Int Urogynecol J (2013) 24:1843–1852 DOI 10.1007/s00192-013-2175-y

POP SURGERY REVIEW

Pelvic organ prolapse surgery and bladder function Kaven Baessler & Christopher Maher

# ICUD-EAU 2013

Abstract Introduction and hypothesis The aim was to determine the impact of pelvic organ prolapse surgery on bladder function. Methods Every 4 years, and as part of the Fifth International Collaboration on Incontinence we reviewed the Englishlangauage scientific literature after searching PubMed, Medline, Cochrane library and Cochrane database of systematic reviews, published up to January 2012. Publications were classified as level 1 evidence (randomised controlled trials [RCT] or systematic reviews), level 2 (poor quality RCT, prospective cohort studies), level 3 (case series or retrospective studies and level 4 case reports. The highest level of evidence was utilised by the committee to make evidence-based recommendations based upon the Oxford grading system. Grade A recommendation usually depends on consistent level 1 evidence. Grade B recommendation usually depends on consistent level 2 and/or 3 studies, or “majority evidence” from RCTs. Grade C recommendation

On behalf of Committee 15 “Surgical Management of Pelvic Organ Prolapse” from the 5th International Consultation on Incontinence held in Paris, February 2012 This work has been previously published as: Maher C, Baessler K, Barber M, Cheon C, Deitz V, DeTayrac R, Gutman R, Karram M, Sentilhes L (2013) Surgical management of pelvic organ prolapse. In: Abrams, Cardozo, Khoury, Wein, (eds) 5th International Consultation on Incontinence. Health Publication Ltd, Paris, Chapter 15 and modified for publication in International Urogynaecology Journal. K. Baessler Charité University Hospital Berlin, Berlin, Germany C. Maher (*) University of Queensland, Royal Brisbane and Wesley Urogynaecology, 30 Chaseley Street, Auchenflower, 4067 Brisbane, Queensland, Australia e-mail: [email protected]

usually depends on level 4 studies or “majority evidence” from level 2/3 studies or Delphi processed expert opinion. Grade D “no recommendation possible” would be used where the evidence is inadequate or conflicting and when expert opinion is delivered without a formal analytical process, such as by Delphi. Results Continent women undergoing anterior compartment prolapse surgery have a lower rate of de novo stress urinary incontinence (SUI) after anterior repair than armed mesh procedures (grade A). Data are conflicting on whether colposuspension should be performed prophylactically in continent women undergoing sacral colpopexy (grade C). No clear conclusion can be made regarding the management of continent women undergoing prolapse surgery without occult SUI. In continent women undergoing POP surgery with occult SUI the addition of continence surgery reduces the rate of postoperative SUI (grade A). In women with prolapse and SUI symptoms prolapse procedures alone (transobturator mesh and anterior repair) are associated with low success rates for SUI. Concomitant continence procedures reduce the risk of postoperative SUI (grade B). Preoperative bladder overactivity may resolve in 40 % undergoing POP surgery and de novo bladder overactivity occurs in 12 %. No valid conclusions regarding voiding dysfunction following POP surgery can be drawn from the available data. Conclusion SUI and occult stress urinary incontinence should be treated at the time of prolapse surgery. Keywords Occult stress urinary incontinence . Continence surgery . Pelvic organ prolapse surgery In women with stage II pelvic organ prolapse (POP) about 55 % have concurrent stress urinary incontinence (SUI). This

1844

prevalence decreases with increasing POP stages to 33 % in women with stage IV POP [1]. However, if the prolapse is reduced digitally or with the help of a pessary, sponge holder or speculum, SUI might be demonstrated in a further 10 to 80 % [2–5]. This type of SUI is termed occult, masked or latent SUI, and is present when stress urinary incontinence is only demonstrable with the prolapse reduced in otherwise continent women. The importance of this finding remains ambiguous [6]: the test itself is not optimal [6] as it does not necessarily mimic prolapse surgery and may obstruct or put undue tension on the urethra. Although different techniques to reduce the prolapse have been described, a gold standard has not been established [5, 6]. Neither the speculum nor the pessary test to reduce the prolapse had acceptable positive predictive values to identify women in need of a concomitant continence procedure. The negative predictive values, however, were 92.5 % (95 % CI 90.3–1.00) and 91.1 % (95 % CI 88.5–99.7) respectively. Therefore, women with negative tests for occult SUI preoperatively are at a low risk of developing SUI postoperatively [5, 7]. Women with occult SUI are at risk of developing SUI after POP repair. Reducing the prolapse may also restore normal voiding function during urodynamics [8]. These findings demonstrate the importance of testing bladder function in continent women with and without the prolapse reduced. The Cochrane review on the surgical management of POP found that new or de novo SUI symptoms were reported by 187 out of 1,280 women (15 %) after prolapse surgery [9]. The term de novo stress urinary incontinence is used to describe stress incontinence that develops following surgical correction of the prolapse, amongst women who were continent prior to surgery. De novo SUI may develop because POP surgery has unkinked the previously obstructed urethra [10, 11]. De novo stress urinary incontinence is clearly disappointing to women and this outcome measure is considered in this review. A third of women with stage II or more POP experience difficulties emptying the bladder [1]. Voiding difficulties may disappear postoperatively because the obstruction caused by the prolapse has been corrected [8]. In contrast, they may develop as described in the Cochrane review in new voiding in 12 % [12], possibly because of kinking of the urethra due to the surgical technique. This review assesses the effect of POP surgery on bladder function, including stress urinary incontinence, overactive bladder and voiding dysfunction. In order to optimally evaluate pre- and postoperative bladder symptoms, only studies with standardised or validated pre- and postoperative outcome measures, more than 20 operated women and a followup time of at least 12 months are included and summarised in Table 1. The follow-up time of 12 months does not apply to studies assessing voiding dysfunction. We will evaluate the evidence surrounding common clinical scenarios.

