Reevaluating occult incontinence

Comparison of urethral parameters in females presenting cystoceles with and without stress urinary incontinence based on dynamic magnetic resonance imaging: are they different?

PURPOSE

To compare urethral parameters between cystocele patients with and without stress urinary incontinence (SUI) and explore factors influencing SUI in cystocele patients via dynamic MRI.

METHODS

The two-dimensional parameters evaluated included the paravaginal defects, levator ani muscle defects, urethral length, urethral funnel shape, bladder neck funnel width, bladder neck funnel depth, urethral angle, posterior vesicourethral angle, and anterior bladder protrusion. The three-dimensional parameters included the proximal urethra rotation angle, the distal urethra rotation angle, bladder neck mobility, urethral midpoint mobility, and external urethral meatus mobility. The independent samples t test was used for continuous variables, and the chi-square test was used for categorical variables. Binary logistic regression was used to identify factors independently associated with SUI in cystocele patients.

RESULTS

The baseline parameters were similar between the 2 groups. Cystocele patients with SUI had a significantly higher point Aa (1.63 ± 1.06 cm vs. 0.81 ± 1.51 cm, p = 0.008); more anterior bladder protrusion (33.3% vs. 11.4%, p = 0.017); greater bladder neck mobility (36.38 ± 11.46 mm vs. 28.81 ± 11.72 mm, p = 0.005); mid-urethral mobility (22.94 ± 6.50 mm vs. 19.23 ± 6.65 mm, p = 0.014); and external urethral meatus mobility (22.42 ± 8.16 mm vs. 18.03 ± 8.51 mm, p = 0.022) than did cystocele patients without SUI. The other urethral parameters were similar in the groups (p > 0.05). Binary logistic regression showed that bladder neck mobility was independently associated with SUI in females with cystoceles (odds ratio, 1.06; 95% CI 1.015-1.107; p = 0.009).

CONCLUSION

Cystocele patients with SUI have a higher point Aa, more anterior bladder protrusion, and greater urethral mobility than those without SUI. Bladder neck mobility is independently associated with SUI in females with cystoceles.

REGISTRATION NUMBER

NCT03146195.

Unilateral levator avulsion increases the risk of de novo stress urinary incontinence after cystocele repair

INTRODUCTION

Patients without concurrent baseline stress urinary incontinence (SUI) can develop de novo SUI after transvaginal mesh surgery (TVM) for cystocele repair. Surgeons should be aware of de novo SUI risk factors after TVM.

METHODS

A total of 1124 women who were underwent TVM surgeries were recruited and assessed for eligibility from January 1, 2012 to April 30, 2021. All data related to patients and surgeries was collected, which included general conditions, clinical examination, surgery records, and follow-up results. Patients were divided into three groups according to follow-up results and data were compared with each group. The relative risk (RR) of de novo SUI with levator avulsion was also calculated.

RESULTS

Three hundred thirty-six patients were included in this study. They were divided into no complication group (n = 249), de novo SUI group (n = 68), and other complications group (n = 19). It seemed elder or obese women had a higher risk of de novo SUI after TVM (p < 0.05). In de novo SUI group, incidence of levator avulsion before surgery were higher than the other two groups (p = 0.001). TVM can significantly change a prolapse to point Aa and Ba on POP-Q quantification system (p < 0.05). RR ratios of de novo SUI with unilateral avulsion group is 2.60 (95% confidence interval [CI] 1.39-4.87), and 2.58 (95%CI 0.82-8.15) for bilateral group.

CONCLUSION

Unilateral levator avulsion, instead of bilateral levator avulsion, is a risk factor of de novo SUI after cystocele repair surgery.

Summary: 2021 International Consultation on Incontinence Evidence-Based Surgical Pathway for Pelvic Organ Prolapse

(1) Background: There is wide variation in the reported prevalence rates for pelvic organ prolapse (POP). There is also wide variation in the rate at which surgical interventions for pelvic organ prolapse are performed, as well as the type of interventions undertaken. As part of the International Consultation on Incontinence (ICI), our committee was tasked to produce evidence-based pathways for the surgical management of POP, any associated stress urinary incontinence (SUI), and bowel dysfunction. (2) Methods: To enable us to generate such evidence, we undertook a thorough search for the POP surgery-related, English-language scientific literature published up to April 2021. (3) Results: The committee evaluated the literature and made recommendations based on the Oxford grading system. (4) Conclusions: This review serves to provide a summary of the 2021 ICI surgical management of an evidence-based prolapse pathway and outline the evidence used to inform this guidance.

Robot-Assisted Laparoscopic Paravaginal Repair and Sacrocolpopexy in Patients with Pelvic Organ Prolapse

OBJECTIVES

To evaluate the surgical effects of robotic paravaginal repair and sacrocolpopexy in patients diagnosed with lateral cystocele due to paravaginal defect.

PATIENTS AND METHODS

Robotic paravaginal repair and sacrocolpopexy were performed contemporaneously in 43 patients with high-grade pelvic organ prolapse combined with a lateral or mixed cystocele. To objectively evaluate prolapse correction, the POP-Q test was performed at the 12-month visit and the results compared to those of the preoperative period. Subjective satisfaction was scored using the PGI-I questionnaire.

