Intraoperative complications after repair of anterior vaginal prolapse are, for the most part, infrequent. Febrile morbidity occurs in 6% to 20% of patients and is most often self-limited. Lower urinary tract injury occurs in 0% to 4%, similar to other pelvic reconstructive procedures. Excessive blood loss may occur, requiring blood transfusion. This is infrequent with anterior colporrhaphy and retropubic paravaginal repair. Although paravaginal repair through the vaginal approach offers some potential advantages over the retropubic approach including shorter recovery time, the ability to simultaneously correct midline anterior defects, and the avoidance of an abdominal incision, it may have a higher rate of intraoperative hemorrhage and blood transfusion, as high as 9% to 12% in some series. This is in contrast to a transfusion rate of 0% to 4% in series of abdominal paravaginal defect repair. The limited exposure and technical challenge of the vaginal approach likely explains this difference.

Postoperative complications from the repair of advanced anterior vaginal prolapse are not unlike those of other vaginal reconstructive procedures. These may include prolonged urinary retention, de novo urinary urge or stress incontinence, recurrent prolapse, or vaginal shortening. Urinary retention is usually a transient phenomenon and often resolves on its own. Rarely, one may require a prolonged course of suprapubic catheter drainage or intermittent catheterization until satisfactory spontaneous voiding occurs. De novo urinary incontinence (urge or stress) may occur in a small portion of patients, quite possibly those with higher-grade prolapse and long-term obstruction. Urge incontinence may subside with time but often requires behavioral therapeutic modifications as well as anticholinergic therapy to assist in controlling symptoms. New-onset stress incontinence may result from inadequate bladder neck and urethral support or because of intrinsic sphincteric dysfunction. Accordingly, some advocate routine placement of a sling or some form of bladder neck support to minimize this potential.

In our experience, patients with stage III to IV cys-toceles often require concomitant surgical procedures to correct other often severe defects in pelvic floor support in the form of enterocele, rectocele, or uterine prolapse. Simply repairing the cystocele without addressing these other potential defects in pelvic support may lead to recurrent vaginal bulges and require secondary procedures. As the anterior vaginal wall is transferred superiorly, this may allow a weakened cul-de-sac and posterior vaginal wall to prolapse in the form of an enterocele or rectocele. Vaginal shortening can be avoided by minimizing the amount of anterior vaginal wall tissue that is excised; thus, this should be a rare complication.

Ureteric obstruction may occur postoperatively, despite patency being demonstrated on cystoscopic examination, as kinking of the ureters results from the support sutures. If this occurs, one must address the obstruction by placement of either a stent or percutaneous nephrostomy tube and passage of a glidewire down the narrowed channel. After a period of observation, if no patency ensues, one may proceed with ureteric reimplantation. Our preference is to not disturb the repair site, therefore, avoid transvaginal exploration.

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