Clinical outcomes of detrusor underactivity in female with advanced pelvic organ prolapse following vaginal pelvic reconstructive surgery

Voiding Dysfunction in Patients With Advanced Pelvic Organ Prolapse and Bladder Outlet Obstruction Following Pelvic Reconstructive Surgery: Urodynamic Profile and Predictive Risk Factors

STUDY OBJECTIVE

To determine the outcome of voiding function 1 year after pelvic reconstructive surgery (PRS) in women with bladder outlet obstruction (BOO).

DESIGN

Retrospective cohort study.

SETTING

Tertiary referral hospital.

PATIENTS

A total of 1894 women underwent PRS for advanced pelvic organ prolapse (POP) stages 3 to 4 with urodynamic findings of BOO.

INTERVENTIONS

PRS.

MEASUREMENTS

The primary outcome measured was the resumption of normal voiding function, defined clinically with multichannel urodynamic testing at 1 year postoperatively. The secondary outcomes were to identify the different risk factors for persistence voiding dysfunction (VD) 1 year after PRS.

MAIN RESULTS

A total of 431 women with Pelvic Organ Prolapse Quantification stages 3 and 4, urodynamic study of maximum urinary flow rate ≤15 mL/s, and detrusor pressure at maximum flow ≥20 cm H2O were included. Resumption of normal voiding function was found in 91% (n = 392 of 431), whereas 9% (n = 39 of 431) remained to have VD 1 year postoperatively. Those with persistent VD, 20.5% (n = 8 of 39) remained having urodynamic diagnosis of BOO. Univariate and multivariate logistic regression revealed factors associated with postoperative VD were pre-operative maximal cystometric capacity ≥500 mL and postvoid residual volume ≥200 mL.

CONCLUSION

VD may persist in women with BOO after PRS, particularly in those with preoperative maximal cystometric capacity of >500 mL and postvoid residual volume >200 mL.

The effect of prolapse surgery on voiding function

INTRODUCTION AND HYPOTHESIS

Of women with symptomatic prolapse, 13-39% experience voiding dysfunction (VD). The aim of our observational cohort study was to determine the effect of prolapse surgery on voiding function.

METHODS

Retrospective analysis of 392 women who underwent surgery between May 2005 and August 2020. All had a standardized interview, POP-Q, uroflowmetry and 3D/4D transperineal ultrasound (TPUS) pre-and postoperatively. Primary outcome was change in VD symptoms. Secondary outcomes were changes in maximum urinary flow rate (MFR) centile and post-void residual urine (PVR). Explanatory measures were change in pelvic organ descent as seen on POP-Q and TPUS.

RESULTS

Of 392 women, 81 were excluded due to missing data, leaving 311. Mean age and BMI were 58 years and 30 kg/m2, respectively. Procedures performed included anterior repair (n = 187, 60.1%), posterior repair (n = 245, 78.8%), vaginal hysterectomy (n = 85, 27.3%), sacrospinous colpopexy (n = 170, 54.7%) and mid-urethral sling (MUS) (n = 192, 61.7%). Mean follow-up was 7 (1-61) months. Pre-operatively, 135 (43.3%) women reported symptoms of VD. Postoperatively, this decreased to 69 (22.2%) (p < 0.001), and of those, 32 (10.3%) reported de novo VD. The difference remained significant after excluding concomitant MUS surgery (n = 119, p < 0.001). Postoperatively, there was a significant decrease in mean PVR (n = 311, p < 0.001). After excluding concomitant MUS surgery, there was a significant increase in mean MFR centile (p = 0.046).

CONCLUSIONS

Prolapse repair significantly reduces symptoms of VD and improves PVR and flowmetry.

Straining to void at preoperative urodynamic study as a risk factor for prolapse recurrence after surgery

OBJECTIVES

Straining to void is the need to make a muscular effort in order to initiate, maintain or improve the urinary stream, through an increase in abdominal pressure. This pattern of bladder emptying is frequently observed in women with pelvic organ prolapse causing urinary obstruction, to overcome the increased resistance to urine flow. However, frequent increases in abdominal pressure are a risk factor for developing pelvic organ prolapse, and might play a role in its recurrence after surgery. The aim of this study was to investigate the role of straining identified at urodynamic study in prolapse recurrence after surgical repair.

