The patient is placed in the dorsal lithotomy position. The perineum, vulva, and vagina are surgically prepared. The anterior repair can be performed with the uterus in place or after it has been removed. The technique is the same. The urethrocele and cystocele are shown. A transverse incision is made at the junction of the vaginal mucosa and cervix. This incision should be carried down to the pubovesical cervical fascia while the cervix is held on traction with a Jacobs tenaculum.

The uterus has been removed. The lateral edges of the vaginal cuff are held with Allis clamps on tension. Several Allis clamps are placed 3-4 cm apart up the midline of the anterior vaginal wall. The vaginal mucosa itself is held with thumb forceps and, with curved Mayo scissors, is undermined for approximately 3-4 cm up to the first of the Allis clamps placed in the midline. It is important for the assistant to hold the three Allis clamps in the immediate area of dissection on tension, creating a triangle. This will assist the surgeon in keeping the dissection in the proper plane between vaginal mucosa and pubovesical cervical fascia.

When the vaginal mucosa has been dissected off the pubovesical cervical (PVC) fascia, it is opened with scissors in the midline.

The procedure in Step 3 is repeated after wide Allis clamps have been applied to the edges of the vaginal mucosa.

The vaginal mucosa is opened in the midline up to the next Allis clamp. This is continued until the vagina is opened to within 1 cm of the urethral meatus. As the vagina is opened, the edges of the mucosa are grasped with wide Allis clamps and held in the lateral position by the assistants.

The pubovesical cervical (PVC) fascia is separated from the vaginal mucosa. The surgical assistants maintain tension on the wide Allis clamps to form an opening like a "Chinese fan." Scalpel, scissors, or blunt dissection can be used to remove the fascia from the vaginal mucosa. It is helpful to start the dissection with a scalpel, cutting the pubovesical cervical fascia at the edge of the vaginal mucosa and dissecting it downward with the finger or the handle of the scalpel. This dissection should be continued until the bladder and urethra are separated from the vaginal mucosa and are clearly identified and the urethral vesical angle has been ascertained.

If the patient has stress incontinence of urine and needs a Kelly plication, the first mattress suture is placed in the wall of the urethra approximately 1 cm below the urethral meatus. Traditionally, a nonabsorbable suture has been used for the plication. The suture, 1 cm in length, should be placed along the lateral margin of the urethra. When the suture is completed, a curved Kelly clamp is held in position to invert the urethral tissue as the suture is tied.

Additional Kelly plication sutures are placed.

The last Kelly plication suture is placed approximately 2 cm beyond the urethral vesical angle.

The anterior repair is started by placing 0 synthetic absorbable sutures in the pubovesical cervical (PVC) fascia, starting at the level of the first Kelly plication suture or 1 cm below the urethral meatus. The suture should be placed only in the pubovesical cervical fascia, not in the bladder wall.

The edges of the vaginal mucosa are retracted laterally with Allis clamps. The remaining pubovesical cervical fascia is plicated in the midline with multiple interrupted 0 absorbable mattress sutures.

The plication of the pubovesical cervical fascia should continue until the entire cystourethrocele has been reduced.

The edges of the vaginal mucosa are held on tension. The excessive vaginal mucosa is trimmed away. The lower portion of the drawing shows a cross section of vaginal cuff and plicated pubovesical cervical fascia.

The vaginal mucosa is sutured in the midline with interrupted 0 synthetic absorbable suture down to the vaginal cuff. The edge of the vaginal cuff is sutured with a running 0 absorable suture and left open.

The completed anterior repair and Kelly plication with the sutured anterior vaginal mucosa is shown. The sutured but open vaginal cuff is seen. A Foley catheter is inserted transurethrally.

An alternative method of bladder drainage is the suprapubic insertion of a Foley catheter (see Bladder and Ureter).