Prolapse surgery with or without incontinence procedure: a systematic review and meta-analysis

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.

Prevalence and management of urinary incontinece after pelvic organ prolapse surgery (sacrocolpopexy). A literature review

INTRODUCTION

Stress urinary incontinence (SUI) is frequently associated with pelvic organ prolapse (POP) and may occur after its surgical treatment.

AIM

To determine the incidence, risk factors and management of SUI during and after POP surgery through a review of the available literature.

MATERIALS AND METHOD

Narrative literature review on the incidence and management of SUI after POP surgery after search of relevant manuscripts indexed in PubMed, EMBASE and Scielo published in Spanish and English between 2013 and 2023.

RESULTS

Occult SUI is defined as visible urine leakage when prolapse is reduced in patients without SUI symptoms. De novo SUI develops after prolapse surgery without having previously existed. In continent patients, the number needed to treat (NNT) to prevent one case of de novo SUI is estimated to be 9 patients and about 17 to avoid repeat incontinence surgery. In patients with occult UI, the NNT to avoid repeat incontinence surgery is around 7. Patients with POP and concomitant SUI are the group most likely to benefit from combined surgery with a more favorable NNT (NNT 2).

CONCLUSION

Quality studies on combined surgery for treatment SUI and POP repair are lacking. Continent patients with prolapse should be warned of the risk of de novo SUI, although concomitant incontinence treatment is not currently recommended. Incontinence surgery should be considered on an individual basis in patients with prolapse and SUI.

Cost-Utility Analysis of Midurethral Sling Timing Among Women Undergoing Prolapse Surgery

IMPORTANCE

There are no guidelines regarding the ideal timing of midurethral sling (MUS) placement following prolapse repair.

OBJECTIVE

The objective of this study was to estimate the cost-utility of concomitant MUS versus staged MUS among women undergoing apical suspension surgery for pelvic organ prolapse.

STUDY DESIGN

Cost-utility modeling using a decision analysis tree compared concomitant MUS with staged MUS over a 1-year time horizon. The primary outcome was the incremental cost-effectiveness ratio (ICER). Six scenarios were modeled to estimate cost-utilities for women with preoperative overt, occult, or no stress urinary incontinence (SUI) who underwent either minimally invasive sacrocolpopexy or vaginal native tissue apical suspension. Possible complications of de novo overactive bladder, urinary retention requiring sling lysis, mesh exposure, and persistent SUI were included. Costs from a third-party payer perspective were derived from Medicare 2022 reimbursements. One-way sensitivity analyses were performed.

RESULTS

Among women without preoperative SUI, staged MUS was the dominant strategy for both surgical routes with higher utility and lower costs. For women with either occult or overt SUI undergoing sacrocolpopexy or vaginal repair, concomitant MUS was cost-effective (ICER = $21,114-$96,536 per quality-adjusted life-year). Therefore, concomitant MUS is preferred for patients with preoperative SUI as higher costs were offset by higher effectiveness. One-way sensitivity analyses demonstrated that ICERs were most affected by probability of cure following MUS.

CONCLUSIONS

A staged MUS procedure is the dominant strategy for women undergoing apical prolapse repair without preoperative SUI. In women with either overt or occult SUI, the ICER was below the willingness-to-pay threshold of $100,000 per quality-adjusted life-year, suggesting that concomitant MUS surgery is cost-effective.

The Pros and Cons of Hystero-preservation on Pelvic Reconstructive Surgery

In the "boat at the dock" theory, pelvic organ prolapse (POP) may happen when the ropes (uterine supportive ligaments) break and/or the water level drops (pelvic floor muscles). Thus, it causes the boat (uterus and other pelvic organs) to slip from normal position and protrude out of the vagina. Surgical intervention with or without hysterectomy (hystero-preservation) is the most effective treatment for POP. Both hysterectomy and hystero-preservation for POP had a high anatomic and clinical cure rate. There is an increasing trend of hystero-preservation for POP during the past decades. The choices of either hysterectomy or hystero-preservation depend on the surgical factors, psychosocial factors, self-esteem and sexuality factors, and surgeon factors. Pelvic reconstructive surgery, either hysterectomy or hystero-preservation, can be performed via different approaches, including abdominal, laparoscopic, and vaginal routes, with native tissue or with mesh. This review will elucidate their related pros and cons, with further discussion and comparison of hystero-preservation via different routes.

Efficacy of minimally invasive pectopexy with concomitant I-stop-mini sling for women with pelvic organ prolapse and overt stress urinary incontinence: A retrospective cohort study

OBJECTIVE

To compare the efficacy of minimally invasive pectopexy with I-stop-mini (MPI) and minimally invasive sacrocolpopexy with Obtryx (MSO).

