Pelvic organ prolapse and stress urinary incontinence in women_ Combined surgical treatment.pdf

28.04.2015 Pelvicorganprolapseandstressurinaryincontinenceinwomen:Combinedsurgicaltreatment

http://www.uptodate.com/contents/pelvicorganprolapseandstressurinaryincontinenceinwomencombinedsurgicaltreatment?topicKey=OBGYN%2F80 1/20

OfficialreprintfromUpToDate www.uptodate.com2015UpToDate

AuthorsCharlesWNager,MDJasmineTanKim,MD

SectionEditorLindaBrubaker,MD,FACS,FACOG

DeputyEditorKristenEckler,MD,FACOG

Pelvicorganprolapseandstressurinaryincontinenceinwomen:Combinedsurgicaltreatment

Alltopicsareupdatedasnewevidencebecomesavailableandourpeerreviewprocessiscomplete.Literaturereviewcurrentthrough:Mar2015.|Thistopiclastupdated:Sep24,2014.

INTRODUCTIONPelvicorganprolapse(POP)andstressurinaryincontinence(SUI)coexistinupto80percentofwomenwithpelvicfloordysfunction[1,2].Whiletheseconditionsareoftenconcurrent,onemaybemildorasymptomatic.WomenwithoutsymptomsofSUIwhoundergosurgeryforprolapseareatriskforpostoperativeurinaryincontinence[3].SUImayalsoworsenafterprolapserepair.

DecidingwhethertoperformacombinedsurgicalproceduretotreatbothprolapseandSUIorasingleprocedurethataddressesonlyoneconditionrequiresbalancingtheriskofincompletetreatmentwiththeriskofexposingthepatienttounnecessarysurgery[4].Thisdecisionmustbebasedonthebestapproachtoaddressthepatient'sgoals,ratherthansimplyonanatomiccorrection[5,6].Therateofconcurrentprolapserepairandcontinenceproceduresappearstobeincreasing.DatafromtheUnitedStatesNationalInpatientsampleshowedthatforapicalprolapserepairprocedures,therateofconcurrentcontinencesurgeryincreasedfrom38percentin2001to47percentin2009[7].

Challengesinsurgicaldecisionmakinginthisclinicalcontextincludeappropriateassessmentofresultsofpreoperativeevaluation,someofwhichmaybeambiguous(eg,prolapsenotedonexaminationinapatientwithnoprolapserelatedsymptomsorapatientwithadvanceprolapsewithnoleakageonprolapsereductiontesting).

CombinedsurgicaltreatmentforPOPandSUIwillbereviewedhere.Otherapproachestosurgicalandmedicaltreatmentoftheseconditionsandothertypesofurinaryincontinencearediscussedseparately.(See"Pelvicorganprolapseinwomen:Anoverviewoftheepidemiology,riskfactors,clinicalmanifestations,andmanagement"and"Approachtowomenwithurinaryincontinence"and"Surgicalmanagementofstressurinaryincontinenceinwomen:Choosingaprimarysurgicalprocedure".)

TERMINOLOGY

Stressurinaryincontinence(SUI)Leakageofurinewithincreasedintraabdominalpressure(eg,cough,laughter).(See"Approachtowomenwithurinaryincontinence".)

OccultSUISUIthatisnotsymptomatic,butbecomesapparentonlyduringclinicalorurodynamicurinaryfunctiontestingwhentheprolapseisreduced(ie,stresstestingwithreductionofprolapsedstructures).Occultstressincontinenceisalsoreferredtoaslatent,hidden,iatrogenic,orpotential.

ThedefinitionofoccultSUIisinconsistentinthemedicalliterature.Whilesomeauthorsusethetermtodescribeonlyincontinencewhichhasbeendemonstratedonurinaryfunctiontesting(asinthistopicreview),othersusethetermoccultincontinencetosignifythatthereisapossibilitythatSUIwilloccurafterprolapserepair.

DenovourinaryincontinenceUrinaryincontinencethatisnewlysymptomatic,asanexample,incontinencesymptomsthatdevelopaftersurgeryinapreviouslycontinentpatient.Thetypeofnewincontinenceshouldbespecified(eg,stress,urge).Asanexample,apatientwithurgencyincontinenceandnoSUIbeforesurgerymayhavepersistenturgencyincontinenceanddenovostressincontinenceaftersurgery.

ProlapsereductiontestingElevationofprolapsedstructurestoapproximatenormalpelvicsupportduringpelvicexaminationorclinicalorurodynamicurinaryfunctiontesting.Thisisperformedincombinationwitha



CLINICALPRESENTATIONPelvicorganprolapse(POP)andstressurinaryincontinence(SUI)maypresentaloneorconcurrentlyinavarietyofcombinations.

SymptomaticprolapseandincontinenceSymptomsofbothPOPandSUImaybepartofthepresentingcomplaint.Ontheotherhand,POPsymptomsmaybenonspecific(pelvicpressureordiscomfort)andsomewomenonlyrecognizetheseasrelatedtoPOPafterevaluationbyaclinician.Thesymptomsofprolapseandincontinencemaybeequallybothersomeoroneconditionmaypredominate.(See"Approachtowomenwithurinaryincontinence",sectionon'Clinicaltests'.)

ProlapsewithnosymptomsofincontinenceAdvancedPOP(pelvicorganprolapsequantitationsystem[POPQ]stageIItoIV)commonlycoexistswithSUI,however,formanywomentheSUImaybecomeapparentonlywhentheprolapsehasbeencorrected[1].ThisphenomenonisknownasoccultSUI.TestingforoccultSUIisdiscussedbelow(see'Detectingoccultincontinence'below).

Anatomically,thisoccursbecauseinwomenwithsignificantanteriororapicalprolapse(usuallyprolapsepastthevaginalintroitus),thebladderneckisdisplacedposteriorlyandtheurethraiskinked,resultinginurethralobstruction.Theobstructionthenbecomesthemechanismofcontinence(figure1)[8].

Whentheprolapsedstructuresareelevated(approximatingnormalanatomy)duringprolapsereductiontestinginwomenwithurethralobstructionduetoadvancedPOP,theurethraisunblockedandSUIoftenbecomesevidentwhenaurinarystresstestisperformed.Ontheotherhand,womenwithstageIPOPareunlikelytohaveurethralobstructionandresultantoccultSUI[912].(See'Detectingoccultincontinence'below.)

OccultSUIisdiagnosedusingpreoperativeprolapsereductiontestingin31to80percentofwomenwithsymptomaticand/oradvancedPOPwhoareplanningsurgicaltreatment[1326].Accordingly,whenwomenwithoccultSUIundergoprolapserepairwithoutaconcomitantcontinenceprocedure,therateofpostoperativedenovoSUIrangesinstudiesfrom13to72percent(mean51percent)(algorithm1)[13].

However,womenwhohavenegativepreoperativetestingforoccultSUIandundergoprolapserepairwithoutacontinenceproceduremaystilldevelopSUIaftersurgery,butatalowerratethanwomenwhotestpositiveforoccultSUIwithpreoperativeprolapsereductiontesting.Therateofpostoperativeincontinenceinwomenwithnegativepreoperativeoccultstresstestingrangesinstudiesfrom0to42percent(mean26percent)(algorithm1)[1416,18,2731].

IncontinencewithnosymptomsofprolapseWomenwhopresentwithSUIwilloftenhavePOPofvaryingdegrees.TreatmentisindicatedonlyforsymptomaticPOP.Approximately40percentofwomenarefoundtohavestageIIorgreaterprolapseatannualgynecologicexaminationhowever,symptomsrelatedtoprolapseoftendonotcorrespondwithanatomicalfindings[912].(See"Pelvicorganprolapseinwomen:Anoverviewoftheepidemiology,riskfactors,clinicalmanifestations,andmanagement",sectionon'Clinicalmanifestations'.)

