De novo urinary incontinence after pelvic organ prolapse surgery-a national database study

De novo urinary incontinence and lower urinary tract symptoms after colpocleisis: A single-center prospective study

Background

Colpocleisis is one of traditional surgical procedures for elderly and frail women with advanced pelvic organ prolapse. The occurrence of de novo urinary incontinence following colpocleisis was considered to impair the postoperative quality of life. The incidence of de novo urinary incontinence after colpocleisis has been reported to be ranging from 6.6 % to 27 %. There was an absence of prospective large-sample study to investigate the accurate incidence of de novo urinary incontinence following colpocleisis and the impact on the quality of life till now.

Purpose

s The primary objective was to report the incidence of de novo urinary incontinence after colpocleisis. The second objectives were to evaluate the long-term quality of life in patients with de novo urinary incontinence, and to conduct detailed pre- and post-operative evaluations of lower urinary tract symptoms.

Methods

This prospective study included 253 patients with symptomatic pelvic organ prolapse who underwent colpocleisis between 2009 and 2021. De novo urinary incontinence was defined as the occurrence of urinary incontinence 3 months postoperatively. All patients were required to complete the Urinary Distress Inventory questionnaire and the Urinary Impact Questionnaire for the evaluation of patients' quality of life, and the Patient Global Impression of Improvement questionnaire for the evaluation of patients' satisfaction.

Results

245 patients (245/253, 96·8 %) completed the 3-month follow-up, and were included in the final analysis. The incidence of de novo urinary incontinence was 5.4 % (10/185). There was no significant difference in the Urinary Distress Inventory -6 scores (22.50 vs. 10.30, P = 0.276) or the subjective satisfaction rate (100 % vs. 98.9 %, P = 0.250) between the patients with or without de novo urinary incontinence at the long-term follow-up. The incidence of voiding difficulty was significantly reduced after colpocleisis (27.8 % vs. 0.0 %, P < 0.001). The patients' quality of life indicated by Urinary Distress Inventory-6 and Urinary Impact Questionnaire-7 scores were significantly improved postoperatively (26.27 vs. 13.39, and 19.13 vs. 6.05, P < 0.05).

Conclusion

The incidence of de novo urinary incontinence after colpocleisis was very low. Patients' quality of life, and low urinary tract symptoms were significantly improved after colpocleisis.

Changes in Stress Urinary Incontinence Symptoms after Pelvic Organ Prolapse Surgery: a Nationwide Cohort Study (FINPOP)

INTRODUCTION AND HYPOTHESIS

Various strategies are employed to manage stress urinary incontinence (SUI) during pelvic organ prolapse (POP) surgery. This study was aimed at facilitating shared decision-making by evaluating SUI symptom changes, staged SUI procedures, and their prognostic factors following POP surgery without concomitant SUI intervention.

METHODS

We analyzed 2,677 POP surgeries from a population-based observational cohort, excluding patients with prior SUI surgery. The outcome measures were subjective SUI utilizing the Pelvic Floor Distress Inventory-20 questionnaire and number of subsequent SUI procedures. Multivariable linear models were applied to identify predictors of persistent SUI, procedures for persistent SUI, and de novo SUI. The primary assessment occurred at the 2-year follow-up.

RESULTS

At baseline, 50% (1,329 out of 2,677) experienced SUI; 35% (354 out of 1,005) resolved, an additional 14% (140 out 1,005) improved, and 5.1% (67 out of 1,308) underwent a procedure for persistent SUI. De novo SUI symptoms developed in 20% (218 out of 1,087), with 3.2% (35 out of 1,087) reporting bothersome symptoms; 0.8% (11 out of 1,347) underwent a procedure for de novo SUI. High baseline symptom severity increased the risk of persistent SUI (adjusted odds ratio [aOR] 2.04, 95% confidence interval [CI] 1.65-2.53), whereas advanced preoperative apical prolapse decreased the risk (aOR 0.89, 95% CI 0.85-0.93). De novo SUI was more common with advancing age (aOR 1.03, 95% CI 1.01-1.05), baseline urgency urinary incontinence (aOR 1.21, 95% CI 1.06-1.38), and after transvaginal mesh surgery (aOR 1.93, 95% CI 1.24-3.00). It was not dependent on the compartment or preoperative degree of prolapse.

