Before surgical intervention, consideration should be given to the patient’s age, functional status, medical comorbidities, sexual activity, and prior surgeries. A critical factor to consider is the severity of the patient’s symptoms and impairment on quality of life.

Regarding vaginal native-tissue anterior repairs, patients should be informed of potential complications including but not limited to: recurrence of prolapse, de novo or occult stress urinary incontinence, de novo overactive bladder, urinary retention, significant bleeding, infection, bladder or ureteral injury, vesicovaginal fistula, dyspareunia, vaginal shortening, and de novo apical or posterior prolapse.

Anatomic recurrence of anterior prolapse is reported at a rate between 3 and 70 % [3, 4]. Subjective recurrence rates are lower with some reporting a recurrence rate of 11–21 % [5, 6]. Risk factors for prolapse recurrence include increasing age and vaginal parity, smoking, conditions that impair wound healing (diabetes mellitus and steroid use), and conditions that could strain the repair (constipation, chronic pulmonary disease, heavy lifting, and obesity). Additionally, patients with more severe initial prolapse have higher likelihood of recurrence. Some surgeons suggest mesh-augmented repairs in appropriately counseled patients with recurrent or Stage 3 or higher prolapse [7]. Patients undergoing concomitant sacrospinous ligament suspensions for apical prolapse have an increased risk of recurrent anterior vaginal prolapse. It is unknown whether this is due to the retroflexion of the vaginal axis or simply due to a predisposition to failure after pelvic surgery [8].

Randomized controlled trials reported a 0–10 % rate of de novo stress urinary incontinence following anterior vaginal prolapse repair [6]. This risk can be reduced by preoperative detection of occult SUI with reduction of prolapse and performing a simultaneous anti-incontinence procedure.

De novo detrusor overactivity has been reported in 5–17 % of patients postoperatively [6]. Conversely, Weber et al. demonstrated a 56 % rate or resolution of urge incontinence after surgical correction of anterior prolapse, suggesting a potential benefit of surgical repair on urgency symptoms [3].

Rates of urinary retention after anterior colporrhaphy may be seen in approximately 20 % of patients [9]. Patients undergoing concomitant anti-incontinence procedures are more likely to develop postoperative urinary retention. Retention is often transient, and patients should be taught clean intermittent self-catheterization. The majority of patients have return of spontaneous voiding within 6 weeks of self-catheterization.

Bladder or ureteral injuries are rare with native-tissue anterior colporrhaphy. Altman et al 2011 reported a rate of 0.5 % [10]. The risk is higher in women with atrophic tissues and may occur during dissection of vaginal flaps. Ureteral injury is reported at 2 % in some series, likely to occur during placement of lateral plication sutures [11]. Cystoscopy should be performed intraoperatively to rule out bladder or ureteral injury. Indigo carmine or methylene blue can be administered to assist with identification of ureteral jets. If efflux is not visualized, evaluate for kinking or ligation with ureteral catheterization or retrograde pyelography. If obstruction is suspected, the plication sutures should be taken down. Sutures should also be immediately removed if inadvertently placed within the bladder or urethra. If a bladder injury occurs, repair this intraoperatively with an absorbable suture in two layers and leave an indwelling catheter for 7–14 days.

Sexual function can improve, remain unchanged, or worsen after anterior repair. Most studies demonstrate modest improvement in sexual function scores post-operatively. Others report rates of de novo dyspareunia ranging from 0 to 43 %, with an average of 6.25 % [6]. Care should be taken to avoid excessive trimming of vaginal edges at the conclusion of the procedure. This decreases risk for vaginal narrowing and stenosis that can cause dyspareunia.

Missed or de novo apical or posterior prolapse may occur after anterior compartment repair. However, this risk is increased in repairs augmented with mesh [12].