STUDY DESIGN

This was a retrospective study on women submitted to prolapse repair by vaginal hysterectomy with modified McCall culdoplasty and anterior colporraphy. All patients underwent a preoperative urodynamic evaluation including a pressure-flow study performed after prolapse reduction by means of a vaginal pessary; straining was defined by a simultaneous and similar increase in intravesical and abdominal pressures of at least 10 cmH₂O over the baseline during bladder emptying, corresponding to intermittent peaks of urine flow. Patients were divided into two groups according to the presence or absence of straining, and they were compared for surgical results at 12 months and for the rate of anterior or central recurrence over time.

RESULTS

Women with straining (n = 16), compared to women with normal voiding (n = 43), showed a higher risk of anterior recurrence over time at Kaplan-Meier curves, for both stage II (p = 0.02) and stage III prolapse (p = 0.02). No difference was seen for central recurrence during the follow up period. POP-Q staging at 12 months was similar for the two groups, except for the location of the Aa point which was significantly better for women without straining (-1.6 ± 0.1 cm vs -0.8 ± 0.3 cm, p = 0.03).

CONCLUSIONS

Straining to void identified in preoperative urodynamic study seems to increase the risk of anterior recurrence after surgical repair of pelvic organ prolapse.

Urodynamic profile of voiding in patients with pelvic organ prolapse after surgery: a systematic review with meta-analysis

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse (POP) is a defect of the female pelvic floor. Stress urinary incontinence (SUI), urge urinary incontinence (UUI), and obstructive symptoms may occur in these patients. The objective of surgical treatment is to restore the anatomy and function of the pelvic floor; however, it may prompt urinary symptoms not present previously. We performed a systematic review and meta-analysis to determine urodynamic changes in patients undergoing surgical correction for POP.

METHODS

PubMed and Cochrane databases were searched for studies that contained data from urodynamic evaluation before and after vaginal surgery for POP. The main urodynamic data collected were free uroflowmetry (maximum flow [Qmax], voided volume, and post-void residual volume [PVR]), cystometry (bladder capacity, presence of detrusor overactivity [DO], SUI or UUI, and Valsalva leak point pressure), and pressure × flow study (detrusor pressure at maximum flow [PdetQmax], Qmax, and PVR).

RESULTS

A total of 22 studies were included (1,549 women). Patients had a significantly higher prevalence of DO before surgery (OR = 1.56; 95% CI = 1.06-2.29), and surgeries without sling placement demonstrated a tendency to ameliorate DO. Patients who did not receive a sling were more incontinent after surgery. Bladder-emptying parameters improved after surgery, with higher PdetQmax before surgery (IV = 3.23; 95% CI = 0.45-1.18). Patients who did not receive MUS presented a lower Qmax (IV = -3.19; 95%CI = -4.09 to -2.30) and a higher PVR (IV = 27.89; 95%CI = 15.68-40.1) before surgery.

CONCLUSION

Correction surgery for POP yields better urodynamic emptying parameters, with a reduction in the prevalence of DO. In contrast, sling placement enhances obstructive parameters.

Clinical and urodynamic findings before and after surgical repair of pelvic organ prolapse in women with lower urinary tract symptoms. A prospective observational study

OBJECTIVES

To investigate the association between urodynamic findings and lower urinary tract symptoms (LUTS) before and after surgical treatment of POP.

METHODS

Seventy-four patients with stage II or more anterior POP associated with LUTS and eligible for surgical repair of POP were included in this prospective study. All cases had clinical evaluation and urodynamic testing (UDS) before and 6 months after surgical repair of POP.

