Managing urethra at the time of prolapse surgery

Prof Dr Mohamed Shafik

Alexandria University

Dilemma
SUI may occur following prolapse repair
   

How often? Following which type of prolapse repair? Can we predict who will get it? What should we do about it?

No consensus on the optimal management

Prolapse & SUI

If preoperative SUI ( symptomatic and/or urodynamic) and prolapse
Most would repair cystocele and sling

Despite lack of level 1 evidence to support this approach !!! But what about.
No preoperative SUI & prolapse - 10-30 % of patients at risk of de novo SUI

Evidence in literature
3rd International Consultation on Incontinence: Level I Evidence:
None supporting any type of Rx in this scenario

Level II Evidence:
Incontinence & voiding dysfunction may follow POP surgery and these outcomes are variable and unpredictable

Slings & Grade IV Cystocele

We all agree that a sling should be done if the patient has:
- Subjective and objective stress incontinence - Urodynamic stress incontinence - Occult incontinence ( demonstrated after reduction of the prolapse)

The question is to sling or not in a dry patient without clinical, urodynamic or occult incontinence.

All patients with high grade cystocele should also have a sling

why should we do slings?

Prevents the 5-30% of secondary SUI No reliable preoperative testing can predict the functional status of the urethra Minimal morbidity of the distal polypropylene sling
Level I Evidence that a urethral supporting procedure - Low urinary retention rate ( < 4-7%) should be done as part of the repair of Reduced incidence ofprolapse vaginal vault 2ry cystocele

(19% vs. 34)

Brubaker, 2006, NEJM

Stress incontinence (SUI) & Grade IV cystocele

Repair of G IV cystocele lead to 13-35% denovo SUI
Richardson DA et.al (1983); Borsted E, et. Al (1989); Bump R C, et.al. (1988)

We agree that a sling should be done if the patient has preoperative clinical, urodynamic or occult stress urinary incontinence What to do if no preop. SUI

Stress incontinence (SUI) & Grade IV cystocele

Can be predict which patients should have a sling? Do concomitant sling procedures increase risk of complications? Should we perform a sling in every patient? Is there other rationale to do a concomitant sling in the dry patient?

Stress incontinence (SUI) & Grade IV cystocele

Can be predict which patients should have a sling? Do concomitant sling procedures increase risk of complications? Should we perform a sling in every patient? Is there other rationale to do a concomitant sling in the dry patient?

Can be predict who should have a sling?

Methods of prolapse reduction are not standardized Rate of diagnosis of preop. SUI varies from 5-65%
Gilleran JP, et.al.(2005);Chiakin DC, et.al.(2000);Bump RC, et.al. (1988)

Preoperative reduction methods

Detection rate of SUI with prolapse reduction varied significantly SUI with prolapse reduction at 300 mls
- Pessary - Manual - Forceps - Speculum 6% (5 of 88) 16%(19 of 122) 21% (21of 98) 30%(35 of 118)

RCT: Prolapse repair +/- Burch +/ Preoperative negative prolapse reduced:

- With Burch: - Without Burch:

stress

test

with

17% had postop. SUI 17% 35% had postop. SUI 35%

Regardless of preoperative result of reduction stress test: post op scores were significant worse if Burch procedure was not done ( 6% vs. 24%)

Stress incontinence (SUI) & Grade IV cystocele

Can be predict which patients should have a sling? Do concomitant sling procedures increase risk of complications? Should we perform a sling in every patient? Is there other rationale to do a concomitant sling in the dry patient?

Risk of obstruction and stress incontinence

The risk of intervention for obstruction after sling procedures is 8.5% The risk of intervention for stress incontinence in patients without clinical, urodynamic or occult stress incontinence without sling was 8.3%

Do concomitant sling procedures increase risk of complications ?

Yes we do agree that slings can lead to significant complications

Studies only with TVT midurethral slings
Liang CC, et.al. (2004); Mechia M, et.al.(2004), Groutz A, et.al.(2004)

- De-novo urge incontinence: 10-16% - Urinary retention: 2-10% (not with TOT) It would we be great to have a sling procedure that is effective, with minimal complications of retention, erosion or overactive bladder

Stress incontinence (SUI) & Grade IV cystocele

Can be predict which patients should have a sling? Do concomitant sling procedures increase risk of complications? Should we perform a sling in every patient? Is there other rationale to do a concomitant sling in the dry patient?

Is there other rationale to do a concomitant sling in the dry patient

Suburethral sling placement associated with reduction in rate of post operative cystocele recurrence (42% vs. 19%)
Goldberg RP, et. al. (2001)

Transvaginal bladder neck slings repair were associated with reduction in risk of recurrent cystocele
Gandhi S, et.al.(2005)

Stress incontinence (SUI) & Grade IV cystocele

Can be predict which patients should have a No sling? Do concomitant sling procedures increase risk of complications?
Depends

Should we perform a sling in every patient?

Yes, I think so

Is there other rationale to do a concomitant sling in the dry patient?

Yes

To sling with prolapse repair

Reduction of prolapse cant predict which patient will have postop incontinence 5-20% of the patients with grade IV cystocele repair will develop 2ry incontinence regardless of your preoperative assessment Sling help to prevent recurrent cystocele Why submit the patient to a second surgery?

To sling with prolapse repair

Sling placement is a minimally invasive procedure with no more than 10 min over Sling has a high success rate to cure stress incontinence with rare/no postop. retention If you have rare complications, you could do a prophylactic sling to prevent the 5-20% postop. incontinence

It is all about your personal experience