RESULTS

POP-Q measurement results before and after surgery, an objective indicator of surgery, the Ba and C scores improved significantly from 2.1 ± 1.2 preoperatively to -2.0 ± 1.1 postoperatively (p<0.01), and from 0.3 ± 1.3 preoperatively to -4.3 ± 1.1 postoperatively (p<0.01), respectively. In PGI-I questionnaire, the numbers of patients who awarded scores of 1 and 2 (evidencing high-level symptom improvement) were 33 at 1 month (76.7%), 30 at 3 months (69.8%), and 28 (65.1%) at 12 months. When respondents awarding 3 points (a little improvement) were included, the numbers rose to 38 (88.4%) at 1 and 3 months and 35 (81.4%) at 12 months, indicating satisfaction with symptom improvement. There were no critical complications during and after surgery, but complications such as de novo SUI that lower patient satisfaction occurred in some cases.

CONCLUSIONS

Robot-assisted paravaginal repair and sacrocolpopexy can be safely performed in patients with cystocele-predominant pelvic organ prolapse and good surgical results can be expected with excellent effects.

Evolution of patients with and without preoperative stress urinary incontinence after surgical cystocele repair by mesh implantation using a vaginal approach

INTRODUCTION

To review the short-term evolution of stress urinary incontinence (SUI) after Uphold™ LITE mesh implantation for genital prolapse repair.

MATERIAL AND METHODS

Retrospective, descriptive, single centre study of women undergoing genital prolapse surgery with Uphold™ LITE mesh insertion between July 2016 and April 2019. Pre-, peri- and 1-year postoperative follow-up data were collected.

RESULTS

Thirty-six women were included (mean age: 72±7years). Most patients (75%) had grade III cystocele and three (8.3%) had recurrent prolapse. Mean operative time was 41±12min. During surgery, no visceral injury or haemorrhagic complications were noted but there were three intraoperative bladder injuries (8.3%). Twelve patients (33.3%) had preoperative SUI, half of which (n=6; 50%) responded to prolapse repair. De novo SUI was noted in 6/24 (25%) patients. The risk of having persistent postoperative SUI was 50% in patients with preoperative SUI, and the risk of developing de novo postoperative SUI was 25% in patients without preoperative SUI. Thus, patients with preoperative SUI were twice as likely to have persistent postoperative SUI as those without preoperative SUI (RR=2.0 [95% CI: 0.8175-4.8928]; P=0.128). Five patients with de novo SUI and three patients with persistent postoperative SUI were subsequently treated with insertion of a mid-urethral sling (MUS). The other patients improved with physiotherapy.

CONCLUSION

Risk of persistent SUI after implantation of an Uphold™ LITE mesh is higher in patients with preoperative SUI. Surgical correction with a MUS can be offered in cases of de novo SUI before or after physiotherapy.

LEVEL OF EVIDENCE

4.

Management of Urinary Incontinence before and after Total Pelvic Reconstruction for Advanced Pelvic Organ Prolapse with and without Incontinence

Background:

The effectiveness of an anti-incontinence procedure concomitant with prolapse reconstruction for pelvic organ prolapse (POP) in preventing urinary incontinence (UI) after surgery remains controversial. Our study aimed to describe the incidence of pre- and postoperative UI for pelvic reconstructive surgery and evaluate the management of POP associated with UI.

Methods:

A total of 329 patients who underwent total pelvic reconstruction between June 2009 and February 2015 at a single institution were identified. These patients were divided into two groups (Group A [Prolift reconstruction]: n = 190 and Group B [modified total pelvic reconstruction]: n = 139). Data regarding surgical procedures and patient demographic variables were recorded. Chi-square and Student's t-tests were used for two independent samples.

Results:

A total of 115 patients presented with UI preoperatively. The average follow-up time was 46.5 months, with 20 patients lost to follow-up (6.1%). The cure rates of stress UI (SUI), urgency UI (UUI), and mixed UI (MUI) were 51% (30/59), 80% (16/20), and 48% (14/29), respectively. The cure rate of UUI after total pelvic reconstruction (80% [16/20]) was higher than that of SUI (50.8% [30/59], χ²= 5.219, P = 0.03), and the cure rate of MUI (48%, 14/29) was the lowest. The cure rate of patients with UI symptoms postoperatively was lower than that of those with symptoms preoperatively (9.1% [28/309] vs. 16.2% [50/309], χ²= 7.101, P = 0.01). There was no difference in the incidence of UI postoperatively between Groups A and B (P > 0.05). The cure rate of SUI in patients undergoing tension-free vaginal tape-obturator was not higher than that in those who did not undergo the procedure (42.9% [6/14] vs. 53.3% [24/45], χ²= 0.469, P = 0.49). There were no differences in the cure rate for POP or UI between these two types of reconstructions (P > 0.05).

Conclusions:

No correlation between the incidence of UI and POP was identified. The results suggest that UI treatment should be performed after POP surgery for patients with both conditions.

Surgery for women with pelvic organ prolapse with or without stress urinary incontinence

BACKGROUND

Pelvic organ prolapse (POP) is common in women and is frequently associated with stress urinary incontinence (SUI). In many cases however, SUI is present only with the prolapse reduced (occult SUI) or may develop after surgical treatment for prolapse (de novo SUI).