RESULTS

Mean age was 45±9 years. Mean BMI was 28±6 kg/m². Most cases were multiparous, had stage III cystocele (50/74, 68%), and an associating apical prolapse (37/74, 50%). Native tissue repair was done in 53/74 (72%) cases with a concomitant anti-incontinence procedure (AIP) in 41/74 (55%) for overt (26/74, 35%) or occult (15/74, 20%) stress urinary incontinence (SUI). Preoperative UDS revealed detrusor overactivity (DO) in 19/56 (34%) patients of those presenting with storage LUTS and an obstructed P_detQ_max in 20/26 (77%) patients presenting with voiding LUTS. At the 6-month postoperative follow-up, 61/74 (82%) patients had marked improvement of their LUTS, SUI resolved in 39/41 (95%) patients and 1/33 (3%) patient developed de novo SUI. Preoperative DO and post-void residual urine volume (PVR) were not related to the postoperative improvement, or persistence of LUTS. Meanwhile, detrusor underactivity (DU) was detected both on preoperative and postoperative UDS of 4 patients with persistent voiding LUTS.

CONCLUSIONS

Patients had significant improvement in LUTS after POP surgery with or without an AIP. DU was associated with persistence of voiding LUTS. Meanwhile, preoperative DO and PVR were of limited prognostic value.

Medium-term effects on voiding function after pelvic reconstructive surgery of advanced pelvic organ prolapse: Is postoperative uroflowmetry necessary?

OBJECTIVE

To evaluate the necessity of postoperative repetitive uroflowmetry and postvoid residual volume (PVR) in women with advanced anterior vaginal prolapse.

METHOD

Women with anterior vaginal prolapse stages III and IV who underwent surgery were included in this prospective cohort study. The surgical procedures included laparoscopic sacrocolpopexy (LSC), transvaginal mesh repair (TVM) and native tissue repair (NTR). Uroflowmetry, a PVR examination, the Urinary Distress Inventory-6 (UDI-6) and the Urinary Impact Questionnaire-7 (UIQ-7) were administered pre- and postoperatively. Moreover, pre- and postoperative uroflowmetry parameters were compared in women with/without an improvement in voiding difficulties according to the answer of questionnaires at one year after surgery. Paired sample t-tests, Wilcoxon signed-rank test, χ2 tests were used for analyses.

RESULTS

A total of 85 women were included in the study, and data were available for 47 of them at 1-year follow-up. Approximately half of women with advanced anterior vaginal prolapse had symptoms of voiding dysfunction, the rate of which decreased to approximately 10% postoperatively. The UDI-6 and UIQ-7 indicated a significant improvement postoperatively from baseline (both p<0.05). The PVR decreased significantly after surgery (p = 0.000). Uroflowmetry parameters remained stable within 1 year after surgery (all p＞0.05) both in the improved and unimproved groups (both p＞0.05).

CONCLUSION

Symptoms of voiding dysfunction are improved significantly after surgery. Postoperative uroflowmetry appears to be unnecessary one year after pelvic floor reconstructive surgery.

Changes in voiding function after transvaginal mesh repair for advanced anterior vaginal prolapse

OBJECTIVE

This study evaluated changes in voiding function at 3 months and 1 year after transvaginal mesh (TVM) repair in women with advanced anterior vaginal prolapse (AVP) and identified predictive risk factors of postoperative voiding dysfunction (PVD).

STUDY DESIGN

Women with stage≥3 AVP who underwent TVM repair surgery were included in this retrospective cohort study. Voiding dysfunction was defined as an average flow rate (Q_ave)＜10 ml/s, a maximum flow rate (Q_max)＜15 ml/s, or a postvoid residual volume (PVR)＞50 ml. Pre- and postoperative voiding function was assessed by uroflowmetry, PVR examination, and the Urinary Distress Inventory-6 (UDI-6) and the Urinary Impact Questionnaire-7 (UIQ-7). Statistical analyses were performed using paired-sample t tests, χ2 tests, and multivariate logistic regression.

RESULTS

Sixty-two women were included in this study, uroflowmetry data were available for 35 of them at 1-year follow-up. Forty-three percent of women showed evidence of voiding dysfunction preoperatively. The PVR decreased significantly from baseline to 1 year postoperatively (17.97 ± 38.48 vs. 0.00 ± 0.00, p < 0.001). Voiding difficulties decreased significantly postoperatively (55 % vs. 5%, p＜0.001); frequency, urgency and urinary incontinence symptoms did not exhibit significant improvement (p＞0.05). The UDI-6 and UIQ-7 indicated significant improvement postoperatively (both p＜0.001). Multivariate analysis identified low Q_ave as an independent predictor of PVD (odds ratio, 0.40; 95 % CI, 0.16-0.98).

