Selective management of the urethra at time of pelvic organ prolapse repair: an assessment of postoperative incontinence and patient satisfaction

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.

Management of Occult Urinary Incontinence with Prolapse Surgery

PURPOSE OF REVIEW

The purpose of this paper is to review (1) the epidemiology and pathophysiology of pelvic organ prolapse (POP) and occult stress urinary incontinence (SUI), (2) examine the data on combined operative management of POP and occult SUI, (3) discuss the approaches to clinical decision making, and (4) present future therapies.

RECENT FINDINGS

Prospective data on many approaches to concomitant treatment of prolapse and occult stress urinary incontinence, such as minimally invasive sacrocolpopexy and midurethral sling, or older approaches that have regained favor among patients and clinicians wishing to avoid synthetic mesh, such as native tissue prolapse repair and pubovaginal sling, are limited. Safe durable treatments with absorbable graft materials that promote a beneficial host response are intriguing but may be far from clinical implementation. Stem cell therapy for the treatment of stress urinary incontinence has demonstrated benefit in phase I/II trials but has not been studied in the setting of concomitant treatment of occult SUI with POP surgery and remains in the preclinical phase for the treatment of POP. A personalized approach to concomitant SUI surgery that incorporates individual risk assessment as well as informed patient preferences likely optimizes the risk/benefit ratio and patient satisfaction. Novel therapies, including graft materials and cellular therapies that stimulate a regenerative response, may improve or maintain continence outcomes while mitigating risk and alter the approach to both POP and SUI surgery.

Stress incontinence surgery at the time of prolapse surgery: mandatory or forbidden?

INTRODUCTION

Concomitant anti-incontinence surgery at the time of prolapse repair has been a long-debated topic. Still today, there remains no clear answer to this question, although in recent years the literature has become more robust with the addition of more randomized controlled trials. The lifetime risk for women of undergoing surgical correction of pelvic organ prolapse is significant, and concomitant anti-incontinence surgery is an important question during surgical planning.

MATERIALS AND METHODS

This review delves further into the current literature to discuss a possible algorithm for managing the risk of stress incontinence after pelvic organ prolapse repair and examines the support in the literature for the following treatment methods: (1) anti-incontinence surgery for all women undergoing pelvic organ prolapse repair, (2) anti-incontinence surgery for no women undergoing pelvic organ prolapse repair, and (3) anti-incontinence surgery in select women undergoing pelvic organ prolapse repair.

CONCLUSIONS

While there are data both for and against each of these approaches, after a review of the literature, we recommend anti-incontinence surgery for select women undergoing pelvic organ prolapse repair, including women with a history of symptomatic and occult stress incontinence diagnosed preoperatively.

Patient satisfaction following midurethral sling surgeries

PURPOSE OF REVIEW

Patient-reported outcomes and satisfaction are recognized as being equally important as traditional objective measures of success following midurethral sling (MUS) procedures. The objective of this article is to review the success after MUSs in the context of patient satisfaction.

RECENT FINDINGS

Patient satisfaction for both transobturator and retropubic MUSs at 2 years is high with rates up to 88%. Factors that positively influence satisfaction include improvement in quality of life and reduction in severity of symptoms. Satisfaction has been found to be negatively impacted by persistent stress incontinence, preoperative urinary urgency, mixed urinary incontinence, detrusor overactivity, and selected comorbidities such as diabetes. Factors, such as postoperative incomplete bladder emptying, irritative voiding, and complications after MUS surgery, can also influence satisfaction adversely.

SUMMARY

Combining patient-reported outcome measures with customary objective measures offer a more comprehensive assessment of success. Even though the data are limited, the short-term and intermediate-term rates of satisfaction are promising for both transobturator and retropubic MUSs. Future studies should focus on further elucidating long-term predictors of satisfaction after MUS placement.