PREOPERATIVEEVALUATIONWomenwhoareconsideringpelvicreconstructivesurgeryforpelvicorganprolapse(POP)orstressurinaryincontinence(SUI)shouldhaveacomprehensiveevaluationtoguidesurgicalplanning.

GeneralevaluationAnevaluationincludes:

urinarystresstest(coughtest)toattempttodetectoccultSUI.(See"Approachtowomenwithurinaryincontinence",sectionon'Evaluation'.)

MedicalhistoryandsymptomsrelatedtoPOPandSUI(avoidingdiarymaybeuseful(figure2))

Pelvicexaminationwithobjectivequantificationofprolapse

Clinicalorurodynamicurinarystresstestingwithandwithoutreductionofprolapse

Assessmentofpatientgoalsandqualityoflife



ThediagnosticandpreoperativeevaluationofwomenwithPOPorSUIisdiscussedindetailseparately.(See"Pelvicorganprolapseinwomen:Diagnosticevaluation"and"Surgicalmanagementofstressurinaryincontinenceinwomen:Preoperativeevaluationforaprimaryprocedure".)

DetectingoccultincontinenceOccultSUIcanbedetectedbymedicalhistoryandclinicalorurodynamictestingwithreductionofprolapsedstructures.

CluesinthehistorythatsuggestoccultSUIinclude(1)incontinencethatimprovedorresolvedasprolapseworsened(2)theneedtomanuallyreplacetheprolapsedstructuresintothevaginatovoidor(3)worseningordevelopmentofSUIwithuseofapessary[9].

Onclinicalbladderfunctiontestingorurodynamictesting,womenwithPOPshouldbeevaluatedwithandwithoutreductionofprolapse.Thepurposeistosimulatethepatient'svaginalarchitectureaftersurgicalrepair.ReducingtheprolapsewilloftenreduceapreviouslyelevatedpostvoidresidualandunmaskSUI.

Prolapsereductionshouldbeperformedwhilethepatientisstanding.Whileelevatingtheprolapsedstructures,itisimportanttoavoidobstructingtheurethra,whichwouldmaskincontinence.Oneshouldalsoavoidplacingtheanteriorvaginalwallunderexcessivetension,whichcoulddistortthepelvicanatomy.(See"Approachtowomenwithurinaryincontinence",sectionon'Physicalexamination'.)

Themostcommonmethodsofprolapsereductionusethefollowingtoelevatethestructures:examiner'sfingers,largecottonswab,singlespeculumblade,ringforceps,orpessary.Whiletherearefewdatacomparingthesemethods,usingapessarymaybelesseffectiveatdetectingSUIthanothermethods[16,32].Thisislikelybecauseincontinencepessariesincreasethemaximumurethralclosurepressureandfunctionalurethrallengthand,thus,areoftenusedtotreatSUI[33].Somedatasuggestthatthebladdershouldbefilledtoatleast300mLinonestudy,occultSUIidentifiedwithuseofabladdervolumeof300mLwasmorelikelythan100mLtobeassociatedwithpostoperativeSUI[34].

Inthelargeststudytoevaluateprolapsereductiontesting,dataregardingprolapsereductionusingfivemethods(manual,swab,speculum,forceps,pessary)werecollectedinwomenwithadvancedprolapse,butwithoutsymptomsofSUI(n=322)[16].ThesensitivityfordetectionofoccultSUIwassimilaramongmostreductiontestingmethods(17to39percent),withtheexceptionofthepessary,whichwaslesssensitive(5percent).Inourpractice,weuseoneortwolargecottonswabsbecauseitiswelltoleratedbypatientsandtheswabsarelongenoughtoapproximateasurgicalsuspensionofthevaginalapex.

ProlapsereductiontestingmaybeperformedaspartofofficetestingofSUIorduringurodynamicevaluation.BothapproachesappeartohaveasimilarpredictivevalueforthedevelopmentofpostoperativeSUI.Thisisbasedupondatafromtwoprospectivestudiesofwomenwhounderwentpreoperativeprolapsereductiontestingandweretreatedwithaprolapserepairprocedure,butnocontinenceprocedure.Urodynamicevaluationwasusedinonestudy,andtherateofpostoperativedenovoSUIwas58percentforwomenwhotestedpositiveforpreoperativeoccultSUIand38percentforthosewhotestednegative[16].Intheotherstudy,officetestingwasused,andtherateofdenovoSUIwas72percentforwomenwhotestedpositiveand38percentforwomenwhotestednegative[13].

MoststudiesdefineoccultSUIasleakagewithprolapsereductionduringofficetestingorurodynamicevaluation,butsomereportsusedmaximumurethralclosurepressuresorpressuretransmissionratiosof



procedureand16percentwithanincontinenceprocedure.Inasymptomaticwomenwhohavenegativeprolapsereductiontesting,therateofpostoperativeSUIis26percentwithoutanincontinenceprocedureand17percentwithanincontinenceprocedure.

IntheabsenceofmoreeffectivemethodstodetectoccultSUI,however,reductiontestingshouldbeperformedinallwomenplanningvaginalpelvicfloorreconstructivesurgery.Furtherstudyisneededtoidentifyothermethods.

InformedconsentandpatientgoalsWomenplanningsurgicalcorrectionofpelvicfloorreconstructivesurgeryshouldbecounseledaboutthepotentialforincompleteresolutionofsymptoms,ornewsymptomsofSUI,urinaryretentionorurgencyincontinence.

Discussingpatientgoalsandsettingexpectationscanalsohelpboththepatientandsurgeonmeasuresurgicalsuccess.Achievementofpatientgoals,includingsymptomresolution,orimprovementinlifestyle,activity,orsexualfunction,correlatewithpostoperativesatisfaction[5,6].(See"Pelvicorganprolapseinwomen:Anoverviewoftheepidemiology,riskfactors,clinicalmanifestations,andmanagement",sectionon'Establishingpatientgoals'.)

CHOOSINGANABDOMINALORVAGINALAPPROACHForwomenwithbothstressurinaryincontinence(SUI)andpelvicorganprolapse(POP),thesurgicalroute(vaginalorabdominal,includinglaparoscopicorroboticprocedures)ischosenthatismostappropriatefortheanatomicsiteofprolapse(ie,anterior,apical,posterior)withthegoalofavoidingincisionsintwosites.AnabdominalapproachtypicallyincludesasacrocolpopexyandBurchcolposuspension,whileavaginalapproachmayincludeauterosacralligamentfixation(orothertransvaginalprocedure)andsuburethralsling(typicallyamidurethralsling).

Additionalfactorstoconsiderinchoosingarouteare:

Mostcombinedproceduresareperformedvaginallyforseveralreasons.Midurethralslingplacement,avaginalapproach,isthepreferredprocedureformostwomenwithSUI.Also,repairofanteriorandposteriorprolapseareusuallyperformedvaginally.(See"Surgicalmanagementofstressurinaryincontinenceinwomen:Choosingaprimarysurgicalprocedure".)

