Abdominal sacrocolpopexy and urinary incontinence: surgical planning based on urodynamics

Short-term results of stress urinary incontinence in women undergoing laparoscopic sacrocolpopexy with and without midurethral sling

OBJECTIVES

This study aimed to assess the short-term results of stress urinary incontinence (SUI) in women undergoing laparoscopic sacrocolpopexy (LSC) with and without midurethral sling (MUS).

METHODS

This retrospective study was conducted from July 2012 to December 2017. Women with stage 3 or 4 in the Pelvic Organ Prolapse Quantification (POP-Q) who underwent LSC were recruited. Multichannel urodynamic studies were performed in all women. Assessment included pre- and postoperative POP-Q stages, urodynamic parameters, peri- and postoperative complications, and symptoms.

RESULTS

One hundred and eighteen patients met the inclusion criteria in total. A total of 19.5% (23/118) of them had concomitant MUS. The mean follow-up duration was 16.9 ±  16.0 (range 3-69) months. Meanwhile, 33.9% (40/118) of the patients were diagnosed with overt SUI, and 50% (20/40) underwent MUS. In the concomitant MUS group, the rate of having postoperative SUI was only 5% (1/20). Patients diagnosed with SUI and without concomitant MUS had a 45% rate (9/20), and 25% of them (5/20) received MUS later. Preoperatively, 16.1% (19/118) of the patients were diagnosed with occult SUI. Among the patients without anti-incontinence sling during prolapse surgery, 25% (4/16) of them complained about having SUI during the follow-up. However, none of the women required subsequent anti-incontinence surgery. Postoperative de novo SUI occurred to 13.6% (16/118) of them. None of the patients received further operation. Based on the preoperative and postoperative urodynamic studies in the combination surgery group, a significant improvement was observed in the pad test.

CONCLUSIONS

The combination of LSC with MUS procedure is likely to be beneficial in selected patients.

The negative predictive value of preoperative urodynamics for stress urinary incontinence following prolapse surgery

INTRODUCTION AND HYPOTHESIS

There is no consensus for the evaluation of stress urinary incontinence (SUI) in patients planning pelvic organ prolapse (POP) surgery. We sought to determine the negative predictive value (NPV) of prolapse reduction during preoperative urodynamics (UDS) for postoperative SUI.

METHODS

We performed a retrospective study of 322 women with preoperative UDS and subsequent POP surgery. Abstracted data included demographics, prolapse stage, prior prolapse or incontinence surgery, preoperative SUI complaint, prolapse reduction method, and length of follow-up. Any woman who reported SUI symptoms within 6 months from surgery was considered a diagnostic UDS failure. The NPV was calculated by dividing the number of patients who did not demonstrate SUI on UDS and had no postoperative SUI by the number of patients who did not demonstrate SUI on UDS.

RESULTS

Patient characteristics (age, race, parity, prolapse stage, prior surgery, and length of follow-up) were similar among those who had urodynamic-proven SUI and those who did not. The NPV of preoperative UDS for postoperative SUI in patients undergoing any POP repair was 97.9.0% [95% confidence interval (CI) 92.7-99.7%]. The NPV remained high in the subset of patients who underwent an apical suspension-98.6% (95% CI 92.7-100.0%)-as well as those without a preoperative SUI complaint-98.6% (95% CI 92.3-100.0%). In most patients (72.9%), a ring pessary with support combined with intraprocedural manipulation allowed for reliable stress testing.

CONCLUSIONS

Our study supports using preoperative UDS as a screening tool to avoid unnecessary concomitant continence procedures. Further studies are needed to individualize patient preoperative assessment and surgical counseling.

[Urodynamic studies prior to urinary incontinence surgery : What is useful?]

Surgery is often necessary after failure of conservative therapy for urinary incontinence. Guidelines recommend urodynamic studies before surgery. A distinction is made between non-invasive (uroflowmetry) and invasive methods (cystometry and pressure-flow study, if necessary as combined videourodynamics, as well as urethral pressure profile). All examinations serve to objectify and quantify the symptoms, to correctly assign symptoms to the pathophysiology and anatomy as well as to identify risk factors, which often have a significant influence on the success of surgical therapy. Given appropriate experience, complications and often significant sequelae of bladder dysfunction affecting the patient's quality of life and life expectancy can be recognized. Urodynamic studies are performed to help narrow down potential diagnoses, to develop therapeutic strategies, and to obtain prognostic parameters. The following article is intended to provide some support.

Does menopausal status impact urinary continence outcomes following abdominal sacrocolpopexy without anti-incontinence procedures in continent women?

Objective:

We investigated the impact of menopausal status on urinary continence following abdominal sacrocolpopexy (ASC) without an anti-incontinence procedure in continent women.