METHODS

Women with pelvic organ prolapse quantification (POP-Q) stage III or more and overt stress urinary incontinence from May 2018 to May 2021 were included. Patients with meshes fixed on the cervix or vaginal vault and bilateral pectineal ligament with I-stop-mini were classified into the MPI group, while those fixed on the apex and sacral promontory with Obtryx were classified into the MSO group. The primary outcomes were 1-year-postoperative POP-Q stage, patient-reported urinary and prolapse outcomes (Urogenital Distress Inventory-6, International Consultation on Incontinence Questionnaire-Short Form, and Pelvic Organ Prolapse Distress Inventory-6), 1-h pad test, and sexual life quality (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire). Secondary outcomes included operative data and adverse events.

RESULTS

The efficacy of MPI was similar to that of MSO according to the primary outcomes. MPI had shorter operative times (133.4 ± 30.6 min versus 199.3 ± 20.9 min, P = 0.001) and lower incidence rate of abdominal pain (0% vs 20%, P = 0.02) and groin pain (8% vs 40%, P = 0.01) than MSO.

CONCLUSIONS

MPI showed similar efficacy to MSO, but demonstrated shorter operative times and lower incidence rates of abdominal and groin pain.

Incidence of de novo stress urinary incontinence following minimally invasive sacrocolpopexy

INTRODUCTION AND HYPOTHESIS

The objective was to investigate the incidence and risk factors of postoperative de novo stress urinary incontinence (SUI) in stress-continent women following minimally invasive sacrocolpopexy without an anti-incontinence procedure.

METHODS

We completed a multicenter, retrospective cohort study of women undergoing laparoscopic sacrocolpopexy without concurrent anti-incontinence procedures from October 2006 through January 2021.

RESULTS

Of the 169 women who underwent minimally invasive sacrocolpopexy, 17.1% (n=30) developed de novo SUI, and 7.1% eventually underwent a midurethral sling placement. On logistic regression, BMI, preoperative urinary urgency, and history of transvaginal mesh repair were found to be significantly associated with and predictive of de novo SUI. When the concordance index (C-index) was calculated with the model published by Jelovsek et al. for women who developed de novo SUI within 12 months of the prolapse surgery, the current de novo SUI calculator was able to discriminate de novo SUI outcome (C-index = 0.71).

CONCLUSIONS

The incidence of de novo SUI after minimally invasive sacrocolpopexy without anti-incontinence procedure correlates directly with higher BMI, preoperative urinary urgency, and transvaginal mesh history for POP. Preoperative counseling for minimally invasive sacrocolpopexy should include discussing the risk of de novo SUI and preoperative factors that may increase this risk.

Management of female pelvic organ prolapse-Summary of the 2021 HAS guidelines

When a patient presents with symptoms suggestive of pelvic organ prolapse (POP), clinical evaluation should include an assessment of symptoms, their impact on daily life and rule out other pelvic pathologies. The prolapse should be described compartment by compartment, indicating the extent of the externalization for each. The diagnosis of POP is clinical. Additional exams may be requested to explore the symptoms associated or not explained by the observed prolapse. Pelvic floor muscle training and pessaries are non-surgical conservative treatment options recommended as first-line therapy for pelvic organ prolapse. They can be offered in combination and be associated with the management of modifiable risk factors for prolapse. If the conservative therapeutic options do not meet the patient's expectations, surgery should be proposed if the symptoms are disabling, related to pelvic organ prolapse, detected on clinical examination and significant (stage 2 or more of the POP-Q classification). Surgical routes for POP repair can be abdominal with mesh placement, or vaginal with autologous tissue. Laparoscopic sacrocolpopexy is recommended for cases of apical and anterior prolapse. Autologous vaginal surgery (including colpocleisis) is a recommended option for elderly and fragile patients. For cases of isolated rectocele, the posterior vaginal route with autologous tissue should be preferentially performed over the transanal route. The decision to place a mesh must be made in consultation with a multidisciplinary team. After the surgery, the patient should be reassessed by the surgeon, even in the absence of symptoms or complications, and in the long term by a primary care or specialist doctor.

Effect of hysterectomy on re-operation for stress urinary incontinence: 10 year follow-up

Purpose

Hysterectomy and mid-urethral sling (MUS) are common operations, but little is known about how hysterectomy after MUS affects the risk for stress urinary incontinence (SUI) relapse.

Methods

We included 49 women with a MUS before hysterectomy and 41 women with a MUS concomitant with hysterectomy. The controls, matched by age (± 2 years), MUS type (retropubic vs transobturator) and operation year (± 2 years), included 201 women who underwent the MUS operation without a subsequent hysterectomy. We used health care registers for follow-up of 12.4 years in median (IQR 10.9–14.7) after the MUS operation to compare the number of SUI re-operations and hospital re-visits for urinary incontinence.

