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