OBJECTIVES

To determine the impact on postoperative bladder function of surgery for symptomatic pelvic organ prolapse with or without concomitant or delayed two-stage continence procedures to treat or prevent stress urinary incontinence.

SEARCH METHODS

We searched the Cochrane Incontinence Group Specialised Register, which contains trials identified from the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE-In-Process, ClinicalTrials.gov, WHO ICTRP, handsearching journals and conference proceedings (searched 11 November 2017) and reference lists of relevant articles. We also contacted researchers in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) including surgical operations for POP with or without continence procedures in continent or incontinent women. Our primary outcome was subjective postoperative SUI. Secondary outcomes included recurrent POP on examination, overactive bladder (OAB) symptoms, and voiding dysfunction.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as expected by Cochrane.

MAIN RESULTS

We included 19 RCTs (2717 women). The quality of the evidence ranged from low to moderate. The main limitations were risk of bias (especially blinding of outcome assessors), indirectness and imprecision associated with low event rates and small samples.POP surgery in women with SUIVaginal repair with vs without concomitant mid-urethral sling (MUS)A concomitant MUS probably improves postoperative rates of subjective SUI, as the evaluated clinical effect appears large (risk ratio (RR) 0.30, 95% confidence interval (CI) 0.19 to 0.48; 319 participants, two studies; I² = 28%; moderate-quality evidence), and probably decreases the need for further continence surgery (RR 0.04, 95% CI 0.00 to 0.74; 134 participants, one study; moderate-quality evidence). This suggests that if the risk of SUI with POP surgery alone is 39%, the risk with an MUS is between 8% and 19%.Rates of recurrent POP on examination, OAB, and voiding dysfunction were not reported.Vaginal repair with concomitant vs delayed MUSEvidence suggested little or no difference between groups in reporting postoperative SUI (RR 0.41, 95% CI 0.12 to 1.37; 140 participants, one study; moderate-quality evidence).Rates of recurrent POP on examination, OAB, and voiding dysfunction and the need for further surgery were not reported.Abdominal sacrocolpopexy with vs without Burch colposuspensionAn additional Burch colposuspension probably has little or no effect on postoperative SUI at one year (RR 1.38, 95% CI 0.74 to 2.60; 47 participants, one study; moderate-quality evidence), OAB symptoms (RR 0.85, 95% CI 0.61 to 1.18; 33 participants, one study; moderate-quality evidence), or voiding dysfunction (RR 0.96, 95% CI 0.06 to 14.43; 47 participants, one study; moderate-quality evidence). Rates of recurrent POP and the need for further surgery were not reported.POP surgery in women with occult SUIVaginal repair with vs without concomitant MUSMUS probably improves rates of subjective postoperative SUI (RR 0.38, 95% CI 0.26 to 0.55; 369 participants, five studies; I² = 44%; moderate-quality evidence). This suggests that if the risk with surgery alone is 34%, the risk with a concomitant MUS is between 10% and 22%. Evidence suggests little or no difference between groups in rates of recurrent POP (RR 0.86, 95% CI 0.34 to 2.19; 50 participants, one study; moderate-quality evidence), OAB symptoms (RR 0.75, 95% CI 0.52 to 1.07; 43 participants, one study; low-quality evidence), or voiding dysfunction (RR 1.00, 95% CI 0.15 to 6.55; 50 participants, one study; low-quality evidence). The need for further surgery was not reported.POP surgery in continent women Vaginal repair with vs without concomitant MUSResearchers provided no conclusive evidence of a difference between groups in rates of subjective postoperative SUI (RR 0.69, 95% CI 0.47 to 1.00; 220 participants, one study; moderate-quality evidence). This suggests that if the risk with surgery alone is 40%, the risk with a concomitant MUS is between 19% and 40%. Rates of recurrent POP, OAB, and voiding dysfunction and the need for further surgery were not reported.Abdominal sacrocolpopexy with vs without Burch colposuspensionWe are uncertain whether there is a difference between groups in rates of subjective postoperative SUI (RR 1.31, 95% CI 0.19 to 9.01; 379 participants, two studies; I² = 90%; low-quality evidence), as RCTs produced results in different directions with a very wide confidence interval. We are also uncertain whether there is a difference between groups in rates of voiding dysfunction (RR 8.49, 95% CI 0.48 to 151.59; 66 participants, one study; low-quality evidence) or recurrent POP (RR 0.98, 95% CI 0.74 to 1.30; 250 participants, one study; moderate-quality evidence. No study reported OAB symptoms and need for further surgery.Vaginal repair with armed anterior vaginal mesh repair vs anterior native tissue Anterior armed mesh repair may slightly increase postoperative de novo SUI (RR 1.58, 95% CI 1.05 to 2.37; 905 participants, seven studies; I² = 0%; low-quality evidence) but may decrease recurrent POP (RR 0.29, 95% CI 0.22 to 0.38; 848 participants, five studies; I² = 0%; low-quality evidence). There may be little or no difference in rates of voiding dysfunction (RR 1.65, 95% CI 0.22 to 12.10; 125 participants, two studies; I² = 0%; low-quality evidence). Rates of OAB and the need for further surgery were not reported.Adverse events were infrequently reported in all studies; cost was not studied in any trial.

