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Urogynecology
inappropriate micturition reflex and the failure of pelvic floor musculature women suffering from POP and UI were randomly assigned to abdominal POP
and ligaments, leading to POP.
26
repair and concomitant BC (group A: 24 patients) or POP repair alone without
any anti-incontinence procedure (group B: 23 patients). We found that in
However, given their complexity, UI and POP may be considered group A 13/24 patients (54.2%) were still incontinent after surgery compared
two sides of the same coin. Recently, a comprehensive theory, i.e. with 9/23 (39.1%) in group B. The intra-group difference was significant
the ‘trampoline theory,’ has been developed to encompass all of the factors (p=0.003 for group A, p=0.0001 for group B), but there was no significant
that play a role in female pelvic floor disorders.
27
The reconstructive surgeon inter-group difference (p=0.459 for A versus B). We concluded that BC does
has three options regarding continent patients suffering from POP: first, to not provide any additional benefit in POP repair in patients with UI. We found
perform a routine anti-incontinence operation, with the risk that some that the continence rate was lower in patients who received concomitant BC,
patients will be overtreated; second, not to perform the anti-incontinence casting doubts on whether BC should be performed during POP repair in
operation and to follow up the patient, reserving a second operation for women suffering from pre-operative UI.
women whose SUI symptoms warrant it; and third, to predict which
patients will have troublesome post-operative SUI. In incontinent patients We realize that these results are difficult to explain. One potential
with POP the surgeon has to offer surgery to the patient that repairs the explanation could be that the degree of anterior wall support provided by
anatomical defect and corrects incontinence. our technique of sacropexy alone may be adequate for continence in a
subset of patients, and that Burch suspension is highly variable in outcome
Generally, the BC operation along with other reconstructive surgeries has been and difficult to control for reliable continence. We adopted the surgical
recommended for treating co-existing SUI and POP. BC has long been technique as it is an integral POP reconstruction and includes wide
considered as one of the most effective operations for treating genuine SUI, preparation of the anterior and posterior vaginal walls and the anterior
and even today is still regarded by some urologists and gynecologists as the mesh placement at the urethral level, which could in itself correct any
‘standard’ surgical procedure for treating SUI associated with urethral potential incontinence. Our findings seem to be in line with data from
hypermobility. BC is associated with a high cure rate, but long-term follow-ups Cosson et al., who reported that only 34% of patients with prolapse and
have recently shown that the continence rate declines with time, and BC is pre-operative SUI achieved complete correction of urinary dysfunction with
associated with several adverse effects that result in anatomical and functional a BC procedure during sacrocolpopexy.
33
pelvic floor dysfunctions.
28
However, even in our best series (group B), 40% of patients remained
Interesting questions concerning patients with SUI and concomitant POP are incontinent, and one could conclude that POP repair alone failed to
whether POP repair by itself can achieve a continent status and whether BC, correct UI. However, these patients presented with light incontinence and
when associated with an abdominal POP repair, changes the outcome of POP received behavioral and/or medical treatment; nobody required adjuvant
by acting on the bladder and urethra. Langer et al. and Meltomaa et al. found surgical procedures.
that when associated with hysterectomy, BC did not influence post-operative
bladder and urethra function and the overall cure rate of SUI obtained by Conclusion
BC.
29,30
On the other hand, Snooks et al. and Parson et al. showed that The risk remains unclear regarding post-operative UI in patients who
concomitant abdominal surgeries caused impairment of lower urinary tract underwent surgery for urogenital prolapse. The onset of post-operative
function.
31
Unfortunately, none of these studies are up to date, the follow-ups stress UI after the reparation of severe POP in previously continent women
are short, and the question of the impact of BC on bladder and urethra represents a challenge, and several prophylactic procedures have been
function remains unsolved. developed to prevent it. Although some investigators advise concomitant
SUI operations in all patients with severe POP—regardless of whether
Recently, we investigated the impact of BC as an anti-incontinence measure in demonstrable incontinence is present—we suggest a prudent case-specific
patients with UI undergoing abdominal surgery for POP repair.
32
Forty-seven policy of concomitant incontinence surgery only when clearly indicated. ■
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