Results

The re-operation rates for SUI did not differ between the women with MUS before hysterectomy (n = 2, 4.1%), women with MUS concomitant with hysterectomy (n = 2, 4.9%) and their controls (n = 4, 4.9%, p = 0.8 and n = 6, 5.0%, p = 1.0, respectively). There were significantly fewer urinary incontinence re-visits among women who had a MUS concomitant with the hysterectomy compared to their matched controls (n = 2 and 31, 5 and 31%, p < 0.01) and to the women with a MUS prior to hysterectomy (n = 2 and 10, 5 and 20%, respectively, p = 0.03).

Conclusion

Hysterectomy after or concomitant with MUS does not seem to increase the risk for SUI re-operation or hospital re-visits for urinary incontinence. These results can be used to counsel women considering hysterectomy after MUS operation or concomitant with MUS operation.

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.

Twenty-Five Years of the Midurethral Sling: Lessons Learned

Midurethral slings (MUS) are widely accepted for the surgical treatment of stress urinary incontinence (SUI) in cases where conservative treatment has failed. They have been shown to be a safe and effective surgical treatment for the management of SUI. However, there have recently been growing concerns regarding the safety profile of mesh procedures, generating international debate and leading to national inquiries into the effectiveness and safety of mesh implants. A multitude of clinical, technical, manufacturer-related, and other health jurisdictional factors are involved in the outcomes of MUS. Appropriate patient selection and informed consent to all treatment options, with proper guidance from healthcare providers, are critical for empowering women to choose an appropriate treatment option based on a personalized decision.

Cost-Effectiveness of Prophylactic Retropubic Sling at the time of Vaginal Prolapse Surgery

BACKGROUND

Prophylactic midurethral sling (MUS) at the time of prolapse repair significantly reduces risk of de novo stress urinary incontinence (SUI), but it is associated with some small but significant morbidities. Since there has not been a standardized approach to MUS utilization, decision analysis provides a method to evaluate the cost and effectiveness associated with varying MUS strategies in addressing risk of de novo SUI.

OBJECTIVES

We aimed to compare the cost-effectiveness of the three MUS utilization strategies in treating de novo SUI one year following vaginal prolapse repair. The three approaches are: 1) staged strategy: prolapse repair without prophylactic MUS, 2) universal sling: prolapse repair with prophylactic MUS, and 3) selective sling: prolapse repair with prophylactic MUS only in patients with a positive prolapse-reduced cough stress test (CST).

STUDY DESIGN

We created a decision analysis model to compare staged strategy, universal sling, and selective sling. We modeled probabilities of de novo SUI, patients choosing subsequent MUS surgery for de novo SUI, and outcomes related to MUS. De novo SUI rates were determined for each strategy from published data. Likelihood of patients with de novo SUI choosing MUS surgery as their first-line treatment was also determined from the literature, and this scenario was only applied to patients without prophylactic MUS at their index prolapse repair. Finally, outcomes related to MUS including recurrent or persistent SUI, voiding dysfunction requiring sling lysis, mesh exposure requiring excision, and de novo overactive bladder requiring medications were all derived from publicly available data. All MUS was assumed to be retropubic. The costs for each procedure were obtained from the 2020 Centers for Medicare & Medicaid Services Physician Fee Schedule or previous literature converted to 2020 US dollars with the Consumer Price Index. The primary outcome was modeled as the incremental cost effectiveness ratio (ICER). We performed multiple one-way sensitivity analyses to assess model robustness.

RESULTS

The lowest cost strategy was the staged strategy which costs $1,051.70 per patient, followed by $1,093.75 for selective sling and $1,125.54 for universal sling. The selective sling approach, however, had the highest health utility value; therefore, universal sling was dominated by selective sling as it is both less costly and more effective. When compared to the staged strategy, selective sling was cost-effective with ICER of $2,664/QALY, meeting the predetermined threshold. In multiple 1-way sensitivity analyses, the variable with the largest effect was the percentage of patients electing to undergo subsequent MUS surgery for de novo SUI after index surgery. Only when this proportion exceeded 62% did universal sling become the cost-effective option as selective sling surpassed the predetermined ICER threshold and became dominated.

CONCLUSION

Selective sling was the preferred and cost-effective strategy in treating de novo SUI one year following vaginal prolapse repair. Surgeons should counsel their patients preoperatively regarding the possibility of de novo SUI after prolapse repair as well as the benefits and risks of prophylactic MUS.

Long-term Urinary Outcomes After Transvaginal Uterovaginal Prolapse Repair With and Without Concomitant Midurethral Slings

IMPORTANCE

Many health care providers place concomitant midurethral slings during pelvic organ prolapse repair, yet growing evidence supports staged midurethral sling placement.

OBJECTIVES

The aim of this study was to compare urinary function after transvaginal uterovaginal prolapse repair with and without midurethral sling.

STUDY DESIGN

Secondary analysis of the Study of Uterine Prolapse Procedures Randomized Trial (hysterectomy with uterosacral ligament suspension vs mesh hysteropexy). Our primary outcome was Urinary Distress Inventory score (UDI-6) through 5 years compared between women with and without a concomitant sling within prolapse repair arms. Sling effect was adjusted for select clinical variables and interaction terms (α = .05).