AUTHORS' CONCLUSIONS

In women with POP and SUI (symptomatic or occult), a concurrent MUS probably reduces postoperative SUI and should be discussed in counselling. It might be feasible to postpone the MUS and perform a delayed (two-stage) continence procedure, if required.Although an abdominal continence procedure (Burch colposuspension) during abdominal POP surgery in continent women reduced de novo SUI rates in one underpowered trial, another RCT reported conflicting results. Adding an MUS during vaginal POP repair might reduce postoperative development of SUI.An anterior native tissue repair might be better than use of transobturator mesh for preventing postoperative SUI; however, prolapse recurrence is more common with native tissue repair.

[Preoperative functional explorations of genital prolapse (urodynamics, dynamic MRI)]

The evaluation of genital prolapse is essentially clinical; however imaging tests such as dynamic MRI or urodynamic explorations may be useful in complex cases, especially before surgical management. Dynamic MRI allows morphological and dynamic analysis of pelvic floor and levator ani function. It can also detect post-obstetric injuries, although the long-term significance of these injuries remains to be discovered. Quantification of the severity of prolapse is possible with MRI; however, the correlation of these measures with clinical examination seems poor. Its interest lies mainly in the qualitative assessment of the three stages of prolapse and the detection of elytroceles, which can be difficult to clinical examination. Urodynamics provides useful information on vesico-sphincteric function, but none of these parameters seems to be decisive in the management of prolapse.

[Treatment of Urinary incontinence associated with genital prolapse: Clinical practrice guidelines]

INTRODUCTION

Prolapse and urinary incontinence are frequently associated. Patente (or proven) stress urinary incontinence (SUI) is defined by a leakage of urine that occurs with coughing or Valsalva, in the absence of any prolapse reduction manipulation. Masked urinary incontinence results in leakage of urine occurring during reduction of prolapse during the clinical examination in a patient who does not describe incontinence symptoms at baseline. The purpose of this chapter is to consider on the issue of systematic support or not of urinary incontinence, patent or hidden, during the cure of pelvic organs prolapse by abdominal or vaginal approach.

MATERIAL AND METHODS

This work is based on an systematic review of the literature (PubMed, Medline, Cochrane Library, Cochrane database of systematic reviews, EMBASE) for meta-analyzes, randomized trials, registries, literature reviews, controlled studies and major not controlled studies, published on the subject. Its implementation has followed the methodology of the HAS on the recommendations for clinical practice, with a scientific argument (with the level of evidence, NP) and a recommendation grade (A, B, C, and professional agreement).

RESULTS

In case of patent IUE, concomitant treatment of prolapse and SUI reduces the risk of postoperative SUI. However, the isolated treatment of prolapse can treat up to 30% of preoperative SUI. Concomitant treatment of SUI exposed to a specific overactive bladder and dysuria morbidity. The presence of a hidden IUE represents a risk of postoperative SUI, but there is no clinical or urodynamic test to predict individually the risk of postoperative SUI. Moreover, the isolated treatment of prolapse can treat up to 60% of the masked SUI. Concomitant treatment of the hidden IUE therefore exposes again to overtreatment and a specific overactive bladder and dysuria morbidity.

CONCLUSION

In case of overt or hidden urinary incontinence, concomitant treatment of SUI and prolapse reduces the risk of postoperative SUI but exposes to a specific overactive bladder and dysuria morbidity (NP3). The isolated treatment of prolapse often allows itself to treat preoperative SUI. We can suggest not to treat SUI (whether patent or hidden) at the same time, providing that women are informed of the possibility of 2 stages surgery (Grade C). © 2016 Published by Elsevier Masson SAS.

Incidence and Risk Factors of De novo Stress Urinary Incontinence after Pelvic Floor Reconstruction: A Nested Case-control Study

Background:

Some patients with pelvic organ prolapse may suffer from lower urinary tract symptoms (LUTS), especially stress urinary incontinence (SUI) named de novo SUI after pelvic floor reconstruction. This study aimed to investigate the incidence and risk factors of de novo SUI.

Methods:

This is a nested case-control study of 533 patients who underwent pelvic floor reconstruction due to pelvic organ prolapse (POP) at the Department of Gynecology in Peking University People's Hospital from January 2011 to March 2013. According to the inclusion and exclusion criteria, 401 patients were enrolled in the study with the follow-up rate of 74.8% (101 patients lost to follow-up). There were 75 patients with de novo SUI postoperatively. According to the ratio of 1:3, we ensured the number of control group (n = 225). The preoperative urinary dynamics, POP-quantification scores, and LUTS were compared between the two groups by univariate and multivariate logistic regression analyses to investigate the risk factors of de novo SUI.