Theexceptiontothisisapicalprolapse,whichiscommonlyrepairedusinganabdominal(openorlaparoscopic)sacrocolpopexy.Apicalprolapsecanalsoberepairedviaavaginalroute,withsacrospinousoruterosacralligamentsuspension.Thechoiceofrouteforwomenwithapicalprolapsethendependsuponthebestcombinationofprocedures:(1)midurethralslingandsacrospinousoruterosacralligamentsuspensionor(2)Burchcolposuspensionandabdominalsacrocolpopexy.Evidencefromrandomizedtrialshasdemonstratedthatabdominalrepairsaremoredurable,whilevaginalrepairshavefewercomplications,includingforeignbodycomplications.Comparisonofsurgicaloutcomesforspecificproceduresisdiscussedindetailseparately.(See"Pelvicorganprolapseinwomen:Surgicalrepairofapicalprolapse(uterineorvaginalvaultprolapse)",sectionon'Abdominalversusvaginalapproach'.)

Alternatively,somesurgeonscombinesacralcolpopexywithamidurethralsling,particularlywhenalaparoscopicorroboticapproachisused.(See"Surgicalmanagementofstressurinaryincontinenceinwomen:Choosingaprimarysurgicalprocedure",sectionon'Apicalprolapse'.)

SELECTIONOFPROCEDUREThecombinationofsymptomsandfindingsonpreoperativeevaluationguidethechoiceofprocedurefortreatmentofpelvicorganprolapse(POP)and/orstressurinaryincontinence(SUI).ChoosingaprocedurethataddresseseitherPOPorSUIoracombinedprocedurefordifferentclinicalscenariosisdiscussedhere.

ThechoiceofaprimaryprocedurefortreatmentofSUIisdiscussedindetailseparately.(See"Surgical

Medicalhistorycomorbidities,priorsurgeriesProcedureefficacythisdependsuponprocedureandsurgeon'sexperience[47]Patientpreference



managementofstressurinaryincontinenceinwomen:Choosingaprimarysurgicalprocedure".)

SymptomaticPOPandSUIForwomenwithsymptomsofbothPOPandSUI,werecommendaconcomitantprolapserepairandcontinenceprocedureratherthanPOPrepairalone.DatafromprospectivecomparativestudiesofwomenwithbothsymptomaticPOPandSUIshowasignificantlylowerrateofpostoperativeSUIinwomenwhoundergobothPOPrepairandacontinenceprocedurecomparedwiththosewhoundergoPOPrepairalone(0to40versus36to71percent)(algorithm1)[35,42,4446].

ThereisnosingleprocedurethatadequatelytreatsbothPOPandSUI.Historically,theonlyexampleofaPOPrepairprocedurethatwasperformedwiththeintentionoftreatingSUIwasanteriorcolporrhaphyaloneorwithaKellyKennedyplication.ThisapproachhasbeenfoundtobelesseffectivefortreatmentofSUIthanaBurchcolposuspensionbaseduponrandomizedtrialdata.Likewise,availablecontinenceprocedures(suburethralslings,Burchcolposuspension)arenoteffectivefortreatingsymptomsassociatedwithPOP[42].(See"Surgicalmanagementofstressurinaryincontinenceinwomen:Choosingaprimarysurgicalprocedure",sectionon'Proceduresnolongerrecommended'.)

POPwithnosymptomsofSUIThemanagementofwomenwithsymptomaticPOP,butnoSUIsymptomsiscontroversial.ContinentwomenwithstageIPOPwhoareplanningprolapserepairareunlikelytohaveurethralobstructionandresultantoccultSUI,andthusareunlikelytobenefitfromaconcomitantcontinenceprocedure.However,forwomenwithadvancedprolapse,thereisahighlikelihoodthattheywilldevelopSUIpostoperatively.

TherearethreepossibleapproachesforaddressingpotentialSUIatthetimeofPOPtreatment:

Thechoicebetweentheseapproachesisbestsupportedbydatafromtwolargerandomizedtrials,oneforanabdominalsurgicalapproachandoneforavaginalapproach.

Regardinganabdominalapproach,theColpopexyandUrinaryReductionEfforts(CARE)trialsupportstheuniversalapproach.IntheCAREtrial,womenwithoutSUIsymptomswithstageIItoIVprolapsewereassignedtoundergoopensacrocolpopexywithorwithoutBurchcolposuspension[3,4850].Postoperatively,womenwhodevelopeddenovoSUIwereidentifiedusingquestionnaires,medicalvisitsseekingtreatmentforSUI,andpositivefindingsonstresstesting.Majorfindingswere:

UniversalAcontinenceprocedureisperformedatthetimeofPOPsurgery,regardlessofpreoperativeprolapsereductionandurinarystresstesting.

SelectivePreoperativeprolapsereductionandurinarystresstestingisperformed.IfoccultSUIisdetected,acontinenceprocedureisperformedatthetimeofPOPrepair.IfoccultSUIisnotdetected,POPrepairaloneisperformed.

StagedPOPrepairisperformedwithoutaconcomitantSUIprocedure,regardlessofpreoperativeprolapsereductionandurinarystresstesting.AsubsequentcontinenceprocedureisperformedifSUIsymptomsdevelopandthepatientdesiressurgicaltreatment.

InwomenwithadvancedPOPwhowerecontinentbeforesurgery,prophylacticBurchcolposuspensionatthetimeofopenabdominalsacrocolpopexyreducedpostoperativeSUI.TherateofSUIwasstatisticallysignificantlylowerintheBurchversusnoBurchgroupat3month(24and44percent)and24monthfollowup(32and45percent)[3,50].

TherateofpostoperativeSUIwashigherinwomenwithoccultSUIonpreoperativeurodynamicprolapsereductionandurinarystresstesting,butwasalsopresentatclinicallysignificantratesinwomenwithnooccultSUI.Inasubsetanalysisdividedintogroupsbypreoperativetestingresults,theratesofdenovopostoperativeSUIatthreemonthswere[14]:

OccultSUI:37percentintheBurchgroup60percentinthenoBurchgroup

NooccultSUI:20percentintheBurchgroup39percentinthenoBurchgroup



Regardingavaginalapproach,theOutcomesFollowingVaginalProlapseRepairandMidurethralSling(OPUS)trialfoundasimilardegreeofbenefitinpreventingdenovoSUIasintheCAREtrial,buttheriskofcomplicationswashigherinwomenwhounderwentacontinenceprocedure.IntheOPUStrial,womenwithoutSUIsymptomswithstageIItoIVprolapsewereassignedtoundergotransvaginalprolapserepair(apicalsuspension,anteriorrepair,colpocleisis)witheitheraretropubicmidurethralsling(TVT)orshambilateralsuprapubicincisions[13].

Postoperatively,womenwhodevelopeddenovoSUIwereidentifiedusingquestionnaires,medicalvisitsseekingtreatmentforSUI,andpositivefindingsonstresstesting.Majorfindingswere:

Baseduponthedatafromthesetwotrials,theapproachtocontinentwomenplanningPOPrepairdependsuponthesurgicalapproachandwhethertheywerefoundtohaveoccultSUIonpreoperativeprolapsereductionandurinarystresstesting.

ContinencecalculatorInaddition,acalculatorhasbeendevelopedtopredictpostoperativeSUIinstresscontinentwomenwhoareplanningprolapserepairsurgery[52].UsingdataregardingtherateofpostoperativeSUIfromtheOPUStrial,thecalculatorhadaconcordancescoreof0.72comparedwithascoreof0.62forprediction

TheadditionoftheBurchdidnotincreasethefrequencyofurinaryretention,urgencyincontinence,urinaryurgency,urinarytractinfection(UTI),orotherperioperativecomplications.Althoughcolposuspensionisnotatreatmentforurgencyincontinence,therateofurgencysymptomswaslowerintheBurchgroupat24monthfollowup(32versus45percent),butthedifferencewasnotstatisticallysignificant.

TherateofbothersomeSUIsymptomswassignificantlylowerintheBurchgroupat24monthfollowup(12versus25percent),andtherateofsubsequenttreatmentforSUIwaslowerintheBurchgroup,butthisdidnotreachstatisticalsignificance(13versus20percent).