RESULTS

The sling group included 90 women (43 hysteropexy, 47 hysterectomy), and the no-sling group included 93 women (48 hysteropexy, 45 hysterectomy). At baseline, the sling group reported more bothersome stress (66% vs 36%, P < 0.001) and urgency incontinence (69% vs 48%, P = 0.007). For hysteropexy, there were no significant long-term differences in UDI-6 scores or bothersome urine leakage between sling groups. For hysterectomy, women with sling had better UDI-6 scores across time points (adjusted mean difference, -5.1; 95% confidence interval [CI], -9.9 to -0.2); bothersome stress and urgency leakage were less common in the sling group (stress adjusted odds ratio, 0.1 [95% CI, 0.0-0.4]; urge adjusted odds ratio, 0.5 [95% CI, 0.2-1.0]). Treatment for stress incontinence over 5 years was similar in the sling (7.9%) versus no-sling (7.6%) groups.

CONCLUSIONS

Five-year urinary outcomes of concomitant midurethral sling may vary by type of transvaginal prolapse surgery, with possible benefit of midurethral sling at the time of vaginal hysterectomy with apical suspension but not after mesh hysteropexy.

Postoperative indications for further surgery following post-transvaginal ProliftTM mesh repair after a two-year follow-up period: a single-centre study

We investigated the frequency of further surgery post-artificial mesh (Prolift^TM) repair of pelvic organ prolapse. In total, 257 patients who underwent Prolift^TM repair were evaluated for further surgery frequency, clinical outcomes, and demographic characteristics. Thirty-eight (14.7%) patients underwent further surgery (median time to reoperation, 9.5 months; range, 6-22 months). Six (2.3%) patients underwent prolapse repair at a different (5 patients, 1.9%) or same site (1 patient, 0.3%). One underwent posterior Prolift^TM repair; four, laparoscopic sacrocolpopexy; and one, vaginal hysterectomy. Eight (3.1%) underwent surgery for complications; seven (2.7%) required further surgery for mesh exposure (median, 8 months) and one (0.3%) required further surgery for mesh infection (1 month). Twenty-four (9.3%) received further surgery for stress urinary incontinence (median, 8.5 months). Despite the low frequency of further surgery post-Prolift^TM repair, mesh-related complications should be considered. Careful long-term follow-up is necessary.Impact StatementWhat is already known on this subject? It is widely known that vaginal mesh is used as treatment for pelvic organ prolapse (POP). Vaginal mesh is one of the treatment options for POP. However, it received a bad reputation following reports of complications associated with its use, leading to discontinuation of vaginal mesh in many countries.What the results of this study revealed? The findings of this study show that few patients who received Prolift^TM repair required further surgery. The surgeries included surgery for non-POP-related conditions; subsequent surgery for stress urinary incontinence (SUI); surgery for complications including mesh exposure and infection; primary prolapse surgery for a different site and repeat surgery; and a repeat operation for prolapse arising from the same site.What are the implications of these findings in clinical practice and/or further research? Based on the outcome of this study, transvaginal Prolift^TM mesh repair is a reasonably safe and effective treatment for POP. Despite withdrawal of all mesh products from the market as instructed by the FDA, this study suggested the need to re-evaluate the role of vaginal mesh as a treatment option for POP.

Incidence of Midurethral Sling Revision or Removal by Its Timing With Prolapse Surgery

OBJECTIVE

The aim of the study was to evaluate incidence of midurethral sling removal/revision based on timing with surgery for pelvic organ prolapse.

METHODS

This was a retrospective cohort study of women who underwent midurethral sling placement in a claims-based database of women 65 years or older. Three groups were identified using the Current Procedural Terminology codes: (1) isolated sling, (2) concomitant sling, and (3) prolapse surgery and staged sling after prolapse surgery. In the staged group, placement of sling was identified within 18 months after index prolapse surgery. Fascial grafts were excluded. Sling removal/revision was identified across 3 years after sling surgery using Current Procedural Terminology code 57287. Rates of sling removal/revision were calculated by group. Comparisons were made using the χ2 test and analysis of variance. Cumulative incidence of removal/revision was evaluated using the Kaplan-Meier curves. Cox proportional hazards was performed to evaluate factors influencing removal/revision.

RESULTS

We identified 39,381 isolated MUSs, 25,389 concomitant, and 886 staged. The rate of sling removal/revision was 3.52%. Rates of removal/revision differed between groups (7% staged vs 3.94% concomitant vs 3.17% isolated sling, P < 0.001). Compared with the staged group, the rate of removal/revision was lower in the isolated sling group (relative risk, 0.4550; 95% confidence interval [CI], 0.358-0.568) and the concomitant group (relative risk, 0.5666; 95% CI, 0.4450-0.7287). After adjusting for patient characteristics, sling revision or removal remained significantly less in the isolated MUS (hazard ratio, 0.50; 95% CI, 0.39-0.65) and concomitant (odds ratio, 0.55; 95% CI, 0.43-0.71) groups.