Results:

The incidence of de novo SUI was 25% (75/300). Univariate analysis showed that the ratio of lower urinary tract obstruction (LUTO) before surgery in de novo SUI group was significantly higher than the control group (odds ratio [OR] = 2.1, 95% confidence interval [CI] [1.1–4.0], P = 0.022). The interaction test of LUTO and other factors displayed that Aa value was an interaction factor. With the increasing score of Aa, the incidence of de novo SUI become higher (OR = 2.1, 95% CI [1.0–3.7], P = 0.045). After multivariable adjustment, multiple regression analysis showed that LUTO was independently associated with a greater risk of de novo SUI after pelvic floor surgery (OR = 2.3, 95% CI [1.2–4.6], P = 0.013).

Conclusions:

Preoperative LUTO in patients with POP is a high-risk factor of de novo SUI, and high score of Aa-point is related to the occurrence of de novo SUI, which might be due to the outlet obstruction caused by bladder prolapse.

Occult Stress Urinary Incontinence in Women With Pelvic Organ Prolapse: Is the One Step Surgical Approach a Risky Choice?

OBJECTIVES

Occult stress urinary incontinence (SUI, OSUI) is defined as the demonstration of SUI after pelvic organ prolapse (POP) reduction. The aim of this study was to evaluate the effectiveness and complication rates of the 1-step surgical approach for treating women with POP and OSUI.

METHODS

Retrospective study of women with POP and OSUI who underwent a concomitant prolapse and midurethral sling procedure was conducted. Main outcome measures were absence of postoperative urodynamic stress incontinence (USI) and absence of postoperative SUI at 12 months. Secondary outcome measures included evaluation of objective and subjective parameters related to the lower urinary tract function and assessment of the quality of life.

RESULTS

Of the 244 women, 205 women (84%) attended the 12-month postoperative follow-up visit and were included in the study. Overall, 87.8% (180/205) of the patients had absence of postoperative urodynamic stress incontinence, whereas 95.1% (195/205) did not report postoperative SUI. Evaluation of parameters related to the postoperative lower urinary tract dysfunction showed that (a) 43% of women with preexisting urgency symptoms continued to have urgency, (b) 16.7% of patients presented de novo urgency, (c) de novo detrusor overactivity occurred in 9.3% of patients, and (d) 4.9% of women with preoperative obstructive voiding symptoms continued to have obstructive voiding symptoms after combined surgery. King's Health Questionnaire data analysis showed a statistically significant improvement in all domains.

CONCLUSIONS

This 1-step approach is both safe and effective and could be offered as a valid operative choice for those women who wish or should avoid a repeat surgical procedure for postoperative SUI.

Concomitant trocar-guided transvaginal mesh surgery with a midurethral sling in treating advanced pelvic organ prolapse associated with stress or occult stress urinary incontinence

OBJECTIVE

The purpose of this study was to evaluate the efficacy and feasibility of concomitant trocar-guided transvaginal mesh (TVM) surgery with a midurethral sling (MUS) for treating women with advanced pelvic organ prolapse (POP) and stress urinary incontinence (SUI) or occult SUI (OSUI).

MATERIALS AND METHODS

Eighty-nine women with advanced POP and SUI or OSUI were retrospectively enrolled. The Total Prolift and Tension-free Vaginal Tape-Obturator Systems were used for trocar-guided TVM surgery and MUS. Patients received regular follow-up at 1 week, and 1 month, 3 months, 6 months, and 12 months postoperatively, and then annually thereafter. The endpoints were the success rate for POP, and perioperative and postoperative complications. Functional outcomes were the presence of voiding difficulty, persistent or de novo overactive bladder symptoms, postoperative SUI, and paresthesia.

RESULTS

The median follow-up period was 35 months (range, 12-50 months). Within the follow-up period, 84 patients (94.4%) were objectively cured, five patients (5.6%) had vaginal apical mesh exposure, 29 individuals (32.6%) had persistent or de novo overactive bladder symptoms, six individuals (22.5%) had de novo SUI (two were found by urodynamics), and nine individuals (10.1%) had voiding difficulties (two were found by urodynamics). In addition, the vaginal hysterectomy group had greater blood loss, longer operation times, and a higher mesh erosion rate compared to the uterine suspension group.

CONCLUSION

Concomitant trocar-guided TVM surgery and MUS with the use of total Prolift and Tension-free Vaginal Tape-Obturator offer good efficacy in treating women with advanced POP and SUI or OSUI. The vaginal hysterectomy group had more perioperative complications.

Pelvic Organ Prolapse Repair with and without Concomitant Burch Colposuspension in Incontinent Women: A Randomised Controlled Trial with at Least 5-Year Followup

The aim of this study was to reevaluate and update the followup of a previously published randomized controlled trial (RCT) on the impact of Burch Colposuspension (BC), as an anti-incontinence procedure, in patients with UI and POP, who underwent POP repair. Forty-seven women were randomly assigned to abdominal POP repair and concomitant BC (24 patients; group A) or POP repair alone without any anti-incontinence procedure (23 patients; group B). Median followup was 82 months (range 60-107); from over 47 patients, 30 reached 6-year followup. Two patients were lost at followup. In group A, 2 patients showed a stage I rectocele. In group B, 2 patients had a stage I rectocele and 1 a stage II rectocele. In group A, 13/23 (56.5%) were still incontinent after surgery compared with 9/22 patients (40.9%) in group B (P = 0.298). No significant changes were observed between the first and the current followup. The update of long-term followup confirmed that BC did not improve outcome significantly in incontinent women when they undergo POP repair.