Atsevenyearfollowup,theestimatedprobabilitiesoftreatmentfailurefortheurethropexygroupandthenourethropexygroup,respectively,were0.62and0.77forSUIand0.75and0.81foroverallUI[51].

InwomenwithadvancedPOPwhowerecontinentbeforesurgery,aprophylacticretropubicmidurethralslingatthetimeofvaginalprolapserepairreducedtherateofpostoperativeurinaryincontinence.Therateofincontinence(stress,urge,ormixed)ortreatmentforincontinencewassignificantlylowerintheslingversusshamgroupatthreemonthfollowup(24versus49percent).Therateofurinaryincontinencecontinuedtobesignificantlylowerintheslinggroupat12monthfollowup(27and43percent).

TherateofpostoperativeurinaryincontinencewashigherinwomenwithoccultSUIonpreoperativeofficebasedprolapsereductionandurinarystresstesting,butwasalsopresentatclinicallysignificantratesinwomenwithnooccultSUI.Inasubsetanalysisdividedintogroupsbypreoperativetestingresults,theratesofurinaryincontinenceatthreemonthswere:

OccultSUI:30percentintheslinggroup72percentintheshamgroup.

NooccultSUI:21percentintheslinggroup38percentintheshamgroup.

Therateofseriousadverseeventsdidnotdiffersignificantlybetweentheslingandshamgroups(17versus12percent).However,womenintheslinggrouphadsignificantlyhigherratesofbladderperforation(11versus0women7versus0percent)incompletebladderemptying(atsixweekspostoperatively)(6versus0women4versus0percent)andurinarytractinfection(31versus18percent).Allbladderperforationwasmanagedintraoperativelywithremovalandreplacementofthetrocar.

Therateofsubsequenttreatmentforincontinencewaslowerintheslinggroup,butsomewomenintheslinggrouprequiredsubsequentsurgeryforvoidingdysfunction.At12monthfollowup:

Slinggroup:12womenweretreatedforincontinence(7.3percent),including1whohadsurgery(0.6percent),and4womenhadsurgeryforvoidingdysfunction(2.4percent)

Shamgroup:19womenweretreated(11.0percent),including8whounderwentsurgery(4.7percent).



byagroupof22experturogynecologicsurgeonsand0.54forapreoperativeprolapsereductionurinarystresstest.Thecalculatorisavailableathttp://www.rcalc.com/ExistingFormulas.aspx?filter=CCQHS.

AbdominalapproachForcontinentwomenwithstageIIorgreaterPOPwhoareundergoingabdominalsacrocolpopexywithoutconcurrenttransvaginalrepairs(eg,colporrhaphy),auniversalapproachisoptimal.Forthesewomen,regardlessoftheresultsofpreoperativetestingforoccultSUI,werecommendaconcomitantBurchcolposuspensionratherthansacrocolpopexyalone.

Aconcomitantprocedureavoidsthemorbidityandrecoverytimerequiredfortwoseparateabdominalsurgeries.TheevidencetosupportthiscomesfromtheCAREstudy,asdiscussedabove,inwhichbenefitwasobservedinthosewitheitherpositiveornegativeprolapsereductiontestingandnoincreaseinadverseeventswasobservedinwomenwhounderwentaBurchprocedure[3,50].

VaginalapproachThebestapproachtomanagementislessclearforwomenwithPOPbutnosymptomsofSUIwhoareundergoingvaginalsurgery.Ashareddecisionmakingprocesswiththepatientisrequired.Patientcounselingshouldincludethepotentialbenefitsoftheprophylacticcontinencesurgery(basedupontheresultsofpreoperativeprolapsereductionandurinarystresstesting),potentialcomplications,andpatientgoalsandpreferences.

ThebestevidencetoguideclinicaldecisionmakingforthesewomenisfromtheOPUStrial,asdiscussedabove,whichdemonstratedthatthesewomenreceiveadegreeofbenefitfromprophylacticcontinencesurgerythatissimilartowomenwhoundergoabdominalsurgery[13].However,theadditionofaprophylacticmidurethralslingincreasestheriskofcomplications.ComplicationssuchasbladderperforationorUTItypicallydonotaddsignificantlytopostoperativemorbidity,andresolveeitherwithintraoperativetreatmentorshorttermuseofabladdercatheterorantibiotictherapy.However,somewomenwillhavepersistentvoidingdysfunctionfollowingmidurethralslingsurgery,requiringprolongedcatheterizationandpotentiallyasubsequentsurgicalprocedure.TherateofurethrolysisintheOPUStrial(2.4percent)wasconsistentwiththerateofpostslingpersistentvoidingdysfunctionreportedinotherstudies(0.6to2.0percent)[53,54].Thisisanimportantconsideration,sinceoneoftheprincipalbenefitsofprophylacticcontinencesurgeryisavoidingtheneedforasubsequentsurgery.(See"Surgicalmanagementofstressurinaryincontinenceinwomen:Retropubicmidurethralslings",sectionon'Voidingdysfunction'.)

Giventheavailableevidenceandclinicalconsiderations,forwomenundergoingvaginalsurgeryweuseaselectiveapproach,butsomewomenwithnegativepreoperativetestingforoccultSUImayreasonablychooseastagedapproach.

BasedupontheOPUStrialdata,usingauniversalapproach,thenumberneededtotreatinordertopreventonecaseofurinaryincontinenceat12monthswas6.3,althoughtherewasmodestevidencetosuggestthatpatientswithapositiveprolapsereductionstresstestbeforesurgeryreceivedmorebenefitthanthosewithanegativetest.

ManyexpertsconsiderwomenwithpositivetestingforoccultSUItobesimilartowomenwhopresentwithSUIsymptoms,andadviseacombinedprocedureforprolapseandSUI.WomenwithapositivepreoperativeprolapsereductionstresstestareatthehighestriskofpostoperativeSUI.IntheOPUStrial,therewasmodestevidencetosuggestthatpatientswithapositiveprolapsereductionstresstestbeforesurgeryreceivedmorebenefitthanthosewithanegativetest.TheoverallpositivepredictivevalueofthepreoperativeprolapsereductionstressforpostoperativeSUIbaseduponmultiplestudiesis51percent(algorithm1)anditwas72percentintheOPUStrial[1316,35,55,56].Usingaselectiveapproachandperformingcontinencesurgeryonlyinwomenwithapositiveprolapsereductionstresstest,thenumberneededtotreatinordertopreventonecaseofurinaryincontinenceatthreemonthswas2.4.

ForwomenwithstageIIorgreaterPOPandpositivepreoperativetestingforoccultSUI,werecommendacombinedprocedureforprolapseandSUIratherthanprolapserepairalone.

Ontheotherhand,womenwithnegativepreoperativetestingforoccultSUIshouldbecounseledaboutthe



availableoptionsandtherisksofurinaryincontinence,perioperativecomplications,andvoidingdysfunction.Managementofthesewomendependsupontheirvaluesandpreferences.

ConcomitantcontinencesurgeryintheOPUStrialinthispatientpopulationresultedinanabsoluteriskreductionforpostoperativeurinaryincontinenceof17percent[13].Thisratewasclinicallysignificant,butmustbeconsideredinrelationtotheriskofslingrelatedcomplicationsandassociatedmorbidity.