CONCLUSIONS

In a pragmatic setting, POP surgery results in a low rate of subsequent SUI procedures.

Does vaginal surgery for correction of pelvic organ prolapse improve urinary function? A prospective cohort study

INTRODUCTION AND HYPOTHESIS

Pelvic organ prolapse (POP) is caused by an imbalance in the stability of the pelvic organs, resulting in loss of support. The most common types of POP, anterior and apical, are associated with lower urinary tract symptoms (LUTS) such as bladder outlet obstruction and detrusor overactivity (DO). Vaginal surgery may improve LUTS and overall urinary symptoms. We assessed urodynamic (UD) parameters and urinary symptoms before and after vaginal surgery for POP correction.

METHODS

A prospective cohort of 59 women with symptomatic anterior and/or apical POP associated with urinary symptoms and with indications for vaginal surgery were included. POP surgeries included anterior colporrhaphy and vaginal hysterectomy with culdoplasty (VH) and with/without concomitant posterior colporrhaphy and mid-urethral sling (MUS). All participants underwent UD evaluation and answered urinary symptom questionnaires pre- and 3 months post-surgery.

RESULTS

Anterior colporrhaphy was performed in all patients: 45.7% with associated VH and 54.2% with concomitant MUS. Preoperative ICIQ-OAB score >8 points was significantly associated with DO (p<0.02) and decreased after surgery (9±4.3 to 3.2±3.0, p<0.001). All other questionnaires demonstrated improvements in urinary symptoms. Stress urinary incontinence rate decreased from 59.6% to 21% (p<0.001). Post-void residual (PVR) volume and Valsalva maneuver also decreased (p<0.001).

CONCLUSIONS

Pelvic organ prolapse surgery reduced the prevalence of urgency symptoms, and all questionnaires on urinary symptoms showed clinically significant improvement. Vaginal surgery for POP, even combined with MUS, significantly reduced PVR volume and improved urgency symptoms.

Bilateral posterior Richter sacrospinous fixation with native tissue: anatomical and functional results and quality of life assessment over 10 years

INTRODUCTION

Pelvic organ prolapse (POP) is a common condition that affects 50% of women who have given birth in their lifetime. With stop of vaginal mesh sale in 2019, the sacrospinous fixation technique according to Richter with native tissue has seen its incidence tripled in 15 years. Classically, sacrospinous fixation according to Richter is performed unilaterally, however its unilateral or bilateral character is controversial. Objective of this work is to evaluate the efficacy and safety of bilateral sacrospinous fixation according to Richter by the posterior approach with native tissue (SSB).

METHODS

We performed a retrospective single-center study. From March 12, 2010 to March 23, 2020, all first-time operated patients who underwent SSB in CHU Strasbourg gynecological surgery unit for symptomatic POP management were included. The main endpoint of our work is the anatomical and functional success rate at 12 and 24 months. The secondary judgment criteria of our work were based on the postoperative evaluation of patient's quality of life according to the PFDI-20 score as well as the rate of postoperative complications.

RESULTS

77 patients were included in our work. The anatomical success rate at 12 months is 94% and 81% at 24 months regardless of the compartment affected. The functional success rate is 94% at 12 months and 82% at 24 months. Quality of life evaluation through the PFDI-20 scale revealed a clear improvement in the symptomatology related to POP: 127/300 +/- 27.3. preoperatively and 59.8 ± 14.7 postoperatively.

CONCLUSION

Bilateral sacrospinous fixation according to Richter by posterior approach with native tissue is a safe and effective surgical technique allowing a clear improvement in patients quality of life.

