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ORIGINAL RESEARCH |
From the Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan.
Address reprint requests to: Ching-Chung Liang, MD, Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Medical Center, 5, Fu-Shin Street, Kweishan, Taoyuan, Taiwan, ROC, 333; e-mail: ccjoliang{at}cgmh.org.tw.
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ABSTRACT |
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 ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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METHODS: Among the 79 patients evaluated for severe pelvic organ prolapse without symptoms of stress urinary incontinence, all underwent meticulous urogynecologic evaluations and pessary testing. In group 1, 32 patients had positive pessary tests and underwent vaginal hysterectomy, anterior and posterior colporrhaphy, and TVT. In group 2, 47 patients (17 of whom had positive pessary tests and 30 of whom had negative pessary tests) underwent vaginal hysterectomy and anterior and posterior colporrhaphy alone. A comparison in terms of surgical outcome and clinical manifestations was made between these 2 groups of patients.
RESULTS: After surgery, a small proportion of patients had de novo idiopathic detrusor overactivity (7.6%, n = 6), urinary tract infections (7.6%, n = 6), mild recurrent prolapse (5.1%, n = 4), and urinary retention (3.8%, n = 3). Eleven (64.7%) of 17 patients with positive pessary tests who did not undergo TVT had urine leakage after their hysterectomies in contrast with the 30 patients who had negative pessary test, none of whom developed symptomatic stress urinary incontinence after vaginal hysterectomy. Among the 32 patients with positive pessary tests who had TVT with their hysterectomies, 3 developed urine leakage later; the cure rate was 90.6%.
CONCLUSION: Continent patients suffering from severe pelvic organ prolapse but with a positive pessary test are considered to be at high risk of developing postoperative symptomatic stress urinary incontinence. Among the patients in our medium-range study, TVT effectively prevented postsurgical urinary incontinence.
LEVEL OF EVIDENCE: II-1
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MATERIALS AND METHODS |
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The urodynamic studies included sitting provocative water cystometry (at a filling rate of 60 mL/min), urethral profilometry at rest, and repeated coughing with the bladder at maximum cystometric capacity in the sitting position with reduction of the prolapse with a properly fitted vaginal ring pessary. The diagnosis of urodynamic stress incontinence was made if the patient had symptoms of stress urinary incontinence and observable leakage with stress but without simultaneous detrusor activity during cystometry and urethral profilometry. Idiopathic detrusor overactivity was diagnosed if the patient complained of urgency or urge urinary incontinence and had detrusor contraction and urine leakage on filling cystometry. Mixed urinary incontinence was diagnosed if both occult stress urinary incontinence and an involuntary detrusor contraction were found in the same patient. Diagnostic urethrocystoscopy was performed to evaluate the bladder conditions, for example, the presence of trabeculation.
The patients were divided into 2 groups. In group 1, 32 patients had positive pessary test results and underwent total vaginal hysterectomy, anterior and posterior colporrhaphy (anterior and posterior repair), and TVT. In group 2, of 47 patients who underwent vaginal hysterectomy and anterior and posterior repair alone, 17 had positive pessary tests but did not undergo TVT because prophylactic anti-incontinence surgery to prevent posthysterectomy stress urinary incontinence was still controversial and because our national health insurance did not cover TVT. We assigned these 17 patients to group 2a, and we assigned remaining 30 patients with a negative pessary test result to group 2b.
Except for 4 patients who received general anesthesia, 75 (94.9%) were treated with epidural or spinal anesthesia. The vaginal hysterectomy and anterior and posterior repair procedures were performed as described in our previous report.10 With the uterus extirpated and abdominal peritoneum closed, the uterosacral and cardinal ligaments were tied to each other across the midline, and then they were sutured onto either side of the vaginal cuff to prevent vaginal vault prolapse and enterocele. Approximation of bilateral pubocervical fasciae was routinely performed during anterior colporrhaphy for our patients to reinforce the central part of bladder. After vaginal hysterectomy and cystocele repair, the TVT procedure was performed through 2 separate suprapubic and 1 suburethral incision wounds as described by Ulmsten et al.11
The Foley catheter was removed on postoperative day 3, allowing the patients to attempt to void spontaneously. Intermittent catheterization was stopped once the amount of the postvoid residual urine volume was consecutively less than one fourth of the voided volume 3 times. The patients were evaluated postoperatively at 1 month, 3–6 months, 1 year, and then annually. At the 3- to 6-month follow-up, postoperative urodynamic studies were performed in those patients with abnormal urodynamic findings before surgery and those with de novo urinary incontinence or urgency after surgical correction. An objective cure was defined as no leakage of urine at maximum cystometric capacity while the patient coughed in the sitting position during urodynamic studies, less than 2 mL of urine leakage on the 1-hour pad test, and no urine leakage recorded in the micturition diary. A patient was considered to have achieved subjective cure if she reported no loss of urine during any activity with increased intraabdominal pressure.