To sling or not to sling at the time of anterior vaginal compartment repair

PURPOSE OF REVIEW

Prevention of postoperative stress urinary incontinence at the time of prolapse repair is controversial. There has been a shift away from colposuspension procedures to midurethral slings. As with any surgery, midurethral slings are associated with risks, which must be balanced against the benefits of preventing postoperative stress urinary incontinence. The aim of this overview is to review the controversy, discuss potential complications of midurethral slings, discuss the efficacy of concomitant sling placement, and suggest a method of systematically approaching patients with high-grade anterior compartment prolapse.

RECENT FINDINGS

Several studies have recently advocated for the routine use of anti-incontinence procedures at the time of prolapse surgery; however, applying these data to midurethral slings is problematic. Ultimately, the issue of treatment of the urethra at the time of prolapse repair should be discussed with the patient with treatment rendered depending on the risk the patient is willing to bear.

SUMMARY

The aim of this study is to discuss the risks and benefits of applying a midurethral sling in patients with high-grade anterior compartment prolapse. In these patients, placement of a suburethral sling may be approached systematically, taking into account the patients' variables and their own goals of therapy.

Between hope and fear: patient's expectations prior to pelvic organ prolapse surgery

Introduction and hypothesis

The aim of our study was to analyse the patient’s expectations (fears and goals (hopes)) in women who are scheduled for pelvic organ prolapse (POP) surgery.

Methods

All consecutive women awaiting surgery for POP in a tertiary urogynaecological centre were included. A short questionnaire with two open questions on goals and fears with regard to the operation was used.

Results

Ninety-six out of 111 distributed questionnaires (86%) were analysed. Goals and fears were categorized into five groups. De novo symptoms (63%), POP recurrence (34%) and surgical complications (29%) were the most important fears. Symptom release (96%), improved lifestyle (physical capabilities; 30%) and improved sexual life (18%) were important goals.

Conclusions

A wide variety of expectations both positive and negative can be found in women before POP surgery and should be an integral part of preoperative counselling. Achieving the individual goals as based on expectations, positive (goals) and negative (fears), should be part of the POP surgery evaluation.

Prolapse surgery: which technique and when?

PURPOSE OF REVIEW

More answers are nowadays available about certain aspects of pelvic organ prolapse (POP) treatment. In this overview some of those aspects are addressed that were considered important and published in 2010.

RECENT FINDINGS

When stress urinary incontinence (SUI) is present concomitant with POP the strategy is still to perform an additional procedure for SUI. If there is no SUI the tendency is only to correct the POP. With masked SUI no firm conclusions can be drawn.The studies that look at mesh for POP provide some careful conclusions. Absorbable biomeshes do not have many benefits over repairs without mesh in the long term. Nonresorbable mesh tends to give better results but also higher complication rates and should be applied with care.A last item is how to perform a sacrocolpopexy. Laparoscopic sacrocolpopexy is a well tolerated but time-consuming and difficult procedure to treat prolapse. Comparison with other conventional techniques is lacking. Robotic surgery has the potential of enhancing the widespread introduction of laparoscopic procedures.

SUMMARY

With these findings a better evidence-based choice for surgical technique can be made with regards to POP with or without SUI, the kind of mesh to use and which sacrocolpopexy technique should be chosen.

Incidence of stress urinary incontinence following vaginal repair of pelvic organ prolapse in objectively continent women

OBJECTIVE

To estimate the incidence of stress urinary incontinence (SUI) following vaginal repair of pelvic organ prolapse (POP) in preoperatively continent women and to evaluate the impact of the problem.

METHODS

Women were eligible if they had undergone vaginal repairs for any degree or type of POP with no anti-incontinence procedure between July 1, 2004 and June 30, 2006, and had been continent preoperatively, as defined by a negative cough stress test with or without reduction of prolapse. Demographic, preoperative, operative, and postoperative data were retrieved from hospital charts. The incidence of postoperative SUI (POSUI) and its quality of life (QoL) impact were assessed by mailed questionnaire. The POSUI endpoint was defined by the report of SUI symptoms on the mailed questionnaire and/or affirmation of postoperative treatment for SUI.

RESULTS

Forty-two out of 100 respondents reported POSUI within the 2-year average follow-up period. Twelve of 37 symptomatic women (32%) were moderately or greatly bothered by their symptoms. The QoL impact score was generally low but was statistically greater in women with POSUI compared to those with no POSUI (13 vs. 3, P=0.0006).

CONCLUSION

The risk of POSUI following vaginal repairs of POP may be higher than previously reported and approximately one-third of women are bothered by these symptoms. These findings deserve further investigation.

"Inside-out" transobturator tension-free vaginal tape for management of occult stress urinary incontinence in women undergoing pelvic organ prolapse repair

OBJECTIVES

To assess the safety and effectiveness of the "inside-out" transobturator tension-free vaginal tape procedure for the management of occult stress urinary incontinence (SUI) in clinically continent women undergoing prolapse repair.

