Vaginal arcocolposuspension (VACS) is a minimally invasive vaginal native tissue repair technique designed to restore urethral support by suspending the anterior vaginal wall to the arcus tendineus fascia pelvis (ATFP), without synthetic mesh or retropubic dissection. We hypothesized that VACS restores bladder neck support comparable to abdominal Burch colposuspension, but through a distinct anatomical and biomechanical mechanism. The aim of this study was to quantitatively compare MRI-based anatomical changes following VACS and abdominal Burch colposuspension.

This cadaveric experimental study included eight pelvic specimens undergoing sequential MRI evaluation: baseline (preoperative), post- abdominal Burch colposuspension, and post-VACS. Imaging was performed using a standardized 3-T MRI protocol.
The following parameters were measured:

Bladder neck to pubococcygeal line (BNTPCL)
Urethra to symphysis pubis (UTSP)
Bladder neck to symphysis pubis (BNTSP)
Bladder neck to levator ani (BNTLA)
Levator ani to pubococcygeal line (LATPCL)
Retropubic space volume

Comparisons were performed between baseline, Burch, and VACS conditions.

Both techniques significantly altered anatomical support parameters compared to baseline (Figure 1).

BNTPCL increased from 7.76 mm at baseline to 14.9 mm after Burch and 11.83 mm after VACS (overall p<0.001), with greater displacement observed after Burch (p=0.022).

UTSP decreased significantly following VACS (8.48 mm to 6.16 mm, p=0.043), whereas no significant change was observed after Burch.

BNTLA decreased significantly after VACS (9.35 mm to 6.98 mm, p<0.001) and showed a lesser reduction after Burch (7.98 mm), with a significant difference between techniques (p=0.021).

Retropubic space volume decreased significantly after both procedures (baseline 6.92 vs 5.74 Burch and 5.45 VACS; p<0.05 for both), with no difference between techniques.

No significant differences were observed in BNTSP or LATPCL.

Both VACS and Burch colposuspension restore bladder neck support; however, they appear to operate through fundamentally different anatomical and biomechanical pathways. While Burch produces greater cranial displacement of the bladder neck, previous MRI-based studies have demonstrated that elevation alone is not directly associated with surgical success, and that continence may instead relate to the spatial relationship between the bladder neck and the levator ani complex.
In this context, the findings of the present study suggest that VACS achieves support not primarily through retropubic elevation, but through modification of periurethral support geometry. The observed reductions in urethral–symphysis distance and bladder neck–levator ani distance indicate a closer integration with pelvic floor structures, which is consistent with imaging-based evidence emphasizing the role of paravaginal fascia and connective tissue support in maintaining continence.
Importantly, the conceptual basis of VACS aligns with earlier surgical approaches described by Hirsch, in which the vaginal wall is anchored laterally to the obturator fascia to restore support without relying on retropubic suspension . The present MRI findings provide structural evidence that such lateral fixation may reproduce a more distributed and physiologically integrated support mechanism.

Vaginal arcocolposuspension provides anatomical restoration of urethral support comparable to Burch colposuspension, but through a distinct mechanism characterized by lateral support and integration with pelvic floor structures rather than predominant cranial displacement. These findings support the concept that restoration of continence may depend more on re-establishing functional support relationships than on simple elevation of the bladder neck, and position VACS as a physiologically aligned native tissue repair strategy with a clear anatomical basis.

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