CONCLUSIONS

Sling removal/revision is higher when it is staged after prolapse surgery compared with isolated and concomitant placement. Future studies are needed to confirm these findings in a controlled population.

Development and validation of a prediction model for bothersome stress urinary incontinence after prolapse surgery: a retrospective cohort study

OBJECTIVE

To develop and validate a prediction model for bothersome stress urinary incontinence after prolapse surgery and to compare it with an existing clinical prediction model (CUPIDO model).

DESIGN

Retrospective cohort study.

SETTING

Two tertiary hospitals in South Korea.

POPULATION

A total of 1142 patients who underwent prolapse surgery with or without a concomitant midurethral sling.

METHODS

To construct a prediction model, we performed logistic regression using both exhaustive and stepwise variable selection, validating the model both internally and externally.

MAIN OUTCOME MEASURES

Bothersome stress urinary incontinence defined as the presence of bothersome symptoms of stress urinary incontinence and/or subsequent continence procedure one year after surgery.

RESULTS

Postoperative bothersome stress urinary incontinence occurred in 10% of patients. A model containing six predictors (age, diabetes mellitus, subjective urinary incontinence, prolapse reduction stress test result, type of prolapse surgery, and a concomitant midurethral sling) showed excellent performance for predicting bothersome stress urinary incontinence (area under the curve 0.74, 95% confidence interval 0.62-0.86) and outperformed the CUPIDO model (area under the curve 0.63, 95% confidence interval 0.49-0.76; DeLong's test P = 0.014).

CONCLUSIONS

This prediction model might be a useful tool to guide patient decision making regarding a concomitant continence procedure at the time of prolapse surgery. The predictive value of this model needs to be validated further in cohorts with different characteristics.

TWEETABLE ABSTRACT

The proposed prediction model for bothersome stress urinary incontinence after prolapse surgery outperforms an existing model.

Transvaginal natural orifice transluminal endoscopic surgery for uterosacral ligament suspension: pilot study of 35 cases of severe pelvic organ prolapse

Background

To describe the short-term outcomes of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for uterosacral ligament suspension (USLS) in patients with severe prolapse.

Methods

This was a retrospective study of patients with severe prolapse (≥ stage 3) who underwent vNOTES for USLS between May 2019 and July 2020. The Pelvic Organ Prolapse Quantification (POP-Q) score, Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire short form (PISQ-12) and Pelvic Floor Inventory-20 (PFDI-20) were used to evaluate physical prolapse and quality of life before and after vNOTES for USLS.

Results

A total of 35 patients were included. The mean operative duration was 111.7 ± 39.4 min. The mean blood loss was 67.9 ± 35.8 ml. Statistically significant differences were observed between before and after vNOTES USLS in Aa (+ 0.6 ± 1.7 versus − 2.9 ± 0.2), Ba (+ 1.9 ± 2.2 versus − 2.9 ± 0.3), C (+ 1.5 ± 2.2 versus − 6.9 ± 0.9), Ap (− 1.4 ± 1.0 versus − 3.0 ± 0.1) and Bp (− 1.1 ± 1.4 versus − 2.9 ± 0.1) (P < 0.05 for all). The mean pre- and postoperative PFDI-20 score was 19.9 ± 6.7 and 3.2 ± 5.4, respectively, and the mean pre- and postoperative PISQ-12 score was 24.8 ± 2.3 and 38.3 ± 4.1, respectively (P < 0.05 for both). During 1–13 months of follow-up, there were no cases of severe complications or recurrence.

Conclusions

vNOTES for USLS may be a feasible technique to manage severe prolapse, with promising short-term efficacy and safety. Larger studies with more patients and longer follow-up periods should be performed to evaluate the long-term efficacy and safety profile of vNOTES for USLS.

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 impact of concomitant mid-urethral sling surgery on patients undergoing vaginal prolapse repair

INTRODUCTION AND HYPOTHESIS

The aim of this study was to assess whether mid-urethral sling (MUS) placement at the time of vaginal prolapse repair compared to vaginal prolapse repair alone is associated with an increase in 30-day postoperative complications.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Database, Current Procedural Terminology codes were used to identify cases of vaginal prolapse repair with and without concomitant MUS from 2012 to 2017. Student's t-test and chi-square test were used to compare differences between the groups.

RESULTS

A total of 1469 cases of vaginal prolapse repair with sling were compared to 4566 cases without sling. There was no difference between prolapse repair with sling compared to without sling in mean hospital length of stay (LOS) (1.42 versus 1.32 days, p = 0.65), postoperative urinary tract infection (UTI) (6.1% versus 5.8%, p = 0.670), perioperative blood transfusion (1.1% versus 1.2%, p = 0.673), readmission (2.7% versus 2.6%, p = 0.884) and postoperative wound infection (0.5% versus 0.7%, p = 0.51). There was a higher rate of reoperation (2.2% versus 1.5%, p = 0.049) and venous thromboembolism (VTE) (0.4% versus 0.1%, p = 0.030) in patients undergoing concomitant MUS compared to those undergoing prolapse repair alone.

