that abdominal sacrocolpopexy demonstrates the highest success rates for vaginal vault prolapse, and this is likely due to the use of mesh, which removes reliance on the variable strength of each patient’s own tissues. As mentioned earlier (and in the section on posterior repair), our team began using mesh in 2004. We have observed a significant increase in cure rates (>90% compared to 60% with traditional repairs) and far superior anatomical outcomes.
In the early 2000s, the obturator foramen was described as a new, safe pelvic landmark for the placement of slings used to treat stress urinary incontinence. Dr. Moore and Dr. Miklos were among the first surgeons in the United States to use this technique and helped establish it nationally.
Advantages of the Transobturator Approach
- Safer, faster, and more effective – Return home within 24 hours (or within 8 hours if the procedure is for stress urinary incontinence alone, without vaginal wall prolapse).
- Reduced risks of:
- Bowel injury
- Bladder injury
- Significant bleeding
- No use of a retropubic needle passage
- No abdominal incisions
- Better anatomical positioning of the mesh
The transobturator approach allows the surgeon to place the mesh in a secure and stable position, as safely and minimally invasively as possible.
A small incision is made in the vagina, and the vaginal epithelium is separated from the bladder—similar to what is done in a traditional anterior repair without mesh. The incision is simple and safe. The needles are then passed through very small groin incisions, through the obturator membrane, and into the obturator space. At this point, the surgeon can palpate the needles directly with a finger inserted through the vaginal incision and guide them precisely to the correct location on the pelvic sidewall where the mesh will be positioned. This technique protects the bladder and urethra from potential injury by avoiding blind needle passage. The needles then pass through the pelvic sidewalls (the obturator internus muscle, levator ani, and pelvic fascia), attach to the mesh arms, and exit through the corresponding groin incisions. Once all needles have passed, the mesh arms secure the graft in place.
When positioned correctly, the mesh provides a new layer of support for the bladder from one pelvic sidewall to the other. The vaginal skin is laid back over the mesh, and tissue ingrowth occurs rapidly, allowing the mesh to integrate quickly into the patient’s anatomy. The vaginal skin remains thick throughout the procedure, and no skin is removed (as is often done in traditional repairs), significantly reducing the risk of mesh exposure. After healing, most patients and their partners cannot feel the mesh.
Success rates reach approximately 92%, with key advantages including rapid return home and to work, as well as significantly lower overall procedure costs compared to older surgical techniques.