Int Urogynecol J (2013) 24:1843–1852

Continent women undergoing POP surgery: what is the risk of de novo SUI and is continence surgery required? For symptomatically and clinically dry women an anterior native tissue repair yields lower rates of de novo SUI than transobturator anterior mesh procedures. The overall cumulative de novo SUI rate after anterior repairs is 9 % (44 out of 481; Table 1). In five RCTs [13, 16, 22, 31, 32] de novo SUI was found in 31 out of 377 women (8 %) and in 13 out of 104 women (12 %) in two prospective studies [5, 33]. After armed-mesh repairs the overall cumulative rate is significantly higher at 14 % (134 out of 951; p=0.017, Chi-squared) with a rate of 17 % (101 out of 584) in six RCTs [13, 14, 16, 22, 31, 32] and 9 % (33 out of 367) in eight prospective trials [26, 30, 27, 28, 33–36]. Five RCTs directly compared anterior colporrhaphy and transobturator mesh procedures (mesh kits or self-fashioned) and reported 12-month results [13, 16, 21, 22, 31]. Anterior native tissue repair significantly reduced the risk of de novo SUI (RR 0.64 95%CI 0.42, 0.97; Fig. 1). Although all these trials employed quality of life and symptom questionnaires, different instruments were used and it was not possible to perform a meta-analysis. However, in a longer term follow-up of Hiltunen’s trial [31], more women developed new SUI after anterior repair resulting in similar SUI rates after 3 years of 17 % after both anterior repair (15 out of 86) and the transobturator mesh procedure (15 out of 84) [24]. Similar rates of de novo SUI occurred if the anterior compartment prolapse was repaired using a polypropylene transobturator mesh (2 %; 2 out of 96) or a porcine dermis graft 1 % (1 out of 94) [17]. In a single RCT, de novo SUI was significantly more common after sacrospinous fixation and vaginal repairs compared with abdominal sacral colpopexy (8 out of 24, 33 % vs 2 out of 22, 9 %) [37]; however, these data need to be reviewed cautiously as in the sacral colpopexy group continent women pre-operatively received paravaginal repairs that may be effective in limiting de novo SUI postoperatively. Whether concomitant continence surgery is required in preoperatively continent women was assessed in the large multicentre randomised controlled CARE trial (colpopexy and urinary reduction efforts), Preoperatively continent women were randomly allocated to undergo sacral colpopexy with (n=157) or without Burch colposuspension (n=165). Brubaker et al. demonstrated at 2 years that Burch colposuspension, performed concomitantly with an abdominal sacrocolpopexy, significantly reduced the risk of de novo SUI. Subjective SUI was reported by 38 out of 147 (26 %) after additional Burch colposuspension and by 63 out of 155 women (41 %) after sacral colpopexy alone. However, objective testing yielded similar findings in the two groups: 11 out of 116 (9 %) and 9 out of 134 women (7 %) respectively demonstrated SUI. The study was terminated

Four-armed anterior mesh

LoE 2

LoE 2

RCT

Anterior repair +plication urethrovesical junction Vaginal POP repair Vaginal POP repair + TVT

LoE 2

LoE 2

RCT

Wei [45]

Vaginal POP repair Vaginal POP + TVT

RCT

Abstract, LoE 2

Schierlitz et al. [44] RCT

Meschia et al. [23]

LoE 2

Conventional vaginal repair (anterior repair=58) Prolift (Prolift in anterior compartment=56) Anterior repair + TVT

Conventional vaginal repairs, USLP or sacrospinous fix Prolift

Anterior repair

LoE 2

RCT

LoE 1

RCT

Pelvicol graft inlay fixed with Vicryl Any vaginal POP surgery + TVT Any vaginal POP surgery TVT 3 months later Burch colposuspension

LoE 2

RCT

LoE 2

Anterior tension-free twoarmed PP mesh repair Anterior two-armed porcine dermis graft repair (self-cut) Anterior repair

Anterior colporrhaphy

Anterior Prolift

RCT

LoE 1

1/22 positive stress test

3/25 positive stress test

12

12

Median 21 Median 21 12

24

26

12

12

12

12

12

12

12

12

7/29 (24)

Symptomatically continent, 34 % occult SUI

Occult SUI

Occult SUI

Continent and incontinent

SUI

All SUI

10/28 (36)

45/165 (27)

74/172 (43)

USI 6 months 3/37 (8)

8/88 (9); only anterior repair 6/53 8/81 (10); only anterior Prolift 6/50 1/25 (4) subjective 2/25 (8) objective 9/25 (36) subjective 11/ 25 (44) objective USI 6 months 12/43 (28)

4/13 (31)

3/19 (16)

Na

1/94 (1)

2/96 (2)

24

0/43 Continent

Mean 12

3/42 (7)

7/22 (32)

2/25 (8)

24

Mean 12 Continent

12

12

2/7 (29)

17/33 (52)

47/53 (89) on treatment analysis—72/94 (77) ITT 30/35 (86)

83/87 (95)

4/10 (40)

1/25 (4)

3/25 (12)

1/98 (1)

8/84 (9)

9/98 (9)

7/97 (7)

De novo OAB (%)

22/84 (26)

Persistent SUI (%)

Posterior Prolift Anterior colporrhaphy

RCT

11/176 (6) 22/179 (12)

Cured SUI (%)

7/34 (21)

RCT

Withagen et al. [22] RCT

Sokol et al. [21]

Colombo et al. [20]

Borstad et al. [19]

Hviid et al. [18]

Natale et al. [17]

Sivaslioglu et al. [16]

Ek et al.a [15]

Continent 176/189 Continent 179/200

De novo SUI (%)

