Determining the risk factors and characteristics of de novo stress urinary incontinence in women undergoing pelvic organ prolapse surgery: A systematic review

Risk prediction models for stress urinary incontinence after pelvic organ prolapse (POP) surgery: a systematic review and meta-analysis

OBJECTIVE

To systematically evaluate existing developed and validated predictive models for stress urinary incontinence after pelvic floor reconstruction.

METHODS

Relevant literature in PubMed, Embase, Web of Science, Cochrane Library, OVID, China National Knowledge Infrastructure(CNKI), Wan Fang Database, VIP database and Chinese Biomedical Literature Service System (SinoMed) were search from inception to 1 March 2024. Literature screening and data extraction were performed independently by two researchers. The chosen study's statistics included study design, data sources, outcome definitions, sample size, predictors, model development, and performance. The Predictive Modelling Risk of Bias Assessment Tool (PROBAST) checklist was used to assess risk of bias and applicability.

RESULTS

A total of 7 studies containing 9 predictive models were included. All studies had a high risk of bias, primarily due to retrospective design, small sample sizes, single-center trials, lack of blinding, and missing data reporting. The meta-analysis revealed moderate heterogeneity (I² = 68.8%). The pooled AUC value of the validated models was 0.72 (95% CI: 0.65, 0.79), indicating moderate predictive ability.

CONCLUSION

The prediction models evaluated demonstrated moderate discrimination, but significant bias and methodological flaws. The meta-analysis revealed moderate heterogeneity (I² = 68.8%) among the included studies, reflecting differences in study populations, predictors, and methods, which limits the generalizability of the findings. Despite these challenges, these models highlight the potential to identify high-risk patients for targeted interventions to improve surgical outcomes and reduce postoperative complications. The findings suggest that by integrating these models into clinical decision-making, clinicians can better tailor surgical plans and preoperative counseling, thereby improving patient satisfaction and reducing the incidence of postoperative stress urinary incontinence. Future research should follow TRIPOD and PROBAST principles, focus on addressing sources of heterogeneity, improve model development through robust designs, large sample sizes, comprehensive predictors, and novel modelling approaches, and validate tools that can be effectively integrated into clinical decision-making to manage stress urinary incontinence after pelvic floor reconstruction.

Occult Urinary Incontinence, Diabetes, Obesity, Prolapse Severity, and Type of Surgical Repair as Risk Factors for De Novo Stress Urinary Incontinence in Women Undergoing Surgical Repair of Pelvic Organ Prolapse: A Systematic Review and Meta-Analysis

PURPOSE

The International Continence Society and the International Urogynecological Association have not yet standardized the definition of de novo stress urinary incontinence. Recent studies define the development of stress urinary incontinence as occurring after surgical repair of pelvic organ prolapse in previously continent women. The mechanisms that cause de novo stress urinary incontinence are not yet clear. Knowledge of the predictive factors for this outcome after surgical correction of pelvic organ prolapse would be useful for assessing whether a concomitant anti-incontinence procedure should be performed.

MATERIALS AND METHODS

The aim of this systematic review and meta-analysis was to identify some of the risk factors for de novo stress urinary incontinence: high body mass index, pelvic organ prolapse stage before surgery, presence of occult urinary incontinence, type of surgery, and the presence of diabetes mellitus. The present study was registered in the PROSPERO database under number CRD42021293764, and the systematic review was carried out according to the MOOSE recommendations and with the PRISMA 2020 guidelines.

RESULTS

A total of 2429 articles were identified. Nine cohort studies were included in the systematic review and seven in the meta-analysis. The risk of bias was assessed via the Newcastle-Ottawa scale and the certainty of evidence was assessed using the GRADE approach for each outcome. In the meta-analysis, associations were identified between de novo stress urinary incontinence and occult urinary incontinence (n: 422; OR: 2.01; 95% CI: 1.26-3.22; p = 0.004), diabetes (n: 1213; OR: 2.35; 95% CI: 1.30-4.26; p = 0.005), and advanced pelvic organ prolapse (n: 1003; OR: 1.94; 95% CI: 1.14-3.30; p = 0.01). Consulting a meta-analysis for the type of surgery was deemed impossible. A previous study comparing abdominal sacrocolpopexy with minimally invasive sacrocolpopexy revealed that women who underwent abdominal sacrocolpopexy were more likely to develop de novo stress urinary incontinence (n: 77; OR: 4.73; 95% CI: 1.56-14.34; p = 0.005). Another study found that pelvic organ prolapse repair using a transvaginal mesh was associated with higher levels of de novo stress urinary incontinence compared to robot-assisted sacrocolpopexy (n: 76; OR: 6.74; 95% CI: 1.35-33.75; p = 0.02). A meta-analysis of overweight or obesity was not possible due to the different assessment methods used in the studies.

CONCLUSIONS

This meta-analysis revealed that occult incontinence, diabetes, and advanced pelvic organ prolapse before repair were associated with de novo stress urinary incontinence and these groups may therefore benefit from for anti-incontinence procedures concomitant with pelvic organ prolapse repair.

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.

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

Background

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

Purpose

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

Methods

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

Results

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

Conclusion

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

Transvaginal mesh surgery for pelvic organ prolapse without blind maneuver

AIM

To present the techniques of transvaginal mesh surgery for pelvic organ prolapse without the blind maneuver and elucidate its safety and efficacy.

METHODS

This retrospective study included 45 women with a mean age of 77.9 years old. We investigated surgical outcomes including complications, anatomical recurrence rates, and changes in both subjective symptoms and quality of life.

RESULTS

The surgery required 111 ± 18 min and blood loss was 40 ± 24 g. Minor injuries of the bladder and rectum occurred in two and one patient, respectively. The urethral catheter was removed on postoperative day 1.1 and patients were discharged on postoperative day 4.4. No one experienced voiding dysfunction requiring catheterization. Wound infections occurred in two patients but they subsided with only antibiotics administered. Five patients had anatomical recurrence during a median follow-up of 17 months. Of these, two underwent reoperation and the remaining three were solely followed-up because there were no or few associated problems. Chronic pain, mesh erosion, and exposure were absent in all cases. Subjective symptoms and quality of life significantly improved after surgery at 12 months postoperatively.

CONCLUSION

It is considered that transvaginal mesh surgery without the blind maneuver is a safe and effective way to treat women with pelvic organ prolapse.

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.