Simultaneous Cystocele Repair and Mid-Urethral Sling for Stress Incontinence
Yes, performing concurrent cystocele repair and mid-urethral sling (peri-urethral suspension) is indicated and supported by guideline evidence, with synthetic mid-urethral slings showing 85-87% cure rates when performed with concomitant prolapse repair. 1
Evidence Supporting Concurrent Surgery
The 2017 AUA/SUFU guideline explicitly states that physicians may perform any incontinence procedure (including mid-urethral sling, pubovaginal sling, or Burch colposuspension) in patients undergoing concomitant pelvic prolapse repair. 1 This represents a conditional recommendation based on balancing benefits against potential additional morbidity.
Efficacy Data for Combined Procedures
Synthetic mid-urethral slings with concurrent prolapse treatment:
- Cure/dry rates: 85-88% at 12-23 months 1
- Cure/dry rates: 81-83% at 24-47 months 1
- Retention rates remain low at 3% (same as without prolapse repair) 1
Open retropubic suspensions (Burch) with concurrent prolapse repair:
- Cure/dry rates: 88% at 12-23 months, declining to 67% at 48+ months 1
- Higher retention rates (1-3%) compared to slings 1
- Unacceptably high cystocele recurrence rate of 34% when used for advanced prolapse 2
Recommended Surgical Approach
The optimal approach is anterior colporrhaphy for cystocele repair combined with a synthetic mid-urethral sling (transobturator or retropubic) for stress incontinence. 3, 4
Key Technical Considerations
- Single anterior vaginal wall incision technique allows both procedures through one approach, with success rates of 83.9% for combined surgery versus 87.1% for sling alone (not statistically different). 3
- Mid-urethral sling placement (rather than bladder neck) minimizes retention risk (3% vs 9-10% for bladder neck slings). 1
- Recent comparative data shows anterior colporrhaphy with transobturator tape achieves 82.9% SUI cure and 85.4% cystocele repair success at 12 months. 4
Complications to Anticipate
De novo urge incontinence occurs in 11% of patients when any prolapse treatment is performed concurrently with mid-urethral slings. 1 This compares to 6% without prolapse repair.
Common complications with combined procedures:
- Urinary tract infection: 11% 1
- Bladder injury: 6% 1
- Vaginal mesh extrusion: 7% 1
- Early micturition difficulty: 12.2% (typically resolves) 3
Critical Pitfalls to Avoid
Do not perform Burch colposuspension for advanced cystocele repair. While it provides better continence control than anterior colporrhaphy alone (86% vs 52% subjective cure), it results in a 34% cystocele recurrence rate—making it unsuitable for this indication. 2
Avoid concurrent vaginal hysterectomy if possible. Patients undergoing hysterectomy with prolapse repair and sling have significantly lower continence rates (60.6%) compared to those without hysterectomy. 3
Do not use synthetic mesh near fresh urethral incisions. Synthetic mid-urethral slings are contraindicated in patients undergoing concurrent urethral diverticulectomy, urethrovaginal fistula repair, or urethral mesh excision due to poor wound healing risk and mesh perforation potential. 1
Preoperative Evaluation Requirements
Before proceeding with combined surgery, document:
- Urodynamic confirmation of stress incontinence with cystocele reduced (to unmask occult incontinence) 5
- Cystocele grade by physical examination 5
- Post-void residual to identify baseline retention risk 1
- Presence of intrinsic sphincter deficiency (abdominal leak point pressure <60 cm H₂O suggests need for pubovaginal sling rather than mid-urethral sling) 5
Alternative Approach for Specific Scenarios
For patients with grade III-IV cystocele and intrinsic sphincter deficiency: Consider pubovaginal fascial sling with anterior colporrhaphy instead of synthetic mid-urethral sling, which achieves 86% continence rates and provides additional bladder base support. 5 However, retention rates are higher (5-8%) with autologous fascial slings. 1