Ifastagedapproachisused,apatientwithstageIIorgreaterPOPwithoutsymptomsofSUIwouldonlyundergosurgeryforPOPwithnoconcomitantcontinenceprocedure.ThestagedproceduretypicallytakesplacewithinoneyearoftheoriginalprolapserepairanditisperformedonlyifthepatientdevelopssymptomsofbothersomeSUIrequiringcorrection.Theadvantageofthisapproachisthatunnecessaryprocedureswouldbeavoided.TheOPUStrialdemonstratedthat,forwomenwhounderwentonlyvaginalPOPrepair,49percentdevelopedSUI,butonly5percenthadaslingprocedureinthefirstyear.Comparedwithauniversalapproach,thestagedapproachresultedina95percentreductioninthenumberofslingsplaced.

Giventheavailabledataandclinicalconsiderations,forwomenwithstageIIorgreaterPOPwhoareundergoingvaginalsurgeryandwhohaveNEGATIVEpreoperativetestingforoccultSUI,wesuggestprolapserepairaloneratherthanacombinedprocedureforprolapseandSUI.ConcomitantPOPrepairandcontinencesurgeryisareasonableoptionforwomenwhoplaceahighpriorityonavoidingpostoperativeurinaryincontinenceandarewillingtoacceptanincreasedriskofperioperativecomplicationsandvoidingdysfunction.

ConcomitantversusstagedproceduresSomeexpertshavequestionedwhethertheSUIcurerateisimpacteddependinguponwhetherthecontinencesurgeryisperformedaloneorconcomitantwithaPOPrepairprocedure,butthereappearstobenodifferencebaseduponavailabledata.

ThisissuewasevaluatedinamulticenterrandomizedtrialofwomenwithPOPandSUIwhowereassignedtohaveatensionfreevaginaltape(TVT)eitherconcomitantwithprolapserepairorastagedprocedure(prolapserepairfollowedbyTVTthreemonthslater)[46].Inanintenttotreatanalysis,atoneyearfollowup,therewasnosignificantdifferencebetweentheconcomitantcomparedwithstagedgroupsinSUIcurerate(95versus89percent)ortotaloperativecomplications(18versus13percent).Ofnote,inthestagedgroup,TVTwasultimatelyperformedonlyinwomenwhohadconfirmedSUIatthreemonthsafterprolapserepair(56percent).AmongthewomeninthestagedgroupwhodidnotundergoTVT,oneyearoutcomeswereasfollows:27percentwerestillcontinentand15percenthadsomeSUI,butdeclinedTVT.

Inobservationaldatafromanothertrial,inwhichwomenwererandomizedtoundergoeitheraretropubicortransobturatormidurethralsling,thosewhodidversusdidnothaveconcomitantsurgeryhadsignificantlyhigherobjectivecurerates(88versus79percent),butnotsubjectivecurerates(62versus58percent)[57].Inaddition,observationalcomparativestudieshavefoundnosignificantdifferenceintheSUIcurerateforwomenwhounderwentmidurethralslingplacementalonecomparedtoslingplacementcombinedwithvaginalsurgery(hysterectomyorprolapserepair)[5860].Inaprospectivecohortstudy,womenwhounderwentprolapserepairconcomitantlywithmidurethralslingplacement,comparedwiththosewhoplannedastagedprocedure,hadnosignificantdifferencesinSUIsymptoms(22versus21percent),changeinseverityofSUI,orsatisfaction(8.8verus9.2ona10pointscale)atoneyearfollowup[61].Ofnote,only33percentofthewomenintheplannedstagedgroupunderwentslingplacementwithinthestudyperiod.

SUIwithasymptomaticPOPProlapse,particularlystagesIorII,isoftenasymptomatic[912].Thus,womenwhopresentwithsymptomsofSUIonly,buthavePOPonexamination,presentatreatmentdilemma.Theissueiswhetherrepairofasymptomaticprolapseprovidesawomanwithalongtermbenefit(eg,preventionofsubsequentsymptomsorsurgery)orifitonlyincreasestheriskofperioperativecomplications.

Animportantquestioniswhetherprolapseinthesewomenwillworsenand/orbecomesymptomaticwithageoraftermenopause.Surprisingly,thenaturalhistoryofprolapsedoesnotfollowaprogressivecourseinallwomen.Datasuggestthatthecourseisprogressiveuntilmenopause,afterwhichthedegreeofprolapsemayfollowacourseofalternatingprogressionandregression[6264].



WomenwithongoingriskfactorsforPOParelikelytohaveprogression.Theseincludeincreasingparity,hysterectomy,obesity,andchronicconstipation.Forobesewomen,weightlossdoesnotappeartoresultinregression[65].(See"Pelvicorganprolapseinwomen:Anoverviewoftheepidemiology,riskfactors,clinicalmanifestations,andmanagement",sectionon'Riskfactors'.)

Althoughnaturalregressionofprolapsemayoccur,combinedsurgicaltreatmentforSUIandPOPappearstoreducetheriskofsubsequentsurgery.Thiswasillustratedinaretrospectivestudyofinsuranceclaimsbyover1000womenwhounderwentaslingprocedureforSUI[47].Comparedtowomenwhodidnotundergoconcomitantprolapserepair,womenwhohadaconcomitantrepairweresignificantlylesslikelytohavesubsequentsurgeryforSUIorprolapsewithinoneyearoftheinitialsurgery(SUI:5versus10percentPOP:14versus22percent)[47].However,womenwhohadacombinedSUIandPOPrepairwerealsosignificantlymorelikelytohavepostoperativeurethralobstruction(9versus6percent).Thisstudywaslimitedbythelackofdataonthestageofprolapseandwhethersymptomswerepresent,thusmakingituncertainwhethertheresultsapplytoasymptomaticwomen.

Additionalsurgicalproceduresincreaseoperativetimeandmayincreasetheriskofperioperativecomplications[3,66].Inthestudydescribedabove,concurrentsurgeryforSUIandPOPwasassociatedwithanincreaseinpostoperativeurethralobstruction.However,itiscontroversialwhethercombinedproceduresleadtoanincreaseinobstructiveurinarysymptoms[47,6670].TherearenohighqualitystudiesofcombinedsurgeryforwomenwithSUIandmildorasymptomaticprolapse.

Giventheavailabledataandclinicalconsiderations,forwomenwithstageIasymptomaticprolapse,wesuggestNOTperformingprolapserepairatthetimeofcontinencesurgery.SinceprolapsehasnotbeenproventobeprogressiveandstageIprolapseisalmostneversymptomatic,repairinthesewomenappearstobeunnecessary.TreatmentofwomenwithstageIIorgreaterprolapsewhoareasymptomaticmustbeindividualizedbaseduponadiscussionwiththepatientabouthertreatmentgoalsandtheriskofsubsequentsurgery.(See'Informedconsentandpatientgoals'above.)

MANAGEMENTOFSPECIALPOPULATIONS

WomenathighsurgicalriskDependingonthedegreeofsurgicalrisk,womenwithstressurinaryincontinence(SUI)andpelvicorganprolapse(POP)canbetreatedusingconservativemeasures(eg,pessary,pelvicfloorexercises),however,surgerymaybeanoptionforsome.Colpocleisis(surgicalobliterationofthevaginallumen)istheprocedureofchoiceinwomenathighsurgicalriskwhoarenotplanningfurthersexualintercourseanddesiresurgicaltreatment.Thisprocedureinvolvesminimalsurgicalriskandcanbecombinedsafelyandeffectivelywithaslingprocedure[7072].(See"Pelvicorganprolapseinwomen:Obliterativeprocedures(colpocleisis)".)

WomenplanningfuturepregnancyWomenplanningfuturepregnancyshouldnotundergopelvicfloorreconstructivesurgery,sincepelvicsupportmaybedisruptedduringpregnancyanddeliveryandfurthersurgerymaybenecessaryafterpregnancy.Conservativemeasuresareappropriatetreatmentforthesepatients.(See"Vaginalpessarytreatmentofprolapseandincontinence"and"Treatmentandpreventionofurinaryincontinenceinwomen".)

