Our results showed that MUS can cure low-stage anterior POP. Previous reports suggested that PVS might provide additional support to the bladder base, improving the durability of AC [8]. Colombo et al. [9] conducted a trial comparing Burch colposuspension (35 cases) with AC (22 cases) in the treatment of SUI concomitant with stage 2/3 cystocele. They concluded that neither is an effective treatment. Another trial by Kammerer-Doak et al. [10] found that Burch colposuspension was significantly better than modified AC in the correction of SUI in a randomized trial.

Going through different POP grading systems, Muir et al. [11] found that Baden Walker was used in 19.8% of the 146 articles they studied, next only to the POPQ, which was reported by 22.6% of studies. Correction of anterior POP is traditionally achieved by AC, a technique that has undergone few modifications over time [12]. Weber and Walters [13] concluded that the tissue plicated during AC is probably the vaginal muscularis, not a true fascial layer.

Anterior colporrhaphy was thought to be curative in SUI in the study by Tamussino et al. [14], where AC cured 61% of women (65 out of 107) of their incontinence at 5 years. However, many studies refute this conclusion. Hutchings and Black [15] studied 221 women with SUI and found that the cure rate varied by procedure (colposuspension 34% dry; needle suspensions 13%; AC 19%). After adjusting for confounders, colposuspension was significantly more likely to result in an improvement than AC. Furthermore, Khayyami et al. [16] concluded that AC was associated with a decrease in abdominal pressure of 50 cmH2O (PO-Abd 50) at a median 2-year postoperative follow-up in 28 women with this procedure performed as a treatment for cystoceles. They concluded that the urethral closure mechanism deteriorated after AC.

Although the use of meshes for the correction of cystocele was favorably considered by many [17,18,19,20], the FDA warning in 2011 resulted in a drastic decline in the use of mesh in correction of cystoceles and SUI [21].

Pubovaginal sling using the rectus sheath was found to be an effective treatment for symptomatic cystoceles in 30 women [3]. However, the sling described was a large trapezoid graft that is fixed by four sutures rather than two. Our results show that standard MUS can cure a concomitant stage 1 or 2 cystocele, and the difference between the two groups was insignificant at all follow-up points, considering the recurrence of cystocele or the cure of SUI as evidenced by the stress and pad tests. We also found that regardless of the type of sling used, the impact on concomitant stage 1 or 2 cystoceles was the same.

The difference between the two groups regarding symptoms was insignificant at 6 and 12 months. This means that concomitant colporrhaphy did not affect the patients’ perception of their quality of life.

It was debated that repair of stage 2 cystoceles could be omitted altogether from surgery for SUI associated with cystoceles [22]. Park et al. studied 92 women with SUI and asymptomatic stage II cystocele who were divided into a TVT and concomitant cystocele repair group and found no difference in the surgical outcome and lower urinary tract symptoms between the TVT sling-only group and the concomitant repair group [22]. Our study has shortcomings: the sample size is small; the application of three different sling techniques would confound the outcome of the sling surgery. However, based on the study by Jeon et al. [23], PVS and TVT seem to be more efficacious than TOT at 2 years. Our patients’ cohort is homogenous regarding the age, parity, BMI, and the severity of incontinence at baseline, which is a considerable strength. Nevertheless, all patients were recruited from single-center OPD, which could compromise the generalization of our results. Longer-term follow-up is preferable, considering the natural history of the sling and AC surgeries and a follow-up of a minimum of 5 years is desirable before drawing a firm conclusion. Besides, the best-case scenario would have been the blinding of the investigators as to outcome during the follow-up period.

In conclusion, MUS can correct symptomatic stage 1 or 2 cystoceles without the need for added AC. Adding colporrhaphy was associated with a significantly longer procedure and greater blood loss. Although three different sling techniques were adopted, which is potentially confounding to the outcome of the stud, this could be taken as a strength, as we utilized the three most popular MUS in the same study.