Anterior Prolift + sacrospinous fixation Total Prolift

LoE 2

12+

12

12

Follow- SUI status preoperatively up (months) (%)

?Continent, no concomitant 26/97 (27) SUI procedures 6/34 (18)

Anterior Prolift

Anterior Prolift

LoE 1

RCT

Anterior colporrhaphy

RCT

Altman et al. [13]

Halaska et al. [14]

Study design/LoE Operations

Reference

Table 1 Studies reporting de novo stress urinary incontinence (SUI) or cured SUI after prolapse surgery

Int Urogynecol J (2013) 24:1843–1852 1845

Prospective follow-up Prospective follow-up

Moore et al. [52]

Hung et al. [32]

Prospective follow-up

Prospective follow-up

Sergent et al. [42]

Sentilhes et al. [33]

Prospective follow-up

Sergent et al.[34]

Prospective follow-up Takahashi et al. [30] Prospective follow-up

Groutz et al. [29]

Ellstroem et al.

Feiner et al. [28]

Prospective follow-up

Prospective follow-up Prospective follow-up Prospective follow-up

Ek et al. [26]

Fayyad et al. [27]

Prospective follow-up Prospective

Kuribayashi et al. [36] Alcalay et al. [25]

Transobturator/ infracoccygeal mesh (SurgiproUgytex)—no SUS for SUI Anterior repair+four-corner anchored PP mesh+TVT for SUI

Prolift + sacrospinous ligament fixation + TVT-O for SUI Anterior repair± posterior repair, hysterectomy, apical procedures Vaginal anterior+posterior repairs+TOT TVM (Gynemesh cut like Prolift, transobturator)± TOT for SUI in 208 (67) Transobturator/ infracoccygeal mesh (Ugytex)—no SUS for SUI Transobturator/ infracoccygeal mesh (Ugytex)—no SUS for SUI Perigee±TOT

Anterior Prolift

Trocarless mesh attached near SSL and laterally Anterior Prolift

Nm 17/44 (39)

8/38 SUI occult or overt

12

12+

100 % SUI

SUI 26/52 (50)

Occult USI

24

12+

12+

12

12+

Subjectively continent, occult SUI in 10 %

12

20/21 with TVT-O (95)

4/15 (27)

Cured SUI (%)

5/30 (17)

0/27

Nm

Na

?

8//8

12/17 (71)

Nm

53/74 (72) cured 11/74 (15) improved

12/26 (46)

2/92 (2) subjective 13/92 (14) objective 7/102 TVM alone (7) 207/208 TVM+TOT (99)

8/74 (11) subjective 4/8 (50) objective

2/73 (3)

SUI 21/94 (22)

12

9/52 (17)

2/20 (10)

5/46 (11)

5/21 (24)

Did not need continence procedure

24+

12

12

3

15/64 (23)

Median 34

Vaginal porcine dermis transobturator hammock with sacrospinous fixation Self-cut Prolift (TVM)

11/87 (13)

Median 30

Prospective comparative follow-up LoE 2

Ramanah et al. [65]

15/84 (17)

36

15/86 (17)

Anterior repair + four-armed self-cut mesh Laparoscopic sacral colpopexy

Continent

De novo SUI (%)

36

RCT

Nieminen et al. 3 years FU [24]

Follow- SUI status preoperatively up (months) (%)

Anterior repair

Study design/LoE Operations

Reference

Table 1 (continued)

5/17 (29)

Nm

0/303

39/57 (68) persistent 32/57 worsened 9/15 (60)

Persistent SUI (%)

2/29 (7)

4/114 (4)

1 (TVM alone), 1 TVM+TOT

4 (7)

7/84 (8)

1/22 (5)

3 (5)

1 (1)

De novo OAB (%)

1846 Int Urogynecol J (2013) 24:1843–1852

prematurely because of the high postoperative SUI rate in women who did not receive concomitant Burch colposuspension and as a result of early termination was underpowered. Unfortunately, irregularities in the study design create uncertainty for the reader regarding the study findings. First, different and complicated definitions were used to categorise stress continence prior to and after the interventions, which made it more difficult to classify as stress continent post-intervention than prior to the intervention. Thirty-nine percent of women classified as stress continent prior to surgery would have been classified as stress incontinent using the post-intervention definition! Second, while surgery was standardised for colposuspension neither the paravaginal repair nor sacral colpopexy was standardised with significant variations in the use of suture type and graft materials: in 17 % biological grafts, in 43 % mersilene, in 39 % polypropylene and in 6 % Gore-tex was utilised [38, 39], which may have had an impact on the continence results. After a follow-up of 8 years, Costantini et al., in another, smaller RCT reported contrary results, with 9 out of 31 women (29 %) developing SUI after additional Burch colposuspension compared with 5 out of 31 (16 %) after sacrocolpopexy alone [40, 41]. Figure 2 summarises these two RCTs in a meta-analysis [39, 40]. Because of contrary outcomes resulting in significant heterogeneity, a random-effects model was used. According to this model, women do not benefit from Burch colposuspension in addition to abdominal sacral colpopexy. This is true for subjective de novo SUI (RR 0.96 95 % CI 0.35, 2.62) and objective rates of de novo SUI (RR 1.56 95 % CI 0.82, 2.95).