Postoperative Urinary Incontinence in Diabetic Patients Undergoing Pelvic Reconstructive Surgery

IMPORTANCE

Diabetes is an independent risk factor for urinary incontinence, and its impact on rates of postoperative incontinence after pelvic reconstructive surgery remains unexplored.

OBJECTIVE

The aim of the study was to compare the incidence of postoperative stress urinary incontinence (SUI), urgency urinary incontinence (UUI), and mixed urinary incontinence in patients with diabetes mellitus undergoing surgery for pelvic organ prolapse (POP) with or without SUI surgery.

STUDY DESIGN

This is a secondary analysis of a multicenter retrospective cohort study involving 10 diverse medical centers that identified a cohort of women with diabetes who had prolapse and/or anti-incontinence surgery. We compared rates of postoperative urinary incontinence among patients who had surgery for prolapse and incontinence versus surgery for prolapse only.

RESULTS

Three hundred five patients had surgery for prolapse and incontinence, 330 had surgery for prolapse only, and 189 had anti-incontinence surgery only. De novo UUI was higher among those who underwent surgery for POP and SUI compared with surgery for POP alone (26.4% vs 14.1%, P < 0.01). Rates of persistent SUI (21% vs 4.9%, P < 0.01) and mixed urinary incontinence (15.9% vs 2.7%, P < 0.01) were higher for those who underwent prolapse surgery alone versus prolapse and an incontinence procedure. No differences were seen in hemoglobin A1C levels between those who did and did not report postoperative UI.

CONCLUSIONS

We found that postoperative de novo UUI rates were high among patients with diabetes after pelvic reconstructive surgery, with the incidence being significantly higher for those who had surgery for prolapse and incontinence compared with surgery for prolapse only.

Urinary Incontinence and Pelvic Organ Prolapse

The multifactorial pathophysiology of pelvic floor disorder accounts for the coexistence of several pelvic floor disorders in many women. Up to 54% of women with pelvic organ prolapse (POP) report concurrent stress urinary incontinence (SUI). While POP is a risk factor for coexistent SUI, apical and anterior prolapse can also conceal SUI symptoms that are unmasked by POP repair, resulting in de novo SUI postoperatively. It is important for pelvic reconstructive surgeons to consider the relationship between POP and urinary incontinence in presurgical planning and to discuss with patients the risks and advantages of concurrent versus staged anti-incontinence procedures.

Prospective International Multicenter Pelvic Floor Study: Short-Term Follow-Up and Clinical Findings for Combined Pectopexy and Native Tissue Repair

Efforts to use traditional native tissue strategies and reduce the use of meshes have been made in several countries. Combining native tissue repair with sufficient mesh applied apical repair might provide a means of effective treatment. The study group did perform and publish a randomized trial focusing on the combination of traditional native tissue repair with pectopexy or sacrocolpopexy and observed no severe or hitherto unknown risks for patients (Noé G.K. J Endourol 2015;29(2):210–215). The short-term follow-up of this international multicenter study carried out now is presented in this article. Material and Methods: Eleven clinics and 13 surgeons in four European counties participated in the trial. In order to ensure a standardized approach and obtain comparable data, all surgeons were obliged to follow a standardized approach for pectopexy, focusing on the area of fixation and the use of a prefabricated mesh (PVDF PRP 3 × 15 Dynamesh). The mesh was solely used for apical repair. All other clinically relevant defects were treated with native tissue repair. Colposuspension or TVT were used for the treatment of incontinence. Data were collected independently for 14 months on a secured server; 501 surgeries were registered and evaluated. Two hundred and sixty-four patients out of 479 (55.1%) returned for the physical examination and interview after 12–18 months. Main Outcome and Results: The mean duration of follow-up was 15 months. The overall success of apical repair was rated positively by 96.9%, and the satisfaction score was rated positively by 95.5%. A positive general recommendation was expressed by 95.1% of patients. Pelvic pressure was reduced in 95.2%, pain in 98.0%, and urgency in 86.0% of patients. No major complications, mesh exposure, or mesh complication occurred during the follow-up period. Conclusion: In clinical routine, pectopexy and concomitant surgery, mainly using native tissue approaches, resulted in high satisfaction rates and favorable clinical findings. The procedure may also be recommended for use by general urogynecological practitioners with experience in laparoscopy.

