Anterior vaginal wall suspension

Raz described the first four-corner bladder and urethral suspension procedure in 1989 (1). He recognized that many anti-incontinence procedures failed because they addressed anterior vaginal wall prolapse or urethral hypermobility rather than addressing the two together. For example, the Kelly-type plication corrected the cystocele by reapproximation of the pubocervical fascia, but it was associated with a high failure rate for stress urinary incontinence (SUI) (50-80%) (2) partly because it did not support the proximal urethra and bladder neck. Conversely, the Marshall-Marchetti-Krantz (MMK) bladder neck suspension corrected urethral hypermobility but not the cystocele. Raz believed that bladder base descent and urethral hypermobility must be corrected at the time of cystocele repair regardless of whether incontinence existed. At that time, the only procedure accomplishing this combined goal was the retropubic Burch cystourethropexy. Raz therefore drew from his experience with the modified Peyrera needle suspension procedure to develop a vaginal technique that would simultaneously address urethral hypermobility and anterior vaginal wall prolapse.