Urodynamic evaluation of Altman et al. [13]

Stress urinary incontinent women undergoing POP surgery: what kind of prolapse procedure and which continence surgery is required concomitantly in order to reduce postoperative SUI rates?

a

Na 5/46 (11)

5/30 (17)

Continent n=46

Occult n=30

1847 RCT randomised controlled trial, LoE level of evidence, SUS suburethral sling, USLP uterosacral ligament plication, OAB overactive bladder, TOT transobturator tape, TVT tension-free vaginal tape, TVM transvaginal mesh, Nm not mentioned, Na not available

3/93 (3): 3– 6 months postoperatively 1/24 (4) 23/24 (96) Na 12 Self-shaped anterior mesh Retrospective with two arms positioned with retropubically and under standardised cystocele+TOT if work-up overt SUI pre-/ postoperatively Liang et al. [35]

USI 24/100 (24)

Follow- SUI status preoperatively up (months) (%) Study design/LoE Operations Reference

Table 1 (continued)

De novo SUI (%)

Cured SUI (%)

Persistent SUI (%)

De novo OAB (%)

Int Urogynecol J (2013) 24:1843–1852

The cumulative success rate for SUI after anterior colporrhaphy in two randomised trial arms was 48 % (19 out of 40) [18, 20]. Colombo et al. [20] compared Burch colposuspension and anterior repair for the treatment of women with anterior vaginal wall prolapse and SUI. While women benefited more from Burch colposuspension with regard to SUI (cure of SUI 30 out of 35, 86 % vs 17 out of 33, 52 %), anterior repair better corrected the anterior prolapse (cure of cystocele 23 out of 35 vs 32 out of 33) [20]. Prospective POP surgery studies employing transobturator mesh without additional continence surgery show a cumulative SUI success rate of 61 % (81 out of 132) [33, 34, 35]. Success rates improve considerably if a suburethral tape procedure is performed concomitantly (cumulative rate 235 out of 237, 99 %) [30, 32–35]. Persisting or worsening SUI was described in 9 out of 15 (60 %) by Fayyad et al. [27], who

1848 Fig. 1 De novo stress urinary incontinence (SUI): Forrest plot of five RCTs comparing anterior repair and transobturator mesh repairs

Int Urogynecol J (2013) 24:1843–1852 Anterior repair

Transobturator mesh

Risk Ratio

Total

Events

Altman 2011

11

176

22

179

45.1%

Hiltunen 2007

8

87

15

85

31.3%

0.52 [0.23, 1.16]

Sivaslioglu 2008

3

42

0

43

1.0%

7.16 [0.38, 134.58]

Sokol 2011

3

19

4

13

9.8%

0.51 [0.14, 1.92]

Withagen 2011

6

53

6

50

12.8%

0.94 [0.33, 2.73]

370 100.0%

0.64 [0.42, 0.97]

Total (95% CI)

Total events

Total Weight

Risk Ratio

Events

Study or Subgroup

377

31

M-H, Fixed, 95% CI 0.51 [0.25, 1.02]

47

Heterogeneity: Chi² = 3.88, df = 4 (P = 0.42); I² = 0%

0.01

Test for overall effect: Z = 2.08 (P = 0.04)

prospectively evaluated the role of transobturator polypropylene mesh without any concomitant surgery in the management of recurrent prolapse. Whether a suburethral tape (Tension-free Vaginal Tape, TVT) is inserted concomitantly or after 3 months did not result in significantly different success rates based on an “ontreatment” analysis by Borstad et al. (83 out of 87, 95 % vs 47 out of 53, 89 % 3 months later) [19]. Twenty-seven out of 94 (29 %) women were cured of SUI after prolapse surgery alone and declined a TVT 3 months later [19]. Costantini et al. compared abdominal sacrocolpopexy or sacrohysteropexy with and without concomitant Burch colposuspension in women with POP and SUI [43]. Similar to their randomised trial in continent women, Burch colposuspension increased the postoperative SUI rate: 13 out of 24 (54 %) vs 9 out of 23 (39 %) were incontinent [43].

Should women with POP and occult SUI identified pre-operatively undergo continence surgery at the time of POP surgery? Three randomised trials addressed this issue [23, 44, 45] and found that after the addition of TVT to vaginal prolapse repairs (mainly anterior and posterior colporrhaphy) significantly fewer women complained of SUI (21 out of 116, 18 % vs 64 out of 125, 51 %). The meta-analysis of these three trials calculated that a concomitant TVT reduced the risk of postoperative SUI significantly (RR 0.54, 95 % CI 0.41, 0.72; Fig. 3). Two trials included women who tested positive for SUI after the POP was reduced (occult SUI) [23, 44], whereas in the study by Wei (OPUS trial) only 34 % Fig. 2 Meta-analysis of two randomised controlled trials (RCTs) looking at the effect of Burch colposuspension in addition to sacral colpopexy. Subjective rates of de novo SUI are presented

SCP+Burch Study or Subgroup

Events

100

Overactive bladder (OAB) symptoms may be associated with POP [1]. Therefore, prolapse surgery may cure or improve OAB, but it may also result in new OAB symptoms. The current Cochrane review on the surgical management of POP [9, 46] calculated that new overactive bladder symptoms developed in 103 out of 854 (12 %) women in nine trials with various types of prolapse surgery [17, 23, 37, 38, 47–51]. Whether women have been treated with anticholinergics, e.g. postoperatively, is not at all clear and numbers may in fact be higher. The cumulative rate of de novo OAB in women who underwent transobturator anterior mesh procedure is 7 % (39 out of 557), [14, 27–33, 35, 52], whereas it is 10 % (7 out of 71) in the few studies reporting data after anterior repair with or without suburethral tape [23, 53]. This difference is not statistically significant (p=0.4). In a new RCT, Halaska et al. reported de novo overactive bladder in 7 out of 97 (7 %) after anterior Prolift (Ethicon, Somerville NJ, USA), in 7 out of 34 (21 %) after anterior Prolift and sacrospinous fixation, in 8 out of 84 (9 %) after SCP

Risk Ratio

Risk Ratio

M-H, Random, 95% CI

38

147

63

155

60.0%

0.64 [0.46, 0.89]

9

31

5

31

40.0%

1.80 [0.68, 4.76]

186 100.0%

0.96 [0.35, 2.62]

178

M-H, Random, 95% CI

68

Heterogeneity: Tau² = 0.41; Chi² = 3.94, df = 1 (P = 0.05); I² = 75% Test for overall effect: Z = 0.07 (P = 0.94)

10

Favours control

Overactive bladder symptoms

Total Events Total Weight

47

1

demonstrated occult incontinence [45]. However, they reported data separately for women with a positive stress test after reduction of the prolapse: 41 out of 57 women without and 16 out of 54 with an additional TVT were stress incontinent at the 3-month follow-up (Fig. 3). In a retrospective trial of 60 women who tested negative for occult SUI on preoperative urodynamic studies, 15 (25 %) developed SUI after vaginal mesh surgery [12]. However, 12 % (7 out of 60) had preoperative symptomatic SUI.

