A prospective evaluation of four-corner bladder neck suspension for grade II/III cystocele repair

During a one-year period, thirteen consecutive patients with stress urinary incontinence (SUI) and grade II/III cystocele (C) were carefully studied pre and post-operatively by urodynamic and/or radiographic criteria. Patients' age ranged from 38-73 years old (median-56) and duration of SUI symptoms ranged from ten months to five years (median 28 months). Three patients had prior anti-SUI surgery, eight underwent prior hysterectomy. Standing cystograms were done pre and post-operatively (3 months) in eleven patients. Urodynamic data revealed the presence of stress incontinence in all patients. Procedures performed with Four-Corner BNS included sacrospinalis fixation for vault prolapse (1) and rectocele and perineal repairs (8). SUI was corrected in all patients at one year follow-up. Three of eight patients, who had hysterectomy before, demonstrated clinically and radiographically a persistent cystocele, accompanied by enterocele despite adequate rectocele and perineal repairs. The five patients with the uterus in place had no radiographic or clinical evidence of enterocele or cystocele. Contrary to recent reports, this limited prospective study showed adequate repair of moderate cystocele when the uterus was present using the four corner BNS, but persistent cystocele for patients after prior hysterectomy. Since the four corner suspension elevates the proximal urethra and bladder neck but not the posterior part of the bladder base over the vaginal vault, a formal complete cystocele repair is recommended after previous hysterectomy.