SUMMARYANDRECOMMENDATIONS

Pelvicorganprolapse(POP)andstressurinaryincontinence(SUI)coexistinupto80percentofwomenwithpelvicfloorsymptoms.Thiscorrelationbetweentheseconditionsisduetotheircommonpathophysiology.(See'Introduction'above.)

Awomanmayfindsymptomsofprolapseandincontinenceequallybothersomeoroneconditionmaypredominateorbeasymptomatic.(See'Clinicalpresentation'above.)

Upto80percentofwomenwithadvancedPOPhaveoccultSUIcausedbyurethralobstruction.ThesewomenareatriskofdevelopingSUIafterprolapserepair.(See'Prolapsewithnosymptomsofincontinence'



UseofUpToDateissubjecttotheSubscriptionandLicenseAgreement.

REFERENCES

above.)

Allwomenwhoareconsideringpelvicreconstructivesurgeryshouldhaveacomprehensiveevaluationforbothprolapseandurinaryincontinencebeforetreatmentisplanned,including:assessmentofurinarysymptoms,pelvicexaminationwithobjectivequantificationofprolapse,clinicalorurodynamicurinarystresstestingwithreductionofprolapse,anddiscussionofpatientgoalsandqualityoflife.(See'Preoperativeevaluation'above.)

Preoperativeprolapsereductiontestinghasapositivepredictivevalueabove50percentforpostoperativeSUI.

ForwomenwithsymptomsofbothPOPandSUI,werecommendaconcomitantprolapserepairandcontinenceprocedureratherthanPOPrepairalone(Grade1B).(See'SymptomaticPOPandSUI'above.)

ForwomenwithsymptomaticPOPandnoSUIsymptoms(see'Prolapsewithnosymptomsofincontinence'above):

ContinentwomenwithstageIPOPwhoareplanningprolapserepairareunlikelytohaveurethralobstructionandresultantoccultSUI,andthusareunlikelytobenefitfromaconcomitantcontinenceprocedure.

ForwomenwithstageIIorgreaterPOPwhoareundergoingabdominalsacrocolpopexywithoutconcurrentvaginalrepairs,regardlessoftheresultsofpreoperativetestingforoccultSUI,werecommendaconcomitantBurchcolposuspensionratherthansacrocolpopexyalone(Grade1B).(See'Abdominalapproach'above.)

ForwomenwithstageIIorgreaterPOPwhoareundergoingvaginalsurgeryandwhohavePOSITIVEpreoperativetestingforoccultSUI,orhaveahighprobabilityofpostoperativestressincontinenceusingthecontinencecalculator,werecommendaconcomitantPOPrepairandcontinenceprocedureratherthanprolapserepairalone(Grade1B).(See'Vaginalapproach'aboveand'Continencecalculator'above.)

ForwomenwithstageIIorgreaterPOPwhoareundergoingvaginalsurgeryandwhohaveNEGATIVEpreoperativetestingforoccultSUI,orhavealowprobabilityofpostoperativestressincontinenceusingthecontinencecalculator,wesuggestprolapserepairaloneratherthanacombinedprocedureforprolapseandSUI(Grade2B).ConcomitantPOPrepairandcontinencesurgeryisareasonableoptionforwomenwhoplaceahighpriorityonavoidingpostoperativeurinaryincontinenceandarewillingtoacceptanincreasedriskofperioperativecomplicationsandvoidingdysfunction.(See'Vaginalapproach'aboveand'Continencecalculator'above.)

WomenwithSUIandasymptomaticprolapse(see'SUIwithasymptomaticPOP'above):

ForwomenwithstageIprolapse,wesuggestNOTperformingprolapserepairatthetimeofcontinencesurgery(Grade2C).

TreatmentofwomenwithstageIIorgreaterprolapsemustbeindividualizedaccordingtopatienttreatmentgoalsandtheriskofsubsequentsurgery.

Choiceofanabdominalorvaginalapproachismadebasedonthefollowingfactors:anatomiclocationoftheprolapse,medicalhistory,procedureefficacy,patientpreference,andsurgeon'sexperience.(See'Choosinganabdominalorvaginalapproach'above.)



1. BaiSW,JeonMJ,KimJY,etal.Relationshipbetweenstressurinaryincontinenceandpelvicorganprolapse.IntUrogynecolJPelvicFloorDysfunct200213:256.

2. MaherCM,FeinerB,BaesslerK,GlazenerCM.Surgicalmanagementofpelvicorganprolapseinwomen:theupdatedsummaryversionCochranereview.IntUrogynecolJ201122:1445.

3. BrubakerL,CundiffGW,FineP,etal.AbdominalsacrocolpopexywithBurchcolposuspensiontoreduceurinarystressincontinence.NEnglJMed2006354:1557.

4. WintersJC.Acriticalappraisalofpreventiveslingsandprolapsesurgerywhat'saurologisttodo?JUrol2008180:809.

5. ElkadryEA,KentonKS,FitzGeraldMP,etal.Patientselectedgoals:anewperspectiveonsurgicaloutcome.AmJObstetGynecol2003189:1551.

6. MahajanST,ElkadryEA,KentonKS,etal.Patientcenteredsurgicaloutcomes:theimpactofgoalachievementandurgeincontinenceonpatientsatisfactiononeyearaftersurgery.AmJObstetGynecol2006194:722.

7. RamanSV,RakerCA,SungVW.Concomitantapicalprolapserepairandincontinenceprocedures:trendsfrom20012009intheUnitedStates.AmJObstetGynecol2014211:222.e1.

8. MuellerER,KentonK,MahajanS,etal.Urodynamicprolapsereductionaltersurethralpressurebutnotfillingorpressureflowparameters.JUrol2007177:600.

9. EllerkmannRM,CundiffGW,MelickCF,etal.Correlationofsymptomswithlocationandseverityofpelvicorganprolapse.AmJObstetGynecol2001185:1332.

10. GutmanRE,FordDE,QuirozLH,etal.Isthereapelvicorganprolapsethresholdthatpredictspelvicfloorsymptoms?AmJObstetGynecol2008199:683.e1.

11. SwiftS,WoodmanP,O'BoyleA,etal.PelvicOrganSupportStudy(POSST):thedistribution,clinicaldefinition,andepidemiologicconditionofpelvicorgansupportdefects.AmJObstetGynecol2005192:795.

12. Mouritsen,L,Larsen,JP.Symptoms,botherandPOPQinwomenreferredwithpelvicorgan.13. WeiJT,NygaardI,RichterHE,etal.Amidurethralslingtoreduceincontinenceaftervaginalprolapse

repair.NEnglJMed2012366:2358.14. LiangCC,ChangYL,ChangSD,etal.Pessarytesttopredictpostoperativeurinaryincontinenceinwomen

undergoinghysterectomyforprolapse.ObstetGynecol2004104:795.15. ReenaC,KekreAN,KekreN.Occultstressincontinenceinwomenwithpelvicorganprolapse.IntJ

GynaecolObstet200797:31.16. ViscoAG,BrubakerL,NygaardI,etal.Theroleofpreoperativeurodynamictestinginstresscontinent

womenundergoingsacrocolpopexy:theColpopexyandUrinaryReductionEfforts(CARE)randomizedsurgicaltrial.IntUrogynecolJPelvicFloorDysfunct200819:607.

17. BumpRC,FantlJA,HurtWG.Themechanismofurinarycontinenceinwomenwithsevereuterovaginalprolapse:resultsofbarrierstudies.ObstetGynecol198872:291.