The data were summarized as means ± standard deviations or percentages, as appropriate. Analysis was performed by using the unpaired 2-tailed Student t test for normally distributed continuous data, the Mann–Whitney U test for continuous data that did not fit a Gaussian curve, and the Fisher exact test for categorical data. The preoperative and postoperative urodynamic data in group 1 cases were compared by paired t test. Multivariable logistic regression was conducted to determine independent predictors of idiopathic detrusor overactivity. Statistical significance was considered at P < .05.
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RESULTS |
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In preoperative evaluations, there were no significant differences in voiding symptoms between the 2 groups (Table 2). Urinary irritation symptoms were common, with more than 90% of the women reporting some degree of frequency and urgency. Symptoms of obstructive voiding also were commonly reported. Nearly one half of our patients experienced urinary hesitancy, weak or intermittent urine stream, incomplete bladder emptying, or straining during voiding. A large percentage of the women also complained of symptoms suggestive of pelvic floor prolapse, including 73 (92.4%) patients with a protruding mass in the vaginal area, 58 (73.4%) with a "bearing-down" sensation on standing or activity, and 17 (21.5%) with backache. Nine (11.4%) patients complained of postmenopausal spotting produced by cervix uteri protrusion or vaginal eversion. Twelve (15.2%) patients complained of constipation, and 4 (5%) had dyspareunia. More patients (28/32) in group 1 reported the sensation of "bearing down" than did those (31/47) in group 2 (P = .037). Other prolapse symptoms did not differ between the groups (Table 2).
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All patients underwent multichannel urodynamic testing with the prolapse reduced before surgery. Twenty-eight patients had no detectable abnormality, whereas the remaining 51 had abnormal urodynamic findings. Of the 51 patients, 30 in group 1 and 17 in group 2a had only urodynamic stress incontinence, 2 in group 2b had only idiopathic detrusor overactivity, and 2 in group 1 had mixed urinary incontinence. Urodynamic parameters for all 32 patients in group 1 who underwent vaginal hysterectomy and TVT were given in Table 3 and reflected no significant differences before and after surgery, except for maximum cystometric capacity and maximum detrusor pressure (P = .007 and P = .009, respectively). The maximum cystometric capacity decreased and maximum detrusor pressure increased after surgery. We also found that 5 (16%) patients had de novo idiopathic detrusor overactivity, whereas the 2 patients with mixed urinary incontinence had normal urodynamic findings after surgery. Thus, the objective cure rate of the TVT procedure for prophylactic anti-incontinence was 100% at the 3- to 6-month follow-up. Because 3 patients developed mild urine leakage during follow-up (7, 9, and 13 months after surgery), the subjective cure rate was 90.6%.
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In group 2a, of the 17 patients with a positive pessary test, 9 (52.9%) had urine leakage on postoperative urodynamic testing, 2 (11.8%) had clinical urine leakage without abnormal urodynamic findings, 5 (29.4%) had normal urodynamic findings, and 1 (5.9%) had de novo idiopathic detrusor overactivity. In group 2b, none of the 30 patients with a negative pessary test had de novo stress or urge urinary incontinence postoperatively. Of the 2 patients with idiopathic detrusor overactivity preoperatively, 1 had normal urodynamic findings and 1 had persistent idiopathic detrusor overactivity after surgery. When comparing group 2a and 2b, who both received total vaginal hysterectomy and anterior and posterior repair alone, the postsurgical urinary incontinence rate was significantly higher for 2a patients than for 2b patients (52.9% versus 0%; P < .001). When comparing the outcomes of patients with preoperative occult stress urinary incontinence between groups 1 and 2a, the subjective and objective stress urinary incontinence rates were significantly lower for group 1 patients who received an additional TVT procedure than for group 2b patients who did not (P < .001; Table 4).
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Diagnostic urethrocystoscopy performed in all the 79 patients as a part of preoperative work-up found trabeculation present in 52 patients (65.8%) and absent in 27 patients (34.2%). To assess the risk factors in relation with postoperative idiopathic detrusor overactivity, several preoperative variables were assessed using a forward selection procedure with entry of P values < .05 and removal of P values > .1. Variables evaluated included hormone therapy, menopause, parity, voiding symptoms, vaginal mass, residual urine volume, maximum cystometric capacity, maximum urethral closure pressure, functional urethral length, and bladder trabeculation. After running logistic regression analysis on all these variables, we discovered trabeculation as the single significant factor with the odds ratio at 2.07 and P value at .039.
