Costantini.qxp 25/9/08 12:09 pm Page 75
Uro-genital Prolapse Surgery – An Update on Post-operative Urinary Incontinence
symptomatic POP associated with SUI in 24 patients (58.1%). At the Various authors have addressed the incidence of post-operative
mean follow-up of 52.7 months (range of 12–133), we found that UI incontinence without a concomitant anti-incontinence procedure.
was present post-operatively in 15 patients (36.5%), although Burch Stanton et al.
20
reported 11% post-operative SUI within three months
colposuspension (BC) was performed in 11 of these 15 incontinence of anterior colporrhaphy with or without vaginal hysterectomy. Two
patients. Four (26.6%) of these patients showed de novo UI (three SUI other observational studies on continent women with various grades
and one urgency incontinence), while 11 (73.4%) had persistent SUI. of prolapse who underwent POP surgery (without urethropexy)
showed 22 and 28% rates of post-operative SUI.
21,22
In a randomised
These data do not clarify whether there is a real link between study on patients with occult incontinence and urethral hypermobility
hysterectomy and SUI, but opens the debate as to whether we should treated with either a Muzsnay needle suspension or bladder-neck
preserve the uterus in young females undergoing POP surgery. Over the endopelvic fascial plication, Bump and Hurt reported 14 and 7% post-
last few decades attitudes to sexuality and the psychological and operative SUI at six months, respectively, concluding that occult
emotional value of the sexual organs have changed in developed incontinence does not predict the need for a urethropexy.
23
countries. The uterus has been shown to contribute positively to the
patient’s self-esteem, body image, confidence and sexuality.
15
We According to some authors, abdominal colpopexy could be more of a
should be ready to meet the wishes and feelings of female patients who risk for post-operative SUI than vaginal repair because of the change
want to preserve vaginal function and the uterus. However, surgeons in the vaginal axis. Even though urologists and gynaecologists have
should not forget that a reconstructive approach to POP using uterus been performing sacropexy for years without excessive traction on the
preservation techniques may represent the ideal anatomical pathway to vaginal walls, in some predisposed patients, i.e. those with occult
follow. Pelvic reconstruction spread over the three compartments and intrinsic sphincter deficiency, the direction of traction alone may be
carried out without tension should allow the pelvic anatomy and statics enough to cause SUI. Factors such as surgical damage to urethral
to remain as close as possible to the physiological norm, with a stable sphincter innervation and to the peri-urethral vascular plexus may also
vaginal axis and good vaginal length, and reduce the personal and come into play. As part of the Pelvic Floor Network sponsored by the
social cost of de novo SUI after hysterectomy during the course of POP National Institutes of Health (NIH), Brubaker et al. carried out a
surgery. One of the main goals is to permit all women who keep their prospective, randomised trial of a sacracolpopexy with BC versus
uterus to be satisfied with their self-image of body integrity, even if we without BC in women with pelvic prolapse but no complaint of
should always advise them about the risks of pregnancy and delivery, significant SUI.
24
Three months after surgery, approximately 24%
and the need for a long-term follow-up to rule out malignant disease. of women with BC had SUI compared with 44% of women
without suspension. The authors concluded that in women without
Incontinence After Pelvic Organ Prolapse a complaint of stress incontinence undergoing abdominal sacraco-
Repair in Continent Women colpopexy for prolapse, a BC significantly reduces post-operative
POP is not usually associated with subjective SUI, despite the symptoms of stress incontinence.
anatomical displacement of the urethrovesical junction and the fact
that the proximal urethra is outside the urogenital diaphragm. It is We reached the opposite conclusion when we investigated, by a
thought that the rotation of the urethra with straining may cause a prospective, randomised study, whether a prophylactic procedure
‘kinking’ or a compression, effectively closing off the urethra. It is also performed during colposacropexy for prolapse repair prevents ex novo
likely that the accompanying large cystocele helps to dissipate the post-operative incontinence.
25
Sixty-six continent patients with advanced
pressure placed on the bladder neck and preserve continence.
16
POP were randomised into two groups: group A patients underwent
The appearance of post-operative SUI after repair of severe POP in sacropexy combined with a BC, while no anti-incontinence procedure
previously continent women is frustrating for both the patient and the was performed in group B patients. At a mean follow-up of 39.5 months,
physician. Avoiding post-operative SUI represents one of the main post-operative incontinence was present in 12 of the 34 patients (35.3%)
challenges for urogynaecologists who perform this surgery. in group A and in three of the 32 patients (9.3%) in group B, with a
significantly greater post-operative incontinence rate in patients who had
The incidence of post-operative SUI after prolapse surgery is not well undergone colposuspension (p<0.05). We concluded that these
established, and is reported as ranging from 8 to 60%.
16
Several studies preliminary data cast doubt on whether colposuspension should be
have indicated various incontinence rates after different prophylactic anti- performed during sacropexy for severe urogenital prolapse as prophylaxis
incontinence procedures, but data on long-term follow-up in these series are for post-operative incontinence, because it seems to be overtreatment.
sparse. In an attempt to predict post-operative SUI or reveal occult
incontinence in currently continent women with POP, the use of reduction Incontinence After Pelvic Organ Prolapse
testing with replacement of the prolapse into the intended post-operative Repair in Incontinent Women
position has been recommended. Many methods have been described, POP may be associated with UI in approximately 50% of patients, and in
including the use of pessaries, cotton swabs, Sims speculums, vaginal order to correct both conditions together a BC or another anti-incontinence
packing, ring forceps and manual reduction; unfortunately, sensitivity, procedure is usually performed with sacrocolpopexy. Over the last few
specificity and predictive values for all reduction tests are not known.
17,18
decades, several theories have been proposed to explain the
Reduction manoeuvres may artificially obstruct the urethra or overly pathophysiology of SUI in women. These theories ranged from alterations in
straighten the urethrovesical junction, thus creating a false impression of the the anatomical position of the urethra and intrinsic sphincter deficiency to
patient’s sphincteric mechanism.
19
In conclusion, it is not known whether the ‘hammock’ and ‘integral’ theories. According to the latter, the laxity of
reduction testing is really effective in predicting post-operative incontinence the vaginal wall causes hypermobility of the bladder neck and urethra with
after different types of prolapse surgery. dissipation of urethral closure pressure, resulting in UI. Furthermore, this
EUROPEAN UROLOGICAL REVIEW 75