Costantini 2010 Total (95% CI)

0.1

Favours experimental

Brubaker 2008

Total events

M-H, Fixed, 95% CI

0.01

0.1

Favours experimental

1

10

100

Favours control

Int Urogynecol J (2013) 24:1843–1852 Fig. 3 The addition of a suburethral sling to vaginal prolapse repairs in women without symptomatic SUI

1849 Vaginal repair

additional TVT

Events

Total

Events

Meschia 2004

11

25

2

25

9.2%

5.50 [1.36, 22.32]

Schierlitz 2007

12

43

3

37

14.9%

3.44 [1.05, 11.27]

Wei 2011

41

57

16

54

75.9%

2.43 [1.56, 3.78]

116 100.0%

2.86 [1.91, 4.30]

Study or Subgroup

Total (95% CI) Total events

125 64

Risk Ratio

Total Weight

21

Heterogeneity: Chi² = 1.46, df = 2 (P = 0.48); I² = 0%

0.01

Test for overall effect: Z = 5.07 (P < 0.00001)

total polypropylene mesh repair and in 1 out of 98 (1 %) after posterior Prolift only [14]. In another RCT, after vaginal sacrospinous fixation 6 out of 29 women complained of OAB, whereas after sacrocolpopexy 11 out of 33 developed symptoms [37]. Sacrocolpopexy with or without Burch colposuspension resulted in similar rates of de novo OAB (3 out of 34 vs 2 out of 32) [41]. Similarly, after vaginal POP surgery with or without TVT, OAB rates were not different (3 out of 25 vs 1 out of 25) [23]. In 22 out of 48 (46 %) of women with several different prolapse operations urgency incontinence resolved, whereas it persisted in 26 out of 48 (54 %) and developed de novo in 3 (12 %) [53].

Voiding problems The Cochrane review noted new voiding dysfunction in 56 out of 476 (12 %) women in six randomised trials with various prolapse surgeries with or without continence procedures [37, 47–49, 51, 54]. However, owing to variations in defining and reporting voiding problems meta-analysis is unfeasible. After anterior repair, voiding dysfunction ranges from 0 % to 37 % [20, 22, 23, 55–57]. In their RCT Withagen et al. described significantly different temporary urinary retention rates in 5 out of 97 (5 %) after anterior repair compared with 15 out of 93 (16 %) after transobturator mesh repair (p=0.008). Normal micturition was restored in all women within 14 days [22]. Anterior repair with or without concomitant vaginal POP surgery resulted in postvoid residuals exceeding 150 ml in 27 out of 126 (21 %) in an RCT comparing transurethral and suprapubic catheterisation [55]. After anterior mesh repair, voiding difficulties occur in between 5 and 42 % [22, 28, 37, 56–61]. One study looked at postoperative urinary retention defined as the need to discharge the patient with an indwelling catheter because of a failed voiding trial [59]. Voiding dysfunction ranged from 34 % (10 out of 29) after isolated anterior mesh repair to 42 % of cases (30 out of 71) after combined anterior and posterior repairs. After isolated posterior repair 8 out of 42 (19 %) developed urinary retention. At the 3-month followup, there were no more voiding complaints [59].

Risk Ratio M-H, Fixed, 95% CI

M-H, Fixed, 95% CI

0.1

Favours no additional TVT

1

10

100

Favours concomitant TVT

If there are postoperative voiding problems with residuals exceeding 150 ml, clean intermittent catheterisation is superior to an indwelling catheter for 3 days with regard to bacteriuria, urinary tract infection and length of required catheterisation, according to one RCT [62], and intermittent transurethral catheterisation is equivalent to a suprapubic catheter regimen [55]. Insertion of a suprapubic catheter, however, resulted in more related complications including dislodgment or blockage of the catheter and haematuria [55]. Another RCT [63] reported on the duration of postoperative urethral catheterisation between 2 and 4 days after anterior repair and found no differences in voiding dysfunction. This was confirmed by an RCT comparing 2 and 5 days of routine postoperative indwelling catheter placement. Longer hospital stay and more urinary tract infections were associated with the 5-day protocol [64]. Patients do not seem to benefit from postoperative urethral catheterisation beyond 2 days [63, 64].

Conclusion &

&

& &

The trials assessed were considerably heterogeneous regarding inclusion and exclusion criteria, clinical testing for stress urinary incontinence and operations performed. Also, the lack of separate reports of bladder symptoms account for a difficult interpretation of outcomes. Continent women undergoing anterior compartment POP surgery have a lower rate of de novo SUI after anterior repair than after armed mesh procedures ( grade A). Data are conflicting on whether colposuspension should be performed prophylactically in continent women undergoing sacral colpopexy (grade C). No clear conclusion can be drawn regarding the management of continent women undergoing POP surgery without occult SUI. In symptomatically continent women undergoing POP surgery with occult SUI the addition of continence surgery reduces the rate of postoperative SUI (grade A). In women with POP and SUI symptoms prolapse procedures alone (transobturator mesh and anterior repair) are associated with low success rates for SUI. Concomitant continence procedures reduce the risk of postoperative SUI (grade B).

