OBJECTIVE We determined the efficacy of performing a pubovaginal sling concurrently with a formal cystocele repair in patients with grade III to IV cystoceles. METHODS We studied 42 women with grade III to IV cystoceles diagnosed by physical examination and video urodynamics. Of the patients 9 (22%) had intrinsic sphincter deficiency diagnosed by an abdominal leak point pressure of less the 60 cm. water, and 24 (57%) had type II stress incontinence with urethral hypermobility and an abdominal leak point pressure greater than 90 cm. water. A pubovaginal sling and anterior colporrhaphy were performed and, if indicated, other vaginal procedures were done at that time. RESULTS A total of 36 patients (86%) was available for postoperative pelvic examinations performed at 3-month intervals, for a mean followup of 20.4 months (range 12 to 39). Only 3 patients had symptomatic grade III cystoceles and 2 had enteroceles. Two patients required collagen injections and 2 underwent a repeat pubovaginal sling. Therefore, all patients were continent at the time of followup. CONCLUSIONS This study confirms that in patients with large cystoceles and stress urinary incontinence a pubovaginal sling and anterior colporrhaphy effectively treat the incontinence and reduce the cystocele. In addition, the fascial sling appears to provide additional support to the bladder base, improving the durability of the anterior colporrhaphy.