Methods:

We conducted a clinical follow-up study of 137 patients diagnosed with stage 3 or higher pelvic organ prolapse (POP) without urinary incontinence between January 2012 and December 2014. Patients were provided with detailed a priori information pertaining to the abdominal sacrocolpopexy procedure and were invited to attend follow-up visits at 1, 3, 12, and 24 months. Follow-up visits included a gynecological examination, cough test, and validated Urinary Distress Inventory-6 (UDI-6) and Incontinence Impact Questionnaire-7 (IIQ-7) questionnaires.

Results:

The mean follow-up time for the cohort was 16.5±3.45 months. The study group was divided according to menopausal status: premenopausal (Group-1) and postmenopausal women (Group-II). Anatomical recurrence was not detected during the follow-up period in either group, but de novo stress urinary incontinence was seen in 15 of 53 (28.3%) Group-I patients and in 6 of 84 (7.1%; p < 0.01) Group-II patients.

Conclusions:

The risk of de novo stress urinary incontinence in postmenopausal women after ASC is low. However, premenopausal patients have a higher incidence of de novo stress incontinence which affect quality of life.

Is de novo stress incontinence after sacrocolpopexy related to anatomical changes and surgical approach?

INTRODUCTION AND HYPOTHESIS

The objective was to investigate the relationship between new onset postoperative stress urinary incontinence (SUI) after sacrocolpopexy (SCP) and anatomical change/surgical approach.

METHODS

We analyzed a retrospective cohort of patients with negative preoperative testing for SUI who underwent SCP from 2005 to 2012. Our primary outcome was new onset postoperative SUI. Logistic regression was used to examine the relationship among anatomical change, defined as ΔAa, ΔBa, ΔC, and ΔTVL, and surgical approach, categorized as abdominal (ASCP) for open cases and minimally invasive (MISCP) for laparoscopic and robot-assisted cases, and postoperative SUI.

RESULTS

Of 795 cases, 33 ASCP (43%) and 44 MISCP (57%) met the inclusion criteria for analysis. New onset SUI was demonstrated by 15 patients (45%) of the ASCP group and 7 patients (15%) of the MISCP group (p = 0.005). New onset SUI was significantly associated with route of SCP and ΔAa (p = 0.006 and p = 0.033 respectively). Controlling for ΔAa, the odds of new onset SUI were 4.4 times higher in the ASCP group compared with the MISCP group (OR 4.37, 95% CI 1.42, 13.48). Controlling for route of SCP, the odds of new onset SUI were 2.2 times higher with moderate ΔAa compared with low ΔAa (OR 2.16 95% CI 1.07, 4.38). The odds of new onset SUI was 4.7 times higher in those with high ΔAa than in those with low ΔAa (OR 4.67 95% CI 1.14, 19.22). ΔBa, ΔC, and ΔTVL were not associated with new onset SUI.

CONCLUSIONS

Greater reduction in point Aa and abdominal surgical route are risk factors for new onset postoperative SUI after SCP.

Uterine sparing robotic-assisted laparoscopic sacrohysteropexy for pelvic organ prolapse: safety and feasibility

BACKGROUND AND PURPOSE

The aim of this study was to describe the surgical technique and report the safety and feasibility of robotic-assisted laparoscopic sacrohysteropexy, a uterine sparing procedure to correct pelvic organ prolapse (POP). Hysterectomy at the time of POP surgery has yet to be proven to improve the durability of repair. Nevertheless, the leading indication for hysterectomy in postmenopausal women is POP.

PATIENTS AND METHODS

We reviewed the medical records of a consecutive case series of uterine sparing prolapse repair procedures from 2005 to 2011. Fifteen women were identified. Procedures utilized a type I polypropylene mesh securing the posterior uterocervical junction to the sacral promontory. This was later modified to utilize a Y-shaped strip that was inserted through the broad ligaments to include the anterior uterocervical junction.

RESULTS

Objective success was defined as Baden Walker grade 0 uterine prolapse and subjective success was defined as no complaint of vaginal bulge or pressure. The mean age of women was 51.8 years (28-64 years). No intraoperative complications were noted. The mean operating time was 159.4 minutes (130-201 minutes) and mean estimated blood loss was 35 mL (0-100 mL). The mean length of stay was 1.6 days (1-4 days) and mean length of follow-up was 10.8 months. Uterine prolapse improved in all 15 patients. Objective success was 93% (14/15) and subjective success was 80% (12/15).

CONCLUSION

Robotic-assisted laparoscopic sacrohysteropexy was found to be a safe and feasible surgical treatment option for POP patients who desire uterine preservation.

Sequential urodynamic assessment before and after laparoscopic sacrocolpopexy

OBJECTIVE

Controversial data are available as to whether to perform a simultaneous abdominal or vaginal colposuspension operation in laparoscopic sacrocolpopexy procedures. We wanted to evaluate the effect of a modified laparoscopic operation technique on urodynamic parameters and lower urinary tract symptoms.

DESIGN

Prospective single center cohort study.

SETTING

Teaching hospital.

POPULATION

Forty-nine consecutive patients who underwent a modified laparoscopic sacrocolpopexy/hysteropexy operation using bone anchor fixation and synthetic mesh, performed by the same laparoscopic surgeons.