Predictors of occult stress urinary incontinence

BACKGROUND

Causes for occult stress urinary incontinence (SUI) are poorly recognised.

AIMS

To explore the mechanisms behind occult SUI. We hypothesised that cystocele type affects the risk of occult SUI.

MATERIALS AND METHODS

We conducted a retrospective, cross-sectional study on 878 consecutive women assessed at a tertiary urogynaecologic clinic between July 2016 and November 2018. The population of this study consisted of 424 women with urodynamic stress incontinence. Women with previous anti-incontinence surgery were excluded. All women underwent a standardised interview, clinical examination and urodynamic testing. Translabial ultrasound was used to categorise cystoceles into Green type II (cystocele with open retrovesical angle) and Green type III (cystocele with intact retrovesical angle). We compared women with overt SUI to those with occult SUI (defined as stress incontinence only observed after prolapse reduction) for demographic characteristics, urodynamic findings and functional anatomy. Predictors for occult SUI were identified with a multivariable logistic regression model.

RESULTS

Of 424 women, 362 (85%) had overt, and 62 (15%) occult SUI. There were 136 (32%) women who had a significant cystocele on imaging; 57 (42%) were classified as type II and 79 (58%) as type III. On multivariable regression, age and cystocele type were significantly associated with occult SUI. Odds for occult SUI was 10.9 times higher with type III (cystocele with an intact retrovesical angle) than with type II cystocele (cystocele with an open retrovesical angle; 95% CI 1.3-90.9).

CONCLUSIONS

Cystocele type affects the risk of occult SUI. Type III cystocele (intact retrovesical angle) associates with occult SUI.

Complications and reoperation after pelvic organ prolapse, impact of hysterectomy, surgical approach and surgeon experience

INTRODUCTION AND HYPOTHESIS

The surgical treatment of pelvic organ prolapse (POP) is associated with specific complications. Our primary objective was to assess the recurrence requiring reoperation after prolapse surgery, and our secondary objectives were to assess the early complications and secondary surgery for urinary incontinence.

METHODS

Retrospective study of a population-based cohort of all hospital or outpatient stays including POP surgery from 2008 to 2014, using the French nationwide discharge summary database. We calculated the rates of hospital readmission following surgery as well as the rates of reoperation for recurrent prolapse and subsequent procedures performed for urinary incontinence.

RESULTS

A total of 310,938 patients had undergone surgery for POP. Two hundred fourteen (0.07%) patients died, and 0.45% were admitted to an intensive care unit; 4.4% of the patients underwent surgery for the recurrence of prolapse. Concomitant hysterectomy in the first surgery was associated with a significantly lower risk of POP surgery recurrence: (hazard ratio (HR) [95% confidence interval (CI)] = 0.51 [0.49; 0.53]). A total of 1386 (2.5%) patients were readmitted to the hospital for early (30-day) complications of prolapse surgery. The most frequent reasons for early readmission were local infection (32.8%), hemorrhage (21.4%) and pain (17.2%). Risk factors for complications were obesity, hospitals with low levels of activity and associated incontinence surgery; 4.6% of the patients required secondary surgery for urinary incontinence; obesity was a risk factor (HR [95% CI] = 1.12 [1.01; 1.24]), and the vaginal route was a protective factor (odds ratio = 1.86 for laparoscopy, 1.44 for laparotomy and 1.25 for multiple approaches).

CONCLUSIONS

POP surgery is associated with low rates of complication and recurrence. Complications occurred most commonly following combined surgeries for both prolapse and incontinence and in hospitals with low surgical volumes. Concomitant hysterectomy appears to be protective for the need for additional prolapse surgery, and the vaginal route leads to a lower frequency of secondary surgery for urinary incontinence.