18. ChaikinDC,GroutzA,BlaivasJG.Predictingtheneedforantiincontinencesurgeryincontinentwomenundergoingrepairofsevereurogenitalprolapse.JUrol2000163:531.

19. GallentineML,CespedesRD.Occultstressurinaryincontinenceandtheeffectofvaginalvaultprolapseonabdominalleakpointpressures.Urology200157:40.

20. GordonD,GoldRS,PauznerD,etal.Combinedgenitourinaryprolapserepairandprophylactictensionfreevaginaltapeinwomenwithsevereprolapseandoccultstressurinaryincontinence:preliminaryresults.Urology200158:547.

21. GroutzA,GoldR,PauznerD,etal.Tensionfreevaginaltape(TVT)forthetreatmentofoccultstressurinaryincontinenceinwomenundergoingprolapserepair:aprospectivestudyof100consecutivecases.NeurourolUrodyn200423:632.

22. RichardsonDA,BentAE,OstergardDR.Theeffectofuterovaginalprolapseonurethrovesicalpressuredynamics.AmJObstetGynecol1983146:901.

23. RosenzweigBA,PushkinS,BlumenfeldD,BhatiaNN.Prevalenceofabnormalurodynamictestresultsincontinentwomenwithseveregenitourinaryprolapse.ObstetGynecol199279:539.

24. SinhaD,ArunkalaivananAS.Prevalenceofoccultstressincontinenceincontinentwomenwithseveregenitalprolapse.JObstetGynaecol200727:174.



25. StantonSL,HiltonP,NortonC,CardozoL.Clinicalandurodynamiceffectsofanteriorcolporrhaphyandvaginalhysterectomyforprolapsewithandwithoutincontinence.BrJObstetGynaecol198289:459.

26. GroutzA,LevinI,GoldR,etal."Insideout"transobturatortensionfreevaginaltapeformanagementofoccultstressurinaryincontinenceinwomenundergoingpelvicorganprolapserepair.Urology201076:1358.

27. BergmanA,KooningsPP,BallardCA.Predictingpostoperativeurinaryincontinencedevelopmentinwomenundergoingoperationforgenitourinaryprolapse.AmJObstetGynecol1988158:1171.

28. ColomboM,MaggioniA,ZanettaG,etal.Preventionofpostoperativeurinarystressincontinenceaftersurgeryforgenitourinaryprolapse.ObstetGynecol199687:266.

29. KlutkeJJ,RamosS.Urodynamicoutcomeaftersurgeryforsevereprolapseandpotentialstressincontinence.AmJObstetGynecol2000182:1378.

30. AlMandeelH,RossS,RobertM,MilneJ.Incidenceofstressurinaryincontinencefollowingvaginalrepairofpelvicorganprolapseinobjectivelycontinentwomen.NeurourolUrodyn201130:390.

31. KasturiS,DiazSI,McDermottCD,etal.Denovostressurinaryincontinenceafternegativeprolapsereductionstresstestingfortotalvaginalmeshprocedures:incidenceandriskfactors.AmJObstetGynecol2011205:487.e1.

32. VeronikisDK,NicholsDH,WakamatsuMM.Theincidenceoflowpressureurethraasafunctionofprolapsereducingtechniqueinpatientswithmassivepelvicorganprolapse(maximumdescentatallvaginalsites).AmJObstetGynecol1997177:1305.

33. BhatiaNN,BergmanA,GunningJE.Urodynamiceffectsofavaginalpessaryinwomenwithstressurinaryincontinence.AmJObstetGynecol1983147:876.

34. SvenningsenR,BorstadE,SpydslaugAE,etal.Occultincontinenceaspredictorforpostoperativestressurinaryincontinencefollowingpelvicorganprolapsesurgery.IntUrogynecolJ201223:843.

35. deTayracR,GervaiseA,ChauveaudLamblingA,FernandezH.Combinedgenitalprolapserepairreinforcedwithapolypropylenemeshandtensionfreevaginaltapeinwomenwithgenitalprolapseandstressurinaryincontinence:aretrospectivecasecontrolstudywithshorttermfollowup.ActaObstetGynecolScand200483:950.

36. BarnesNM,DmochowskiRR,ParkR,NittiVW.Pubovaginalslingandpelvicprolapserepairinwomenwithoccultstressurinaryincontinence:effectonpostoperativeemptyingandvoidingsymptoms.Urology200259:856.

37. OlsenAL,SmithVJ,BergstromJO,etal.Epidemiologyofsurgicallymanagedpelvicorganprolapseandurinaryincontinence.ObstetGynecol199789:501.

38. SubakLL,WaetjenLE,vandenEedenS,etal.CostofpelvicorganprolapsesurgeryintheUnitedStates.ObstetGynecol200198:646.

39. BorstadE,RudT.Theriskofdevelopingurinarystressincontinenceaftervaginalrepairincontinentwomen.Aclinicalandurodynamicfollowupstudy.ActaObstetGynecolScand198968:545.

40. BumpRC,HurtWG,TheofrastousJP,etal.RandomizedprospectivecomparisonofneedlecolposuspensionversusendopelvicfasciaplicationforpotentialstressincontinenceprophylaxisinwomenundergoingvaginalreconstructionforstageIIIorIVpelvicorganprolapse.TheContinenceProgramforWomenResearchGroup.AmJObstetGynecol1996175:326.

41. ColomboM,MaggioniA,ScalambrinoS,etal.Surgeryforgenitourinaryprolapseandstressincontinence:arandomizedtrialofposteriorpubourethralligamentplicationandPereyrasuspension.AmJObstetGynecol1997176:337.

42. ColomboM,VitobelloD,ProiettiF,MilaniR.RandomisedcomparisonofBurchcolposuspensionversusanteriorcolporrhaphyinwomenwithstressurinaryincontinenceandanteriorvaginalwallprolapse.BJOG2000107:544.

43. GroutzA,GordonD,WolmanI,etal.TheuseofprophylacticStameybladdernecksuspensiontopreventpostoperativestressurinaryincontinenceinclinicallycontinentwomenundergoinggenitourinaryprolapserepair.NeurourolUrodyn200019:671.

44. PartollLM.Efficacyoftensionfreevaginaltapewithotherpelvicreconstructivesurgery.AmJObstetGynecol2002186:1292.

45. WilleS,BraunM,HeidenreichA,etal.SacralcolpopexywithconcurrentBurchcolposuspensioninpatientswithvaginalvaultprolapse.UrolInt200676:339.



46. BorstadE,AbdelnoorM,StaffAC,KulsengHanssenS.Surgicalstrategiesforwomenwithpelvicorganprolapseandurinarystressincontinence.IntUrogynecolJ201021:179.

47. AngerJT,LitwinMS,WangQ,etal.Theeffectofconcomitantprolapserepaironslingoutcomes.JUrol2008180:1003.

48. BrubakerL,CundiffG,FineP,etal.Arandomizedtrialofcolpopexyandurinaryreductionefforts(CARE):designandmethods.ControlClinTrials200324:629.

49. BurgioKL,NygaardIE,RichterHE,etal.Bladdersymptoms1yearafterabdominalsacrocolpopexywithandwithoutBurchcolposuspensioninwomenwithoutpreoperativestressincontinencesymptoms.AmJObstetGynecol2007197:647.e1.

50. BrubakerL,NygaardI,RichterHE,etal.Twoyearoutcomesaftersacrocolpopexywithandwithoutburchtopreventstressurinaryincontinence.ObstetGynecol2008112:49.