1850

& & &

Preoperative bladder overactivity may resolve in 40 % undergoing POP surgery and de novo bladder overactivity occurs in 12 %. No valid conclusions regarding voiding dysfunction following POP surgery can be drawn from the data available. Level 1 evidence demonstrates that there is no need to leave an indwelling catheter beyond 2 days, and that a suprapubic catheter yields similar outcomes to clean intermittent self-catheterisation; however, it is associated with more complications.

Acknowledgments This publication results from the work of the Committee on Pelvic Organ Prolapse Surgery, part of the 5th International Consultation on Incontinence, held in Paris in February 2012, under the auspices of the International Consultation on Urological Diseases, and enabled by the support of the European Association of Urology. The authors wish to acknowledge the fine work of previous consultations led by Professor Linda Brubaker. Conflicts of interest None.

References 1. Slieker-ten Hove MC, Pool-Goudzwaard AL, Eijkemans MJ, SteegersTheunissen RP, Burger CW, Vierhout ME (2009) The prevalence of pelvic organ prolapse symptoms and signs and their relation with bladder and bowel disorders in a general female population. Int Urogynecol J Pelvic Floor Dysfunct 20(9):1037–1045 2. Reena C, Kekre AN, Kekre N (2007) Occult stress incontinence in women with pelvic organ prolapse. Int J Gynaecol Obstet 97(1):31–34 3. Sinha D, Arunkalaivanan AS (2007) Prevalence of occult stress incontinence in continent women with severe genital prolapse. J Obstet Gynaecol 27(2):174–176 4. Haessler AL, Lin LL, Ho MH, Betson LH, Bhatia NN (2005) Reevaluating occult incontinence. Curr Opin Obstet Gynecol 17(5):535–540 5. Ellstrom Engh AM, Ekeryd A, Magnusson A, Olsson I, Otterlind L, Tobiasson G (2010) Can de novo stress incontinence after anterior wall repair be predicted? Acta Obstet Gynecol Scand 90(5):488–493 6. Visco AG, Brubaker L, Nygaard I et al (2008) The role of preoperative urodynamic testing in stress-continent women undergoing sacrocolpopexy: the Colpopexy and Urinary Reduction Efforts (CARE) randomized surgical trial. Int Urogynecol J Pelvic Floor Dysfunct 19(5):607–614 7. Chughtai B, Spettel S, Kurman J, De E (2011) Ambulatory pessary trial unmasks occult stress urinary incontinence. Obstet Gynecol Int 2012:392027 8. Romanzi LJ, Chaikin DC, Blaivas JG (1999) The effect of genital prolapse on voiding. J Urol 161(2):581–586 9. Maher C, Feiner B, Baessler K, Adams EJ, Hagen S, Glazener CM (2010) Surgical management of pelvic organ prolapse in women. Cochrane Database Syst Rev 4:CD004014 10. Kenton K, Fitzgerald MP, Brubaker L (2005) Striated urethral sphincter activity does not alter urethral pressure during filling cystometry. Am J Obstet Gynecol 192(1):55–59

Int Urogynecol J (2013) 24:1843–1852 11. Mueller ER, Kenton K, Mahajan S, FitzGerald MP, Brubaker L (2007) Urodynamic prolapse reduction alters urethral pressure but not filling or pressure flow parameters. J Urol 177(2):600–603 12. Kasturi SDS, McDermott CD, Woodman PJ, Bump RC, Terry CL, Hale DS (2011) De novo stress urinary incontinence after negative prolapse reduction stress testing for total vaginal mesh procedures: incidence and risk factors. Am J Obstet Gynecol 205(5):487e1–487e4 13. Altman D, Vayrynen T, Engh ME, Axelsen S, Falconer C (2011) Anterior colporrhaphy versus transvaginal mesh for pelvic-organ prolapse. N Engl J Med 364(19):1826–1836 14. Halaska M, Sottner O, Maxova K et al (2010) Prolene mesh comparing with sacrospinal fixation in the treatment of genital prolapse in women. Prospective multicentre randomized study. Ceska Gynekol 75(2):126–132 15. Ek M, Tegerstedt G, Falconer C et al (2010) Urodynamic assessment of anterior vaginal wall surgery: a randomized comparison between colporrhaphy and transvaginal mesh. Neurourol Urodyn 29(4):527–531 16. Sivaslioglu AA, Unlubilgin E, Dolen I (2008) A randomized comparison of polypropylene mesh surgery with site-specific surgery in the treatment of cystocoele. Int Urogynecol J Pelvic Floor Dysfunct 19(4):467–471 17. Natale F, La Penna C, Padoa A, Agostini M, De Simone E, Cervigni M (2009) A prospective, randomized, controlled study comparing Gynemesh, a synthetic mesh, and Pelvicol, a biologic graft, in the surgical treatment of recurrent cystocele. Int Urogynecol J Pelvic Floor Dysfunct 20(1):75–81 18. Hviid U, Hviid TV, Rudnicki M (2010) Porcine skin collagen implants for anterior vaginal wall prolapse: a randomised prospective controlled study. Int Urogynecol J Pelvic Floor Dysfunct 21(5):529–534 19. Borstad E, Abdelnoor M, Staff AC, Kulseng-Hanssen S (2010) Surgical strategies for women with pelvic organ prolapse and urinary stress incontinence. Int Urogynecol J Pelvic Floor Dysfunct 21(2):179–186 20. Colombo M, Vitobello D, Proietti F, Milani R (2000) Randomised comparison of Burch colposuspension versus anterior colporrhaphy in women with stress urinary incontinence and anterior vaginal wall prolapse. BJOG 107(4):544–551 21. Sokol AI, Iglesia CB, Kudish BI, Gutman RE, Shveiky DBR, Sokol ER (2012) One-year objective and functional outcomes of a randomized clinical trial of vaginal mesh for prolapse. Am J Obstet Gynecol 206(1):86e1–86e9 22. Withagen MI, Milani AL, den Boon J, Vervest HA, Vierhout ME (2011) Trocar-guided mesh compared with conventional vaginal repair in recurrent prolapse: a randomized controlled trial. Obstet Gynecol 117(2 Pt 1):242–250 23. Meschia M, Pifarotti P, Spennacchio M, Buonaguidi A, Gattei U, Somigliana E (2004) A randomized comparison of tension-free vaginal tape and endopelvic fascia plication in women with genital prolapse and occult stress urinary incontinence. Am J Obstet Gynecol 190(3):609–613 24. Nieminen K, Hiltunen R, Takala T et al (2010) Outcomes after anterior vaginal wall repair with mesh: a randomized, controlled trial with a 3 year follow-up. Am J Obstet Gynecol 203(3):235, e1-8 25. Alcalay M, Cosson M, Livneh M, Lucot JP, Von Theobald P (2011) Trocarless system for mesh attachment in pelvic organ prolapse repair–1-year evaluation. Int Urogynecol J Pelvic Floor Dysfunct 22(5):551–556 26. Ek M, Altman D, Falconer C, Kulseng-Hanssen S, Tegerstedt G (2010) Effects of anterior trocar guided transvaginal mesh surgery on lower urinary tract symptoms. Neurourol Urodyn 29(8):1419– 1423

