In cystocele repair the use of transvaginal mesh has been strongly criticized and suspended in many countries. To date, the search for native tissues surgeries that guarantee duration and efficacy is a priority.
The aim of this study is to describe and illustrate in the accompanying video the bilateral pubococcygeus plication (BPCP) as novel technique for anterior vaginal wall repair and to report the long-term outcomes.

Data were prospectively collected from women undergoing BPCP for the treatment of anterior vaginal wall defect in the period from January 2012 to December 2017. Inclusion criteria was naïve women with symptomatic cystocele > POP-Q 2nd stage. 
Data collected: (i) Demographic details; (ii) Objective anterior vaginal wall defect measurement by POP-Q system assessed by maximum Valsalva effort in the seated semi-lithotomy position; (iii) Subjective evaluation by validated questionnaires: the Global Impression of Improvement (PGI-I) and Patient Perception of Bladder Condition (PPBC); (iiii) Female sexual function by FSFI questionnaire; (iiiii) pre-operative urodynamic evaluation. 
To better evaluate the results we decided to exclude women with concomitant stress urinary incontinence, or other associated prolapses.
Surgery was performed using a standardized technique shown in the video. Clavien-Dindo classification was used to rank complications. For this study women were routinely followed by an examiner not directly involved into the surgical procedure on annual scheduled visit to evaluate objective and subjective results, and female sexual function. 
Objective cure was defined if the anterior vaginal wall was inferior to the POP-Q 2nd stage, while any anterior vaginal wall defects > 2nd stage were considered failures. 
Subjective cure rates were considered patients with PGI-I < 3, and PPBC < 2. 
De novo storage symptoms were assessed by direct questioning and voiding diaries for 3 days. 
To investigate patient’s personal satisfaction, we asked the following questions by a Likert-type scale: (i) “Are you satisfied with the surgical procedure?” (ii) “Would you confirm the same surgical choice during the counseling before surgery?”

153 naïve women for surgery underwent BPCP between the years 2012 and 2017. The mean age was 67.1 yr. POP-Q stage and mean Aa/Ba are reported in table 1.
Mean follow-up was 63.3 months. Mean operative time was 64 minutes. Median length of hospital stay was 2 days. 
Objective success rate was 88.2%. 18 women had an anterior vaginal wall recurrence (11.8%). In table 2 objective success and recurrences are compared between the preoperative and follow-up POP-Q stages. Most of recurrences were POP-Q stage 2 (16/18, 88.9%). Subjective satisfaction rate was 92.2%, mean PGI-I was 1.9, mean PPBC was 1.2. At the VAS scales, 90% of women reported personal satisfaction, and 92% would confirm the same surgical choice.
Preoperative OAB rate was 36.6%, while after surgery this rate significantly decreased by 60.7%. Postoperative storage symptoms were observed in 7.2%, but in only 4.1% these symptoms occurred de novo. OAB-screener score significantly improved at the follow-up (table 3). None of the patients had post void residual, and recurrent urinary tract infections occurred in 3.3%. FSFI domains significantly improved after the surgical treatment in sexually active women. Re-operation rate was 1.3%, in one case a mesh was placed while in the other the same technique was successfully performed. A total amount of 4.6% of patients had complications (table 4).

The BPCP technique is as a novel surgical procedure to repair cystocele. This procedure guarantees a high objective and subjective cure rate in a long-term follow-up avoiding the use of synthetic material or autologous tissues. Main recurrences were low grade, of these only a few required a re-intervention. The BPCP is a fast and safe surgical option that no alter functional outcomes and sexual function.