CONCLUSION

Nearly half of the patients had advanced AVP accompanied by preoperative voiding dysfunction. Improvement in voiding function was observed at 3 months and could last for one year postoperatively.

Anterior-Apical Transvaginal Mesh (Surelift) for Advanced Urogenital Prolapse: Surgical and Functional Outcomes at 1 Year

STUDY OBJECTIVE

To determine the objective and subjective outcomes of pelvic organ prolapse (POP) surgery using a modified Surelift system (Neomedic International, Barcelona, Spain) and to evaluate surgical complications and postoperative impact on quality of life (QOL) and lower urinary tract symptoms.

DESIGN

Retrospective cohort study.

SETTING

Tertiary-care university hospital.

PATIENTS

Patients with symptomatic anterior or apical POP stage III and above.

INTERVENTIONS

All patients underwent pelvic reconstructive surgery with a modified Surelift transvaginal mesh kit.

MEASUREMENTS AND MAIN RESULTS

Eighty-three women who underwent pelvic reconstructive surgery with a modified Surelift for symptomatic anterior or apical prolapse stage III and above from April 2018 to January 2019 were reviewed retrospectively. All completed a 72-hour voiding diary, urodynamic study, and multiple validated QOL questionnaires at baseline and at between 6 and 12 months postoperatively. Descriptive statistics were used for demographics and perioperative data. Paired-samples t test and the McNemar test were applied for comparison of pre- and postoperative continuous and categoric data, respectively. The primary outcomes were the objective cure of POP, defined as anterior and apical prolapse Pelvic Organ Prolapse Quantification System ≤ stage I, and subjective cure on the basis of negative answers to Pelvic Organ Prolapse Distress Inventory 6. The objective and subjective cure rates at 1 year were 97.6% and 92.8%, respectively. There were significant improvements in QOL scores postoperatively. Although bladder outlet obstruction improved, de novo urodynamic stress incontinence and stress urinary incontinence were increased at 18.9% and 21.6%, respectively, at 1-year follow-up. The mesh extrusion rate was 4.8%.

CONCLUSION

A modified Surelift has good objective and subjective cure rates at 1 year postoperatively with 4.8% mesh extrusion rate. There was significant improvement in lower urinary tract symptoms and QOL. De novo urodynamic stress incontinence at 6 months to 12 months was increased, but it was not sufficiently bothersome to warrant surgery.

Systematic review of lower urinary tract symptoms occurring with pelvic organ prolapse

Objective: To review lower urinary tract symptoms (LUTS), which include a large variety of bladder complaints, in women with simultaneous pelvic organ prolapse (POP). Methods: This article is a systematic review of the current literature on LUTS occurring simultaneously with POP following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Results: The prevalence of both conditions is high, but they occur more frequently together than can be explained by chance. It appears that POP is in some women causative of overactive bladder (OAB) symptoms, as in many women correction of the POP resolves the bladder symptoms and small studies of women with detrusor underactivity also demonstrate resolution of symptoms. The most plausible explanation for the relationship is that POP causes bladder outlet obstruction, which results in excess bladder irritability or poor contractility. However, not all women have resolution of their OAB symptoms and some women develop them de novo after POP repair, so this explanation requires more in depth study. Conclusions: Women with both LUTS and symptomatic POP should probably have their POP targeted, as its reduction either via surgery or pessary can correct the LUTS. However, no studies have addressed asymptomatic POP, so it is unclear if treating POP in these instances is of benefit. Abbreviations: BOO: bladder outlet obstruction; DO: detrusor overactivity; DU: detrusor underactivity; OAB: overactive bladder; P_detQ_max: detrusor pressure at maximum urinary flow; POP: pelvic organ prolapse; PVR: post-void residual urine volume; RR: relative risk; SUFU: Society of Urodynamics, Female Pelvic Medicine and Urogenital Reconstruction; UDS: urodynamic studies; (S)(U)UI: (stress) (urgency) urinary incontinence.