METHODS

A total of 117 consecutive continent women (mean age and parity 66.8 ± 9.9 years and 3.2 ± 1.5, respectively) with significant pelvic organ prolapse and urodynamically confirmed occult SUI were enrolled in the present study. Surgical intervention included transvaginal prolapse repair and concomitant prophylactic transobturator tension-free vaginal tape. The main outcome measures were procedure-related complications, early and late postoperative morbidity, postoperative urodynamic SUI, persistent or de novo overactive bladder, and bladder outlet obstruction.

RESULTS

No cases of significant blood loss, hematoma formation, or bladder injury occurred. Of the 117 patients, 6 (5.1%) had immediate postoperative voiding difficulties necessitating catheterization for >2 days. Late postoperative morbidity was assessed in 110 patients with ≥3 months of follow-up (mean 27.2 ± 17.7). Of these 110 patients, 7 (6.4%) had protracted postoperative thigh pain with spontaneous resolution within 1-3 months, and 7 (6.4%) had developed recurrent urinary tract infections. No cases of vaginal erosion developed. The functional outcome analysis was restricted to 92 patients with ≥12 months of follow-up (mean 31 ± 16). Of the 92 patients, 13 (14%) were found to have urodynamic SUI. However only 2 patients (2.2%) were symptomatic for a subjective and objective cure rate of 97.8% and 86%, respectively. Of the 34 patients who had had overactive bladder preoperatively, 22 (64.7%) had persisting symptoms postoperatively. An additional 4 patients (6.9%) had developed de novo overactive bladder symptoms, and 1 patient had bladder outlet obstruction.

CONCLUSIONS

The prophylactic transobturator tension-free vaginal tape procedure is both effective and safe in patients with occult SUI undergoing prolapse repair.

Outcomes following vaginal prolapse repair and mid urethral sling (OPUS) trial--design and methods

BACKGROUND

The primary aims of this trial are to determine whether the use of a concomitant prophylactic anti-incontinence procedure may prevent stress urinary incontinence symptom development in women undergoing vaginal prolapse surgery and to evaluate the cost-effectiveness of this prophylactic approach.

PURPOSE

To present the rationale and design of a randomized controlled surgical trial (RCT), the Outcomes following vaginal Prolapse repair and mid Urethral Sling (OPUS) Trial highlighting the challenges in the design and implementation.

METHODS

The challenges of implementing this surgical trial combined with a cost-effectiveness study and patient preference group are discussed including the study design, ethical issues regarding use of sham incision, maintaining the masking of study staff, and pragmatic difficulties encountered in the collection of cost data. The trial is conducted by the NICHD-funded Pelvic Floor Disorders Network.

RESULTS

The ongoing OPUS trial started enrollment in May 2007 with a planned accrual of 350. The use of sham incision was generally well accepted but the collection of cost data using conventional billing forms was found to potentially unmask key study personnel. This necessitated changes in the study forms and planned timing for collection of cost data. To date, the enrollment to the patient preference group has been lower than the limit established by the protocol suggesting a willingness on the part of women to participate in the randomization.

LIMITATIONS

Given the invasive nature of surgical intervention trials, potential participants may be reluctant to accept random assignment, potentially impacting generalizability.

CONCLUSION

Findings from the OPUS trial will provide important information that will help surgeons to better counsel women on the benefits and risks of concomitant prophylactic anti-incontinence procedure at the time of vaginal surgery for prolapse. The implementation of the OPUS trial has necessitated that investigators consider ethical issues up front, remain flexible with regards to data collection and be constantly aware of unanticipated opportunities for unmasking. Future surgical trials should be aware of potential challenges in maintaining masking and collection of cost-related information.

Is there any evidence to advocate SUI prevention in continent women undergoing prolapse repair? An overview

Postoperative SUI prevention at the time of prolapse surgery is still a challenging issue. Recent findings suggested that a systematic prophylactic Burch colposuspension could be performed in continent women undergoing a sacral colpopexy. The aim of this paper is to collect relevant literature in order to suggest a management strategy. A thorough PubMed research of all papers in the English language was conducted. Evidence-based medicine was analyzed and current unanswered questions were discussed. Despite evident limitations, it appears to be some benefit from preoperative screening with a stress test during prolapse reduction. In continent patient with a positive stress test, adding a preventive procedure could be fully justified. In regard to contradictory published data, when negative stress test, patient counseling is important and the ratio of risk-benefit should be rigorously discussed. Further randomized controlled studies are needed to support either a prophylactic or a second-step strategy.

