Atlas of Pelvic Surgery

Anterior Repair and Kelly Plication

Anterior repair is used for correction of a cystourethrocele. It can be combined with Kelly plication of the urethra when, in
addition to a cystourethrocele, the patient is experiencing stress incontinence of urine.
The purpose of the anterior repair is to reduce the cystourethrocele and reinforce the pubovesical cervical fascia support of the
bladder and urethra. The purpose of the Kelly plication of the urethra is to reduce the diameter of the urethra.
Physiologic Changes. In the Kelly plication, the surgeon increases the intraurethral pressure to a level higher than the
intravesical pressure in the resting and stress state, i.e., with a Valsalva maneuver. When the patient tries to void, however, the
detrusor contractions reverse the pressure relationship so that the intravesical pressure exceeds the intraurethral pressure.
Points of Caution. Care must be taken to dissect the anterior vaginal mucosa off the pubovesical cervical fascia without carrying
the dissection beneath the fascia. The depth of penetration of the plication suture must be controlled; the purpose is to plicate
the fascia, not the urethra. Excessive amounts of mucosa should not be removed to avoid unduly reducing the volume of the
vagina.

Technique

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

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

a Jacobs tenaculum.

When the vaginal mucosa has been dissected off the

pubovesical cervical (PVC) fascia, it is opened with
scissors in the midline.

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.

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.

The procedure in Step 3 is repeated after wide Allis

clamps have been applied to the edges of the vaginal
mucosa.

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.

The last Kelly plication suture is placed approximately 2 cm

beyond the urethral vesical angle.

Additional Kelly plication sutures are placed.

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 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 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.

The plication of the pubovesical cervical fascia should

continue until the entire cystourethrocele has been
reduced.

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.

An alternative method of bladder drainage is the

suprapubic insertion of a Foley catheter (see Bladder
and Ureter).