Int Urogynecol J (2013) 24:1843–1852 27. Fayyad AM, North C, Reid FM, Smith AR (2011) Prospective study of anterior transobturator mesh kit (Prolift) for the management of recurrent anterior vaginal wall prolapse. Int Urogynecol J Pelvic Floor Dysfunct 22(2):157–163 28. Feiner B, Gietelink L, Maher C (2010) Anterior vaginal mesh sacrospinous hysteropexy and posterior fascial plication for anterior compartment dominated uterovaginal prolapse. Int Urogynecol J Pelvic Floor Dysfunct 21(2):203–208 29. Groutz A, Chaikin DC, Theusen E, Blaivas JG (2001) Use of cadaveric solvent-dehydrated fascia lata for cystocele repair–preliminary results. Urology 58(2):179–183 30. Takahashi S, Obinata D, Sakuma T et al (2010) Tension-free vaginal mesh procedure for pelvic organ prolapse: a single-center experience of 310 cases with 1-year follow up. Int J Urol 17(4):353– 358 31. Hiltunen R, Nieminen K, Takala T et al (2007) Low-weight polypropylene mesh for anterior vaginal wall prolapse: a randomized controlled trial. Obstet Gynecol 110(2 Pt 2):455–462 32. Hung MJ, Liu FS, Shen PS, Chen GD, Lin LY, Ho ES (2004) Factors that affect recurrence after anterior colporrhaphy procedure reinforced with four-corner anchored polypropylene mesh. Int Urogynecol J Pelvic Floor Dysfunct 15(6):399–406; discussion 33. Sentilhes L, Sergent F, Resch B, Verspyck E, Descamps P, Marpeau L (2007) Midterm follow-up of high-grade genital prolapse repair by the trans-obturator and infracoccygeal hammock procedure after hysterectomy. Eur Urol 51(4):1065–1072 34. Sergent F, Zanati J, Bisson V, Desilles N, Resch B, Marpeau L (2010) Perioperative course and medium-term outcome of the transobturator and infracoccygeal hammock for posthysterectomy vaginal vault prolapse. Int J Gynaecol Obstet 109(2):131–135 35. Liang CC, Lin YH, Chang YL, Chang SD (2011) Urodynamic and clinical effects of transvaginal mesh repair for severe cystocele with and without urinary incontinence. Int J Gynaecol Obstet 112(3):182–186 36. Kuribayashi M, Kitagawa Y, Narimoto K, Kawaguchi S, Konaka H, Namiki M (2011) Postoperative voiding function in patients undergoing tension-free vaginal mesh procedure for pelvic organ prolapse. Int Urogynecol J 22(10):1299–1303 37. Maher CF, Qatawneh AM, Dwyer PL, Carey MP, Cornish A, Schluter PJ (2004) Abdominal sacral colpopexy or vaginal sacrospinous colpopexy for vaginal vault prolapse: a prospective randomized study. Am J Obstet Gynecol 190(1):20–26 38. Brubaker L, Cundiff GW, Fine P et al (2006) Abdominal sacrocolpopexy with Burch colposuspension to reduce urinary stress incontinence. N Engl J Med 354(15):1557–1566 39. Brubaker L, Nygaard I, Richter HE et al (2008) Two-year outcomes after sacrocolpopexy with and without burch to prevent stress urinary incontinence. Obstet Gynecol 112(1):49–55 40. Costantini E, Lazzeri M, Bini V, Del Zingaro M, Zucchi A, Porena M (2010) Pelvic organ prolapse repair with and without prophylactic concomitant Burch colposuspension in continent women: a randomized, controlled trial with 8-year followup. J Urol 185(6):2236– 2240 41. Costantini E, Zucchi A, Giannantoni A, Mearini L, Bini V, Porena M (2007) Must colposuspension be associated with sacropexy to prevent postoperative urinary incontinence? Eur Urol 51(3):788– 794 42. Sergent F, Gay-Crosier G, Bisson V, Resch B, Verspyck E, Marpeau L (2009) Ineffectiveness of associating a suburethral tape to a transobturator mesh for cystocele correction on concomitant stress urinary incontinence. Urology 74(4):765–770 43. Costantini E, Lazzeri M, Bini V, Del Zingaro M, Zucchi A, Porena M (2008) Burch colposuspension does not provide any

1851

44.

