Objective
The primary objective was to estimate the incidence of de novo stress urinary incontinence after total vaginal mesh procedures in women with negative preoperative urodynamics with prolapse reduction. Secondary objective was to identify associated risk factors.
Study Design
A retrospective cohort study with a nested case-control study of women who underwent total vaginal mesh procedures without midurethral sling after a negative preoperative urodynamics.
Result
Sixty patients were included in the final analysis. Fifteen (25%) patients were diagnosed with de novo stress urinary incontinence. Although no significant associated risk factors were identified, there was a trend for higher gravidity and better anterior wall support among women who had stress urinary incontinence develop.
Conclusion
The incidence of de novo stress urinary incontinence after total vaginal mesh procedures in this cohort was 25%. Patients should be appropriately counseled regarding the same.
Pelvic floor dysfunction is a major health issue for older women, as shown by the 11.1% lifetime risk of undergoing a single operation for pelvic organ prolapse (POP) or urinary incontinence and nearly 30% reoperation rate. Symptomatic stress urinary incontinence (SUI) is often not a complaint of women with advanced POP but may become apparent for the first time after otherwise successful prolapse surgery. The Colpopexy and Urinary Reduction Efforts (CARE) trial reported that the incidence of SUI after an abdominal sacrocolpopexy (ASC) without a concomitant Burch urethropexy in women without preoperative symptoms of SUI is as high as 44.1%. This is most likely because the stress continence mechanism of women with advanced POP: mechanical obstruction of the urethra with increases in abdominal pressure, is eliminated or diminished once the prolapse is successfully corrected. Although preoperative stress testing with prolapse reduction is therefore often performed before POP surgery to predict whether a patient would benefit from a concomitant continence procedure, the incidence of de novo SUI after a negative prolapse reduction urodynamic study (UDS) and an ASC without a continence procedure can be as high as 39%.
Randomized controlled trials with polypropylene-augmented anterior vaginal repairs indicate improved anatomic outcomes with use of mesh and promote the continued use of total vaginal mesh (TVM) procedures for POP. The TVM procedure, like ASC uses mesh to suspend the anterior vagina, posterior vagina, and the vaginal apex and there is a concern that a similar outcome concerning occult incontinence may occur.
The primary objective of this study was to estimate the incidence of de novo SUI after TVM procedures without concomitant continence procedures in women with negative preoperative stress testing with prolapse reduction. A secondary objective was to identify potential risk factors associated with the development of de novo SUI in these patients.
Materials and Methods
The research plan was reviewed by the Institutional Review Board and received an exempt status. A retrospective cohort study with a nested case control study was performed by reviewing charts of women who underwent TVM procedure without a concomitant continence procedure after a negative preoperative prolapse reduction stress test during a urodynamic session at a tertiary referral center between 2005 and 2008. Patients who did not follow-up for at least 6 months postoperatively were excluded from the final analysis. All procedures were supervised by 2 fellowship-trained urogynecologists. The technique used was similar to the original description of the procedure.
During the postoperative visits, all patients were queried about the symptom of SUI, which was documented as present or absent. All patients who complained of SUI underwent a standing stress test (SST) during the same visit and were offered confirmatory multichannel provocative urodynamic testing. Postoperative de novo SUI was defined as complaints of leakage of urine on coughing, laughing, or sneezing that was confirmed with positive SST or UDS demonstrating urodynamic stress incontinence within a 6-month postoperative period. Patients with de novo SUI were offered physical therapy as initial treatment. Those who desired were offered surgical management.
All the urodynamic studies, both pre- and postoperatively included uroflowmetry and cystometry according to the International Continence Society (ICS) recommendations for practices and terminology. Preoperatively, prolapse was reduced either with the posterior blade of a Grave’s speculum or a pessary. All participants had urinary tract infections ruled out or treated appropriately before UDS.
To identify the incidence of postoperative de novo SUI, a retrospective cohort study was performed. To identify associated risk factors, a case control study that was nested into the cohort study was performed. Potential risk factors included in the analysis were based on previously published studies. Baseline complaints of incontinence and conditions associated with increased intraabdominal pressure such as constipation and chronic lung disease were also looked at and are shown in Table 1 .
| Variable | De novo SUI (n = 15) | No de novo SUI (n = 45) | P value |
|---|---|---|---|
| Age, y | 61.8 (9.4) | 65.5 (8.2) | .145 |
| Gravidity | 4 (2, 5) | 3 (0, 6) | .089 |
| Parity | 4 (2, 5) | 3 (0, 6) | .121 |
| BMI | 31.9 (9.8) | 28.7 (4.8) | .103 |
| Smoker | 0 (0%) | 4 (8.9%) | .564 |
| Hx lung disease | 3 (20%) | 6 (13.3%) | .678 |
| Prior hysterectomy | 10 (66.7%) | 31 (68.9%) | > .99 |
| Previous UI surgery | 1 (6.7%) | 7 (15.5%) | .666 |
| Baseline C/o SUI | 2 (13.3%) | 5 (11.1%) | > .99 |
| Baseline C/o MUI | 5 (33.3%) | 11 (24.4%) | .516 |
| Baseline C/o SUI or MUI | 7 (46.7%) | 16 (35.5%) | .544 |
| Baseline constipation | 8 (53.3%) | 16 (35.5%) | .242 |
| Baseline Aa | 0.9 (1.8) | 1.1 (1.7) | .660 |
| Baseline Ba | 1.8 (2.4) | 2 (2.4) | .784 |
| Baseline C | −1.1(3.2) | −1.7 (3.8) | .558 |
| MUCP at MCC | 76.2 (51.3) | 70.2 (37.2) | .629 |
| MUCP at rest | 92.6 (62) | 82.5 (37.4) | .450 |
| Max urethral angle (in degrees) | 77.1 (19.1) | 65.9 (28.9) | .165 |
| Baseline UHM (>30 degrees from horizontal) | 14 (93.3%) | 38 (84.4%) | .666 |
| Average stage (Preoperative) | 2.5 (0.5) | 2.6 (0.5) | .505 |
| Stage 3/4 (Preoperative) | 8 (53.3%) | 27 (60%) | .765 |
| Postoperative Aa | −2.5 (0.6) | −2.2 (0.9) | .234 |
| Postoperative Ba | −2.7 (0.4) | −2.3 (0.8) | .069 |
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