51. NygaardI,BrubakerL,ZyczynskiHM,etal.Longtermoutcomesfollowingabdominalsacrocolpopexyforpelvicorganprolapse.JAMA2013309:2016.

52. JelovsekJE,ChaginK,BrubakerL,etal.Amodelforpredictingtheriskofdenovostressurinaryincontinenceinwomenundergoingpelvicorganprolapsesurgery.ObstetGynecol2014123:279.

53. RardinCR,RosenblattPL,KohliN,etal.Releaseoftensionfreevaginaltapeforthetreatmentofrefractorypostoperativevoidingdysfunction.ObstetGynecol2002100:898.

54. LaurikainenE,KiilholmaP.Anationwideanalysisoftransvaginaltapereleaseforurinaryretentionaftertensionfreevaginaltapeprocedure.IntUrogynecolJPelvicFloorDysfunct200617:111.

55. EnnemoserS,SchnfeldM,vonBodungenV,etal.Clinicalrelevanceofoccultstressurinaryincontinence(OSUI)followingvaginalprolapsesurgery:longtermfollowup.IntUrogynecolJ201223:851.

56. JundtK,WagnerS,vonBodungenV,etal.OccultincontinenceinwomenwithpelvicorganprolapseDoesitmatter?EurJMedRes201015:112.

57. RichterHE,AlboME,ZyczynskiHM,etal.Retropubicversustransobturatormidurethralslingsforstressincontinence.NEnglJMed2010362:2066.

58. MeltomaaS,BackmanT,HaaralaM.Concomitantvaginalsurgerydidnotaffectoutcomeofthetensionfreevaginaltapeoperationduringaprospective3yearfollowupstudy.JUrol2004172:222.

59. RafiiA,PaolettiX,HaabF,etal.Tensionfreevaginaltapeandassociatedprocedures:acasecontrolstudy.EurUrol200445:356.

60. HuangKH,KungFT,LiangHM,etal.ConcomitantpelvicorganprolapsesurgerywithTVTprocedure.IntUrogynecolJPelvicFloorDysfunct200617:60.

61. JoYH,KimK,RheeJE,etal.Theaccuracyofemergencymedicineandsurgicalresidentsinthediagnosisofacuteappendicitis.AmJEmergMed201028:766.

62. BradleyCS,ZimmermanMB,QiY,NygaardIE.Naturalhistoryofpelvicorganprolapseinpostmenopausalwomen.ObstetGynecol2007109:848.

63. HandaVL,GarrettE,HendrixS,etal.Progressionandremissionofpelvicorganprolapse:alongitudinalstudyofmenopausalwomen.AmJObstetGynecol2004190:27.

64. DietzHP.Prolapseworsenswithage,doesn'tit?AustNZJObstetGynaecol200848:587.65. KudishBI,IglesiaCB,SokolRJ,etal.Effectofweightchangeonnaturalhistoryofpelvicorganprolapse.

ObstetGynecol2009113:81.66. YipSK,PangMW.Tensionfreevaginaltapeslingprocedureforthetreatmentofstressurinaryincontinence

inHongKongwomenwithandwithoutpelvicorganprolapse:1yearoutcomestudy.HongKongMedJ200612:15.

67. WangKH,WangKH,NeimarkM,DavilaGW.VoidingdysfunctionfollowingTVTprocedure.IntUrogynecolJPelvicFloorDysfunct200213:353.

68. Ballert,KN,Biggs,G,Isenalumhe,A,RosenblumNandNittiVW.Managingtheurethraatthetimeoftransvaginalpelvicorganprolapserepair:aurodynamicapprach(abstract).NeurourolUrodyn200827:147.

69. SokolAI,JelovsekJE,WaltersMD,etal.IncidenceandpredictorsofprolongedurinaryretentionafterTVTwithandwithoutconcurrentprolapsesurgery.AmJObstetGynecol2005192:1537.

70. AbbasyS,LowensteinL,PhamT,etal.Urinaryretentionisuncommonaftercolpocleisiswithconcomitantmidurethralsling.IntUrogynecolJPelvicFloorDysfunct200920:213.



71. AgarwalaN,HasiakN,ShadeM.Graftinterpositioncolpocleisis,perineorrhaphy,andtensionfreeslingforpelvicorganprolapseandstressurinaryincontinenceinelderlypatients.JMinimInvasiveGynecol200714:740.

72. MooreRD,MiklosJR.Colpocleisisandtensionfreevaginaltapeslingforsevereuterineandvaginalprolapseandstressurinaryincontinenceunderlocalanesthesia.JAmAssocGynecolLaparosc200310:276.

Topic8068Version22.0



GRAPHICS

Anatomyofoccultstressurinaryincontinence

(A)Advancedanteriororapicalpelvicorganprolapse(usuallyprolapsepastthevaginalintroitus)displacesthebladderneckposteriorlyandtheurethraiskinked,resultinginurethralobstruction.Theobstructionthenbecomesthemechanismofcontinence.(B)Whentheprolapsedstructuresareelevated(approximatingnormalanatomy)duringprolapsereductiontestinginwomenwithurethralobstructionduetoadvancedprolapse,theurethraisunblockedandstressurinaryincontinenceoftenbecomesevidentwhenaurinarystresstestisperformed.

CourtesyofJasmineTanKim,MD.

Graphic85778Version1.0



Riskofdevelopingpostoperativestressurinaryincontinenceinwomenundergoingsurgeryforpelvicorganprolapse

SUP:suburethralplicationTVT:tensionfreevaginaltapeRPU:retropubicurethropexyNS:needlesuspensionPS:pubovaginalsling%:percent.*Symptomsrecordedperpatientreport.



Denotesabdominalprocedures,allotherprocedureswereperformedvaginally.




Voidingdiary

Thisdiarywillhelpusdeterminewhyyouhavetroubleholdingyoururine,orwhyyougotothebathroomveryoftenKeepthisrecordforatleast2days.Pleasewritedown4thingseverytimeyoupassorleakurine:

1. Thetime(forexample,"10:30AM")



2. Theamountofurinethatyoupass3. Whetheryouleakedanyurine(were"wet")ornot(were"dry")4. Whetheranythingspecialmayhavecausedyoutogo(forinstance,"justhad

coffee,""coughed,""wasrunningtothebathroom,""justtookmywaterpill")Starttherecordinthemorningthefirsttimeyougotothebathroomafteryougetup.Pleasewriteontheformthetimeyougotupandthetimeyouwenttobed.Tomeasuretheamountofurineyoupass,wewillgiveyouaspecialreceptacle(calleda"hat").Placethehatinthetoilettocatchtheurineeverytimeyougo.Lookathowhightheurinefillsthehat,andwritedowntheamountfromthenumbersontheinsideofthehat.Remembertoemptythehataftereachtimeyougo.Ifyouleakurineandcannotmeasuretheamountthatcameout,writedownyourbestguess.




Disclosures:CharlesWNager,MDNothingtodisclose.JasmineTanKim,MDGrant/Research/ClinicalTrialSupport:BostonScientific[vaginalmesh(midurethralslings)].todisclose.Contributordisclosuresarereviewedforconflictsofinterestbytheeditorialgroup.Whenfound,theseareaddressedbyvettingthroughamultilevelreviewprocess,andthroughrequirementsforreferencestobeprovidedtosupportthecontent.AppropriatelyreferencedcontentisrequiredofallauthorsandmustconformtoUpToDatestandardsofevidence.Conflictofinterestpolicy

Disclosures

Pelvic organ prolapse and stress urinary incontinence in women_ Combined surgical treatment.pdf

Documents

Transcript of Pelvic organ prolapse and stress urinary incontinence in women_ Combined surgical treatment.pdf