METHODS

Pre- and postoperative multichannel urodynamic evaluation and validated questionnaires. The same urologist, blinded to the results of the questionnaire survey, interpreted all urodynamic evaluations.

MAIN OUTCOME MEASURES

The effects of surgery on pelvic anatomy and patient satisfaction, urodynamic observations and diagnoses and symptom scores in validated questionnaires.

RESULTS

Forty-two patients consented to pre- and postoperative urodynamic evaluation. Laparoscopic sacrocolpopexy successfully corrected vaginal vault prolapse in all 42 patients with urodynamic evaluation six months after surgery. The bladder volume at first desire to void was significantly increased and the maximal detrusor pressure at voiding phase was significantly decreased. In the questionnaires, irritative and storage voiding symptoms were significantly decreased.

CONCLUSIONS

The results of the study demonstrate that there are no adverse urodynamic findings following this modified technique for laparoscopic sacrocolpopexy. The statistically significant urodynamic improvements are in accordance with the scores on the Urogenital Distress Inventory questionnaires. These results do not support a simultaneous routine prophylactic colposuspension procedure.

Urodynamic studies in adults: AUA/SUFU guideline

PURPOSE

The authors of this guideline reviewed the literature regarding use of urodynamic testing in common lower urinary tract symptoms. The findings are intended to assist clinicians in the appropriate selection of urodynamic tests, following an evaluation and symptom characterization.

MATERIALS AND METHODS

A systematic review of the literature using the MEDLINE® and EMBASE databases (searched from 1/1/90 to 3/10/11) was conducted to identify peer-reviewed publications relevant to using urodynamic tests for diagnosis, determining prognosis, guiding clinical management decisions and improving patient outcomes in patients with various urologic conditions. The review yielded an evidence base of 393 studies after application of inclusion/exclusion criteria. These publications were used to create the evidence basis for characterizing the statements presented in the guideline as Standards, Recommendations or Options. When sufficient evidence existed, the body of evidence for a particular treatment was assigned a strength rating of A (high), B (moderate) or C (low). In the absence of sufficient evidence, additional information is provided as Clinical Principles and Expert Opinion.

RESULTS

The evidence-based guideline statements are provided for diagnosis and overall management of common LUTS conditions.

CONCLUSIONS

The Panel recognizes that each patient presenting with LUTS is unique. This Guideline is intended to serve as a tool facilitating the most effective utilization of urodynamic testing as part of a comprehensive evaluation of patients presenting with LUTS.

When are urodynamics indicated in patients with stress urinary incontinence?

Despite technical and procedural advances in urodynamics over the past decade, the role of urodynamics in women with stress urinary incontinence (SUI) remains controversial. Many of these advancements have been the result of multicentric studies in the United States, such as the UITN and PFDN, which will be highlighted in this article. It appears to be the consensus that urodynamics may not be needed in pure stress incontinence. Urodynamics can be valuable in unmasking stress urinary incontinence in prolapse, although its impact on the ultimate management of occult incontinence remains debated. This article reviews the indications for urodynamic testing in women with SUI but will exclude more complex conditions such as mixed or recurrent incontinence which are outside the scope of this review.

Traditional native tissue versus mesh-augmented pelvic organ prolapse repairs: providing an accurate interpretation of current literature

The objective of this paper was to review the literature on pelvic organ prolapse (POP) and compare the success of traditional/native tissue versus mesh-augmented repairs. A comprehensive literature review was performed using PubMed and bibliography searches to compare the anatomic success rates of native tissue (NT) and mesh-augmented (MA) prolapse repairs and to analyze outcome measures used to report success rates. Articles were included if anatomic outcomes were stated for the specific compartment of interest and included both prospective and retrospective studies. The published success rates for NT repairs versus MA repairs by anterior, posterior, or apical compartments are reported. When continence is used as the primary outcome measure, anterior NT has a success rate of 54%. Anterior NT success is as low as 30% in some studies, but generally is 88-97% when prolapse is the primary outcome particularly if apical support is included. This compares to the 87-96% success reported for anterior MA. Posterior NT success is 54-81%, which is lower than the 92-97% reported for posterior MA when prolapse is the outcome measure. The success rates for apical NT are 97-98% for uterosacral ligament suspension and 96% for sacrospinous ligament suspension, which compare favorably to sacrocolpopexy (91-100%). There are some differences in the complications reported for NT and MA. The rate of complications is approximately 8% for NT and is reported at 0-19% for MA. The higher rate for MA is largely due to mesh erosion/exposure. When similar outcome measures are compared, the published anatomic success rates of POP of anterior and apical compartmental surgery are similar for NT and MA repairs. There may be a higher rate of complications noted for mesh implantation. POP surgery is complex, and both NT and MA techniques require skills to perform proper compartmental reconstruction. An understanding of the published literature and knowledge of individual surgeon factors are important in deciding which surgical approach to use and how to best counsel patients during informed consent.