Concurrent Surgery for Prolapse Repair and Stress Urinary Incontinence to Reduce the Risk of Postoperative Surgical Intervention for Incontinence

INTRODUCTION

Urinary incontinence (UI), is a common and distressing medical condition which affects 26% of women in developing countries and stress urinary incontinence (SUI) (12.6%) is the most common type.1 One of the important risk factors for SUI is pelvic organ prolapse.2 Pelvic organ prolapse(POP) is descent of pelvic organs resulting in protrusion of pelvic structures including bladder, rectum and uterus beyond their anatomical confines. In low and middle-income countries, the prevalence of pelvic organ prolapse is 19.7% (estimated range is 3.4%-56.4%).3 In a study, the prevalence of prolapse in Pakistan was 10.3%.4 Globally in up to 54 % of women, pelvic organ prolapse and stress incontinence coexists.5 In Pakistan 12.5% women will suffer with both prolapse and urinary incontinence.2

Patients showing no improvement with conservative measures are offered surgery. The surgical methods used for SUI include Burch colposuspension (BC), tension-free vaginal tape (TVT)and trans obturator tape (TOT).6 For prolapse the route of repair can be abdominal or vaginal and surgical methods include reconstructive procedures preserving uterus or vaginal hysterectomy.7 The uterus preserving surgeries include Sacrohysteropexy (ASC), sacrospinous ligament fixation, ventrosuspension and Manchester repair.8,9

Many women undergoing surgery for pelvic organ prolapse (POP) will experience incontinence after prolapse repair. Developing incontinence after prolapse repair is even more common among women with urinary incontinence before the surgery.10 In a recent study women with coexisting SUI have a 40% risk of undergoing subsequent surgery for postoperative SUI and women with occult SUI have a 15% risk. 10 It is shown in some studies that women could have lower risk of subsequent continence surgery for SUI after combination surgery than after prolapse surgery only.11 However, another study showed that about a third of women with POP and SUI will experience resolution of SUI symptoms following isolated POP repair.12,13 Van der Ploeg et al. conducted a large multicentre RCT, and results showed a significant reduction in postoperative SUI rates in the combined surgery group as compared to POP repair only; 22% versus 61% .Despite 61% of women reporting postoperative SUI in the POP repair-only group, only 17% went on to receive surgical treatment for SUI within 12 months of follow-up. Potential explanations include the use of alternative non-surgical treatments, the SUI not being severe enough to warrant surgery, or the woman's desire to avoid further surgery and operative risks. 14 Costantini et al. evaluated concomitant colposuspension at the time of abdominal sacrocolpopexy surgery versus sacrocolpopexy alone and showed no significant benefit in adding Burch colposuspension.15 Overall, there is sufficient evidence that for women who are symptomatic of SUI and POP, concomitant vaginal POP repair and anti-incontinence surgery is beneficial for reducing postoperative SUI. However, it must be borne in mind that in women undergoing vaginal POP surgery alone, almost one-third may experience cure of SUI symptoms and despite concomitant continence surgery, SUI can still persist in approximately one-third of women.16 So, we aim to compare the risk of surgical intervention for stress urinary incontinence after combined prolapse and anti-incontinence surgery and prolapse surgery alone.

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