The role of preoperative urodynamic testing in stress-continent women undergoing sacrocolpopexy: the Colpopexy and Urinary Reduction Efforts (CARE) randomized surgical trial

The aim of this study is to describe results of reduction testing in stress-continent women undergoing sacrocolpopexy and to estimate whether stress leakage during urodynamic testing with prolapse reduction predicts postoperative stress incontinence. Three hundred twenty-two stress-continent women with stages II-IV prolapse underwent standardized urodynamics. Five prolapse reduction methods were tested: two at each site and both performed for each subject. Clinicians were masked to urodynamic results. At sacrocolpopexy, participants were randomized to Burch colposuspension or no Burch (control). P-values were computed by two-tailed Fisher's exact test or t-test. Preoperatively, only 12 of 313 (3.7%) subjects demonstrated urodynamic stress incontinence (USI) without prolapse reduction. More women leaked after the second method than after the first (22% vs. 16%; p = 0.012). Preoperative detection of USI with prolapse reduction at 300ml was pessary, 6% (5 of 88); manual, 16% (19 of 122); forceps, 21% (21 of 98); swab, 20% (32 of 158); and speculum, 30% (35 of 118). Women who demonstrated preoperative USI during prolapse reduction were more likely to report postoperative stress incontinence, regardless of concomitant colposuspension (controls 58% vs. 38% (p = 0.04) and Burch 32% vs. 21% (p = 0.19)). In stress-continent women undergoing sacrocolpopexy, few women demonstrated USI without prolapse reduction. Detection rates of USI with prolapse reduction varied significantly by reduction method. Preoperative USI leakage during reduction testing is associated with a higher risk for postoperative stress incontinence at 3 months. Future research is warranted in this patient population to evaluate other treatment options to refine predictions and further reduce the risk of postoperative stress incontinence.

Must Colposuspension be Associated with Sacropexy to Prevent Postoperative Urinary Incontinence?

OBJECTIVES

This prospective, randomised study investigated whether a prophylactic procedure, performed during colposacropexy for prolapse repair, prevents ex novo postoperative incontinence. Sixty-six consecutive continent patients with advanced prolapse were randomised into two groups: group A underwent sacropexy combined with a Burch colposuspension; no anti-incontinence procedure was performed in group B patients.

METHODS

Work-up included clinical assessment (Halfway System and International Continence Society [ICS] classification for prolapse and Ingelman Sunderberg scale for incontinence), the Urogenital Distress Inventory and Impact Incontinence Quality of Life questionnaires, urogynaecologic ultrasound scans, and complete urodynamic testing that included the urethral pressure profile and Valsalva leak point pressure with reduced prolapse. Check-ups were done at 3, 6, 12 mo postoperatively and then yearly. Mean follow-up time was 39.5 mo.

RESULTS

The mean age (+/- standard deviation) was 62+/-9 yr. All patients presented with grade (G) 3-4 prolapse. Postoperative incontinence was present in 12 of the 34 patients in group A: 7 G1; 4 G2, and 1 G3. Postoperative incontinence was present in 3 of the 32 patients in group B: 2 G1, 1 G3. The frequency of postoperative incontinence was significantly greater in patients who had undergone colposuspension (p<0.05).

CONCLUSIONS

These preliminary data cast doubt on whether colposuspension should be performed during sacropexy for severe urogenital prolapse as prophylaxis for postoperative incontinence because it seems to emerge as overtreatment. Incontinence developed ex novo in 35% of continent patients treated with colposuspension combined with sacropexy.

Occult stress incontinence in women with pelvic organ prolapse

OBJECTIVES

To study the prevalence of occult stress urinary incontinence (SUI) among Indian women with genitourinary prolapse, and determine the risk of developing SUI after vaginal hysterectomy and pelvic floor repair in Indian women with occult SUI.

METHODS

A prospective cohort study of 78 women with significant genitourinary prolapse without symptoms of SUI was conducted at Christian Medical College, Vellore, India. Before the surgical intervention, the prolapse was repositioned using a pessary and a Pyridium (Parke Davis, Morris Plains, NJ, USA) pad test was performed to detect occult SUI. The primary outcome studied was the risk of developing postoperative urinary incontinence.

RESULTS

Preoperatively, 67.9% of women were found to have occult SUI. The prevalence of SUI was 43.6% postoperatively, and 64.2% of the women with a positive result to the preoperative Pyridium pad test after pessary insertion were found to have urinary incontinence postoperatively. Postmenopausal women had twice the risk of developing occult SUI.

CONCLUSION

Preoperative testing is useful to identify women with genitourinary prolapse who have occult SUI. Women with a positive result may need a systematic clinical evaluation and urodynamic studies to characterize the incontinence. They can be then counseled preoperatively regarding concomitant anti-incontinence procedures.

Pelvic floor reconstructive surgery: which aspects remain controversial?

PURPOSE OF REVIEW

The article focuses on recently published original and review papers on current controversial aspects of pelvic reconstructive surgery.

RECENT FINDINGS

A detailed Medline search was performed on records published in the previous 12 months. Controversial areas concerning which important work has been recently published include (a) prophylactic treatment of stress urinary incontinence, (b) the use of prosthetic materials (particularly for anterior segment reconstruction), (c) laparoscopic surgery. The considerations of the recent International Consultation on Incontinence are also reported. Other controversial areas in the field of pelvic reconstructive surgery such as the question of uterine preservation during the surgery for uterovaginal prolapse provided no significant new data in the period of this review.

SUMMARY

In this evolving field, there is still poor standardization of what constitutes anatomical and functional cure. The transvaginal approach is the most promising of all techniques, and new techniques are evolved mainly in this area. There continues to be a need for multicenter prospective randomized trials providing level I evidence. Recurrence rates, particularly in the anterior wall, are still unacceptably high. Evidence is urgently needed to decide whether the use of prosthetic materials may provide the answer, if so, which material and which method?