CONCLUSIONS

Compared to prolapse repair alone, the addition of a sling did not increase hospital LOS, UTI, perioperative blood transfusions, readmission or postoperative wound infections. However, concomitant sling was found to be associated with a higher risk of reoperation and VTE.

Balancing the possibility of needing a future incontinence procedure versus a future urethral sling revision surgery: a tradeoff analysis for continent women undergoing pelvic organ prolapse surgery

INTRODUCTION AND HYPOTHESIS

Although urinary incontinence surgery has potential benefits such as preventing de novo stress urinary incontinence in women undergoing pelvic organ prolapse (POP) surgery, it comes with the potential cost of overtreatment and complications. We compared future surgery rates in a population cohort of women undergoing vaginal pelvic organ prolapse surgery.

METHODS

All women undergoing POP repair in California from 2005 to 2011 were identified from the Office of Statewide Health Planning and Development databases. Rates of repeat surgery in those with and without concomitant urethral sling procedures were compared. To control for confounding effects, multivariate mixed effects logistic regression models were constructed to compare each woman's individualized risk of undergoing either sling revision surgery or future incontinence surgery.

RESULTS

In the cohort, 38,456 underwent a sling procedure at the time of POP repair and 42,858 did not. The future surgery rate was higher for sling-related complications in the POP + sling cohort compared with future incontinence surgery in the POP alone cohort (3.5% versus 3.0% respectively, p < 0.001). The difference persisted in multivariate modeling, where most women (60%) are at a higher risk of requiring sling revision surgery compared with needing a future primary incontinence procedure (40%).

CONCLUSIONS

Women who undergo vaginal prolapse repair without an incontinence procedure are at a low risk of future incontinence surgery. Women without urinary incontinence who are considering vaginal POP surgery should be informed of the risks and benefits of including a sling procedure.

Does Previous Pelvic Organ Prolapse Surgery Influence the Effectiveness of the Sub-Urethral Sling Procedure?

Pelvic organ prolapse (POP) often co-occurs with stress urinary incontinence. There is no consensus on whether prolapse repair and anti-incontinence surgery should be performed concomitantly or separately, in a two-step manner. The present study evaluated the effects of the tension-free vaginal tape (TVT) procedure in patients who had previously undergone pelvic floor repair (study group), compared to women who underwent TVT insertion only (control group). The study group comprised 84 patients who underwent the TVT procedure but had previously also undergone surgical POP repair. The control group consisted of 250 women in whom the TVT was inserted. The primary objective was to compare the objective cure rate and the secondary objective was to compare the subjective cure rate in both groups. Negative pad test was achieved in over 91% in both groups. Objective and subjective cure rates were compared, as well as complication rates. Significant improvement was observed in the postoperative 1-h pad test in all patients. In all patients, we observed significant improvement in the quality of life, with no differences between the groups. No differences were found in the occurrence of postoperative urinary retention, urgency and frequency of daytime micturition, or vaginal erosion between the groups. The current results demonstrate that the two-step approach to pelvic reconstruction and anti-incontinence surgery is as safe and effective as primary TVT implantation.

Laparoscopic sacrocolpopexy: A comprehensive literature review on current practice

Sacrocolpopexy is considered the preferred treatment for vaginal vault. However, numerous technical variants are being practiced. We aimed to summarize the recent literature in relation to technical aspects of laparoscopic sacrocolpopexy (LSC). We focused on surgical technique, mesh type, concomitant surgeries, and training aspects. We performed 2 independent literature searches in Medline, Scopus, the Cochrane library, and Embase electronic databases including the keywords: 'sacrocolpopexy', 'sacral colpopexy' and 'promontofixation'. Full text English-language studies of human patients, who underwent LSC, published from January 1, 2008 to February 26, 2019, were included. Levels of evidence using the modified Oxford grading system were assessed in order to establish a report of the available literature of highest level of evidence. Initially, 953 articles were identified. After excluding duplicates and abstracts screening, 35 articles were included. Vaginal fixation of the mesh can be performed with barbed or non-barbed (level 1), absorbable or non-absorbable sutures (level 2). Fixation of the mesh to the promontory can be performed with non-absorbable sutures or non-absorbable tackers (level 2). The current literature supports using type 1 mesh (level 2). Ventral mesh rectopexy can safely be performed with LSC while concurrent posterior repair has no additional benefit (level 2). There is no consensus regarding the preferred type of hysterectomy or the benefit of an additional anti urinary incontinence procedure. A structured learning program, as well as the number of procedures needed in order to be qualified for performing LSC is yet to be established. There are numerous variants for performing LSC. For many of its technical aspects there is little consensus.