45.

46.

47.

48.

49.

50.

51.

52.

53.

54.

55.

56.

57.

additional benefit to pelvic organ prolapse repair in patients with urinary incontinence: a randomized surgical trial. J Urol 180(3):1007–1012 Schierlitz L, Dwyer P, Rosamilia A, Murray C, Thomas E, Taylor AW (2007) A prospective randomised controlled study comparing vaginal prolapse repair with and without tension free vaginal tape (TVT) in women with severe pelvic organ prolapse and occult stress incontinence (Abstract number 114). Neurourol Urodyn 26(5):743–744 Wei JA (2011) Midurethral sling prevents incontinence among women undergoing vaginal prolapse repair—the OPUS trial (Abstract). Neurourol Urodyn 30 (S1):1–54 Maher CM, Feiner B, Baessler K, Glazener CM (2011) Surgical management of pelvic organ prolapse in women: the updated summary version Cochrane review. Int Urogynecol J 22(11):1445– 1457 Bump RC, Hurt WG, Theofrastous JP et al (1996) Randomized prospective comparison of needle colposuspension versus endopelvic fascia plication for potential stress incontinence prophylaxis in women undergoing vaginal reconstruction for stage III or IV pelvic organ prolapse. The continence program for women research group. Am J Obstet Gynecol 175(2):326–333, discussion 33–35 Colombo M, Maggioni A, Scalambrino S, Vitobello D, Milani R (1997) Surgery for genitourinary prolapse and stress incontinence: a randomized trial of posterior pubourethral ligament plication and Pereyra suspension. Am J Obstet Gynecol 176(2):337–343 Colombo M, Maggioni A, Zanetta G, Vignali M, Milani R (1996) Prevention of postoperative urinary stress incontinence after surgery for genitourinary prolapse. Obstet Gynecol 87(2):266– 271 Natale F, La Penna C, Padoa A, Panei M, Cervigni M (2008) High levator myorrhaphy for transvaginal suspension of the vaginal apex: long-term results. J Urol 180(5):2047–2052; discussion 52 De Tayrac R, Mathe ML, Bader G, Deffieux X, Fazel A, Fernandez H (2008) Infracoccygeal sacropexy or sacrospinous suspension for uterine or vaginal vault prolapse. Int J Gynaecol Obstet 100(2):154– 159 Moore RD, Miklos JR (2009) Vaginal repair of cystocele with anterior wall mesh via transobturator route: efficacy and complications with up to 3-year followup. Adv Urol 2009:743831 Foster RT Sr, Barber MD, Parasio MF, Walters MD, Weidner AC, Amundsen CL (2007) A prospective assessment of overactive bladder symptoms in a cohort of elderly women who underwent transvaginal surgery for advanced pelvic organ prolapse. Am J Obstet Gynecol 197:82e1–82e4 Natale F, Mako A, Panei M, Weir J, Antomarchi F, Cervigni M (2007) Prospective randomized controlled study between two different procedures to suspend the vaginal vault: high levator myorrhaphy and uterosacral vaginal vault suspension (Abstract number 6). Neurourol Urodyn 26(5):608–609 Stekkinger E, van der Linden PJ (2011) A comparison of suprapubic and transurethral catheterization on postoperative urinary retention after vaginal prolapse repair: a randomized controlled trial. Gynecol Obstet Invest 72(2):109–116 Meschia M, Pifarotti P, Bernasconi F, Magatti F, Riva D, Kocjancic E (2007) Porcine skin collagen implants to prevent anterior vaginal wall prolapse recurrence: a multicenter, randomized study. J Urol 177(1):192–195 Gandhi S, Goldberg RP, Kwon C et al (2005) A prospective randomized trial using solvent dehydrated fascia lata for the

1852

58.

59.

60.

61.

prevention of recurrent anterior vaginal wall prolapse. Am J Obstet Gynecol 192(5):1649–1654 Withagen MI, Vierhout ME, Milani AL (2010) Does trocarguided tension-free vaginal mesh (Prolift) repair provoke prolapse of the unaffected compartments? Int Urogynecol J 21(3):271–278 Steinberg BJ, Finamore PS, Sastry DN, Holzberg AS, Caraballo R, Echols KT (2010) Postoperative urinary retention following vaginal mesh procedures for the treatment of pelvic organ prolapse. Int Urogynecol J 21(12):1491–1498 Maher C, O’Rourke P (2011) Trocar-guided mesh compared with conventional vaginal repair in recurrent prolapse: a randomized controlled trial. Obstet Gynecol 117(6):1435–1436 Feiner B, O’Rourke P, Maher C (2011) A prospective comparison of two commercial mesh kits in the management of anterior vaginal prolapse. Int Urogynecol J 23(3):279–283

Int Urogynecol J (2013) 24:1843–1852 62. Hakvoort R, Roovers J (2011) Comparing clean intermittent catheterisation and transurethral indwelling catheterisation for incomplete voiding after vaginal prolapse surgery: a multicentre randomised trial. BJOG 119(1):115–116 63. Huang CC, Ou CS, Yeh GP, Der Tsai H, Sun MJ (2010) Optimal duration of urinary catheterization after anterior colporrhaphy. Int Urogynecol J 22(4):485–491 64. Weemhoff M, Wassen MM, Korsten L, Serroyen J, Kampschoer PH, Roumen FJ (2011) Postoperative catheterization after anterior colporrhaphy: 2 versus 5 days. A multicentre randomized controlled trial. Int Urogynecol J 22(4):477–483 65. Ramanah R, Ballester M, Chereau E, Rouzier R, Darai E (2012) Effects of pelvic organ prolapse repair on urinary symptoms: a comparative study between the laparoscopic and vaginal approach. Neurourol Urodyn 31(1):26–31