Uterine-preserving pelvic organ prolapse surgery using the UPHOLD LITE vaginal support system: The outcomes of 291 patients

This article aims to evaluate the safety and outcome of women with pelvic organ prolapse (POP) treated by a minimally invasive bilateral sacrospinous hysteropexy (UPHOLD LITE Vaginal Support System, Boston Scientific) without concomittent anti-incontinence surgery.This retrospective study was conducted between 2014 and 2016. Evaluated items included surgical parameter and postoperative outcome.Three hundred thirteen women with POP were eligible and 22 were excluded because of history of either or more following situations, such as hysterectomy, mesh augmentation, previous anti-incontinence procedures, and radical pelvic surgery before. With a median follow-up of 26 months, surgery-related morbidity rate was 23.7% (69/291), including 1 with bladder injury (0.3%), 2 with hematoma (0.7%), 8 with urinary tract infection (2.8%), 48 with voiding dysfunction (16.5%) and 10 with mesh problems (3.4%). Among these morbidities, 12 patients (4.1%) needed surgical intervention, including 6 for mesh problems, 1 for bladder injury, 2 for hematoma, and 3 for anti-incontinence surgery. The difference of pelvic organ prolapse quantification (POP-Q) stage before and after surgery showed a statistical significance (anterior portion from 1.36 ± 2.60 to -2.69 ± 0.26, posterior portion from -1.29 ± 2.08 to -2.46 ± 0.62, and cervix portion from 2.03 ± 4.80 to -6.98 ± 2.26, all P < .001). At the end of August 2018, re-intervention rate for POP recurrence was 2.1% (n = 6), including abdominal sacrocolpopexy (n = 1), anterior repair (n = 1), vaginal total hysterectomy and uterine-sacral ligament suspension (n = 1), vaginal total hysterectomy and LeFort (n = 1), LeFort (n = 1), and pessary support (n = 1).Because some women developed postoperative lower urinary tract symptom, preoperative evaluation, including careful and detailed history taking, and urodynamic evaluation is suggested. After adequate counseling, uterine-preserving sacrospinal ligament suspension by UPHOLD LITE Vaginal Support System surgery could be considered in the management of women with POP, because of its high successful rate (97.9%) and low morbidity rate.

Urodynamic factors associated with the large capacity bladder and incomplete emptying after prolapse repair (2009-2015)

AIMS

To identify the clinical and urodynamic factors associated with the large capacity bladder and incomplete bladder emptying after prolapse repair.

METHODS

We identified 592 women who underwent anterior and/or apical prolapse repair at our institution from 2009 to 2015. Women were stratified by urodynamic capacity. The primary outcome was incomplete emptying at the longest follow-up (postvoid residual [PVR] > 200 mL). Data were analyzed in the Statistical Analysis System software.

RESULTS

Two hundred and sixty-six women (mean age, 61 years) had preoperative urodynamic tracings available for review. After surgery, there were 519 PVRs in 239 women recorded at up to 2949 days (mean, 396) and nine time points (median, 2; IQR, 1-3). The receiver operator curve for predicted probability of longest follow-up PVR greater than 200 mL (area under curve = 0.67) identified the 600 mL cutpoint which defined large capacity bladder. Large capacity bladders (capacity, >600 mL [n=79] vs ≤600 mL, [n=160]) had a mean: detrusor pressure at maximum flow (21 vs 22 cm H₂ O; P = 0.717), maximum flow rate (19 vs 17 mL/s; P = 0.148), significantly elevated PVR (202 vs 73 mL; P < 0.001), and significantly lower voiding efficiency (VE) (74 vs 82%, P < 0.05). Following prolapse repair, elevated PVR was associated with large capacity (PVR 101 vs 49 mL, P < 0.05). Large bladders had a two- to three-fold risk of longest follow-up PVR greater than 200 mL (14.3%-20.3% [capacity, >600 mL] vs 4.1%-7.0% [capacity, ≤600 mL]). VE was similar after surgery regardless of the capacity (87% vs 88%, P = 0.772).

CONCLUSIONS

The decision to pursue prolapse repair should be individualized and take into account, the bladder capacity and goals for PVR improvement after surgery.