Predictors for de novo stress urinary incontinence following pelvic reconstruction surgery with transvaginal single-incisional mesh

The study aims to identify predictors for de novo stress urinary incontinence (SUI) following Elevate mesh surgery. A total of 164 women who underwent Elevate mesh surgeries between November 2011 and February 2014 in a single center were included. Seventy-three women were excluded due to preoperative incontinence or concomitant mid-urethral sling surgery. Fourteen others were excluded due to incomplete medical records. Fisher’s exact test and χ² test were applied. The univariate logistic regression was used for odds ratios. Of the 77 continent women, 24 (31.2%) experienced de novo SUI after the operation. Significantly more women with de novo SUI were over the age of 64 years (75.0% vs. 47.2%, p = 0.023, OR 3.36, 95% CI 1.15–9.79). Preoperative occult urodynamic stress incontinence (29.2% vs. 3.8%, p = 0.003, OR 10.0, 95% CI 2.0–50.0) and previous SUI history (41.7% vs. 7.6%, p = 0.001, OR 9.1, 95% CI 2.38–33.3) were 2 other predictors of de novo SUI postoperatively. In conclusion, age over 64 years old, occult urodynamic stress incontinence, and previous history of SUI are 3 significant predictors for de novo SUI following the single-incision mesh surgeries.

Medium-term outcomes for primary native tissue reconstructive surgeries with and without transobturator vaginal meshes in stress continent women with stage 3 or higher pelvic organ prolapse

AIMS

To compare the surgical outcomes of conventional surgeries with or without concomitant transobturator vaginal mesh (TVM) for ≥Stage 3 pelvic organ prolapse (POP).

METHODS

We retrospectively investigated 166 women who received conventional surgery including vaginal total hysterectomy, modified McCall culdoplasty, and AP-repair (conventional group) and 98 women with concomitant TVM (mesh group). Follow-up at 3, 12, and 24 months comprised symptom interview, pelvic examination, and ultrasound assessments. The primary outcome was anatomical success defined as ≤Stage 1 POP. Secondary outcomes were subjective symptoms, ultrasound manifestations, and complications.

RESULTS

Both groups showed improvements in functional and anatomical outcomes after operations. Compared with the conventional group, the mesh group had higher rates of de novo stress urinary incontinence (SUI) at 3-month (3.6% vs 19.4%; P < .001), 12-month (3.7% vs 26.4%; P < .001), and 24-month (2.4% vs 21.4%; P = .001) follow-up, a higher POP-C point (-7.3 ± 0.7 cm vs -7.6 ± 0.6 cm; P < .001) at 3-month follow-up, a smaller straining bladder neck angle indicating a more cranioventral straining bladder neck position (117 ± 25° vs 102 ± 20°; P < .001) at 3-month follow-up, and a less bladder neck mobility at 3-month (19 ± 24° vs 8 ± 14°; P = .002) and 12-month (26 ± 18° vs 12 ± 15°; P = .003) follow-up.

CONCLUSIONS

Concomitant TVM is associated with a higher rate of de novo SUI, more cranioventral straining bladder neck position, and less bladder neck mobility.

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.

Stress urinary incontinence after vaginal prolapse repair: development and internal validation of a prediction model with and without the stress test

OBJECTIVE

To develop a prediction model for stress urinary incontinence (SUI) after vaginal prolapse repair (postoperative stress urinary incontinence [POSUI]) and assess the value of a preoperative stress test.

PATIENTS AND METHODS

Secondary analysis of two trials in which women were randomised for prolapse repair with or without a midurethral sling (MUS). The trials included women with (CUPIDO-1, n = 134) and without (CUPIDO-2, n = 225) coexisting SUI. POSUI was defined as bothersome SUI one year after surgery and/or treatment of SUI in the first postoperative year. Logistic regression analysis was used to define a reference model, which was extended with the preoperative stress test. The stress test was performed with and without reduction of the prolapse. Missing values were imputed 20 times, with bootstrap resampling for internal validation of discriminatory ability.

RESULTS

Three hundred fifty-six women could be included. POSUI occurred in 17% of the women (n = 61). The reference model included age (<55 years), point Ba of the pelvic organ prolapse quantification system (<-1), vaginal parity (≤3), subjective urinary incontinence, and MUS. The stress test had an odds ratio of 2.4 (95% confidence interval [CI], 1.2-4.6) in the extended model, which increased the optimism-corrected area under the receiver-operating curve from 0.74 to 0.76. The stress test was especially valuable in women with a 10% to 30% POSUI risk, where a stress test substantially impacted the POSUI risk. In more than 50% of the women, the stress test had no additional value in predicting POSUI.

CONCLUSION

A preoperative stress test is not valuable for women at low risk of SUI after vaginal prolapse repair.

External validation of de novo stress urinary incontinence prediction model after vaginal prolapse surgery

INTRODUCTION AND HYPOTHESIS

Stress urinary incontinence (SUI) may appear after the correction of pelvic organ prolapse (POP). The aim of this study was to externally validate a described predictive model for de novo SUI and to assess its clinical performance when used as a diagnostic test.

METHODS

This was a retrospective descriptive study on a cohort of consecutive women treated in our institution. The main outcome used to validate the model was the presence of objective or subjective SUI 1 year after surgery. A receiver operating characteristic curve was generated from our population to evaluate the predictive accuracy and to compare it with the original model. A cutoff point of ≥50% was used to evaluate its clinical performance as a diagnostic test.

RESULTS

Of the full cohort, 169 women were suitable for analysis. The rate of de novo SUI was 11.8%. The predictive accuracy of the model in our population was similar to the original [area under the curve (AUC) = 0.69; 95% confidence interval (CI) = 0.58-0.80). However, its performance measures when evaluated as a diagnostic test were low: positive likelihood ratio = 2.71 and negative likelihood ratio = 0.86. Only 15 women presented a positive test result.

CONCLUSIONS

External validation of the model found a global predictive accuracy similar to that of the original model. Despite the study being underpowered to give firm conclusions, the test did not show a good clinical performance when applied to our population with low de novo SUI prevalence. A larger sample size is needed to validate the model conclusively.

Should we combine vaginal prolapse surgery with continence surgery?

The risk of postoperative stress urinary incontinence (SUI) can be reduced by combining prolapse repair with continence surgery. However, more women face a serious adverse event (SAE) after vaginal prolapse surgery combined with a midurethral sling (MUS). It is difficult to predict a woman's individual postoperative SUI and SAE risk; therefore, weighing the benefits and risks of combination surgery is complex. We offer a concept that might help in considering combination surgery. According to this concept, women whose risk of needing subsequent surgery for postoperative SUI is on average 9% are likely to benefit from combination surgery.

Complications after minimally invasive sacrocolpopexy with and without concomitant incontinence surgery: A National Surgical Quality Improvement Program (NSQIP) database study

AIMS

To compare surgical complications for patients having minimally invasive sacrocolpopexy (MISCP) with concomitant incontinence procedure, to those having MISCP alone.

METHODS

Patients undergoing MISCP with and without a concomitant incontinence procedure between 2006 and 2015 were identified in the American College of Surgeons National Surgical Quality Improvement Program database using Current Procedural Terminology codes. The main outcome of interest was a composite of surgical site infection, bleeding requiring blood transfusion, return to the operating room within 30 days, and surgical stay >48 h. Log-binomial regression was used to identify independent risk factors for the outcome and to generate adjusted effect measures for variables of interest.

RESULTS

Seven thousand ninety-seven women met the inclusion criteria, of which 2433 (34%) underwent a concomitant incontinence procedure. Patients having incontinence procedures were slightly older (59 ± 11 vs 58 ± 12, P < 0.0001) and had longer total operating time (225 IQR 170-267 vs 184 IQR 120-232 min, P < 0.0001). Pre-operative steroid use, wound class III/IV (vs I/II), and longer operative time were independent predictors of the composite outcome. After adjusting for baseline patient characteristics and co-morbidities, no association was observed between concomitant incontinence procedure and the composite outcome (adjusted RR 0.87, 95%CI 0.65-1.18) but there was an increased likelihood of urinary tract infection (adjusted RR 2.47 95%CI 1.89-3.27).

CONCLUSIONS

Despite being associated with a longer operative time, performing an incontinence procedure at the time of MSCIP was not associated with an increased risk of clinically important surgical complications other than urinary tract infection.

Comparative mid-term anatomical and functional outcomes following laparoscopic sacrocolpopexy in women under and over 65: results from a prospective study

PURPOSE

To compare mid-term anatomical and functional outcomes following laparoscopic sacrocolpopexy (LS) between women under and over 65.

METHODS

Prospective and observational study involving patients with symptomatic pelvic organ prolapse (POP) undergoing LS. Study population was stratified according to patients' age at the time of surgery. POP symptoms and impact on quality of life were assessed by PFIQ-7 and PFDI-20 questionnaires at baseline and during follow-up.

RESULTS

Among our study population (n = 72), 26 women were over 65 and 46 under 65. Mean follow-up duration was 17.6 months, and complete follow-up was available in 90% of patients. No differences between study groups were observed regarding surgery duration, length of stay, and peri-operative complications. Recurrence rate was 1.4% at 18 months of follow-up. Questionnaires analysis revealed a significant improvement in PFIQ-7 and PFDI-20 scores. We found no differences in post-operative scores between control and elderly groups. Sixteen patients experienced de novo stress urinary incontinence (22.2%), with no difference between groups (p = 0.7). Among them, seven required surgical management.

CONCLUSIONS

LS was associated with high anatomical success rate and good functional outcomes, regardless of age at the time of surgery. LS should thus be considered in women over 65. Beyond age, the route of surgery should be driven by patient's choice and medical condition.