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DISCUSSION |
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As a matter of fact, the selection of prophylactic anti-incontinence procedure is still an area of great debate. Some investigators recommend the addition of a modified Burch procedure, and others advocate needle procedures or slings.10,14–16 Chaikin et al14 performed pubovaginal sling in 14 women with pelvic prolapse and occult stress urinary incontinence and reported that postsurgical stress urinary incontinence developed in 14%. In 3 separate prospective studies by Gordon and Groutz et al,17–19 they studied the results of prophylactic Kelly plication, Stamey procedure, and TVT procedure in clinically continent women undergoing urogenital prolapse repair. They found that 50% of patients developed symptomatic postoperative stress urinary incontinence for Kelly plication, 23% for Stamey bladder neck suspension, and none of the patients who received the TVT procedure. In a recent randomized study, Meschia et al20 compared the results of TVT and endopelvic fascia plication in 50 women with genital prolapse and occult stress urinary incontinence. They then recommended performing TVT for patients with prolapse and occult stress urinary incontinence because subjective (96% versus 64%) and objective (92% versus 56%) continence rates were significantly higher after the TVT procedure. The TVT procedure has been proven to be an efficient method to prevent postoperative stress urinary incontinence in clinically continent women undergoing prolapse repair.
Klutke and Ramos16 believed that it was not necessary to perform a prophylactic anti-incontinence surgery in patients with a negative pessary test result. In their retrospective review of 70 patients without demonstrable leakage on preoperative placement of a pessary, none had stress urinary incontinence after reconstruction of the prolapse. However, Klutke and Ramos and other investigators who used prophylactic anti-incontinence surgery for treating occult stress urinary incontinence and prolapse on the basis of the results of urodynamic testing did not study how many patients with a positive test result would have had stress urinary incontinence had they not had an anti-incontinence procedure. The results of our current study contribute to the answer of the aforementioned question. Eleven of the 17 (64.7%) patients with a positive pessary test who did not undergo concomitant TVT had urine leakage after vaginal hysterectomy. None of the 30 patients with a negative pessary test had de novo stress or urge urinary incontinence postoperatively. We believe that patients with negative pessary tests will not have stress urinary incontinence after prolapse repair and, thus, do not need prophylactic anti-incontinence surgery.
Of the 32 patients with occult stress urinary incontinence who received TVT, none had urodynamic evidence of stress urinary incontinence during the 3- to 6-month follow-up. At continuing follow-up, 3 patients later developed mild urine leakage, taking the subjective cure rate to 90.6% for at least 1 year after surgery. A small portion of these patients had urinary tract infection, urinary retention (requiring a catheter for >7 days), and mild recurrent prolapse after surgery.
Gordon et al17 performed TVT on patients suffering from urogenital prolapse with coexistent occult stress urinary incontinence and reported that postoperative de novo idiopathic detrusor overactivity developed in 13% of patients. In our series, idiopathic detrusor overactivity occurred in 16% of patients with occult stress urinary incontinence who received prophylactic TVT. With regard to the relationship between postoperative idiopathic detrusor overactivity and preoperative bladder trabeculation, our study found a slightly significant correlation (P = .039). Whether it is unique to the uterine prolapse situation is an issue that may require further larger series studies to resolve because as many as 65.8% of our patients presented with trabeculation findings in preoperative urethrocystoscopic evaluation, which could be secondary to urethral kinking or increased urethral resistance caused by uterine prolapse.
In conclusion, women with severe pelvic organ prolapse need a preoperative urodynamic evaluation to rule out coexistent stress urinary incontinence. Patients without occult stress urinary incontinence do not need prophylactic anti-incontinence surgery after prolapse repair. Continent patients with a positive stress test were considered at high risk of developing postoperative symptomatic stress urinary incontinence. In these patients, the TVT procedure proved to be an effective measure in reducing postsurgical urinary incontinence as shown from our medium-range follow-up study.
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Footnotes |
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10.1097/01.AOG.0000140689.90131.01
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REFERENCES |
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17. Gordon D, Gold RS, Pauzner D, Lessing JB, Groutz A. Combined genitourinary prolapse repair and prophylactic tension-free vaginal tape in women with severe prolapse and occult stress urinary incontinence: preliminary results. Urology 2001;58:547–50.[Medline]
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20. Meschia M, Pifarotti P, Spennacchio M, Buonaguidi A, Gattei U, Somigliana E. A randomized comparison of tension-free vaginal tape and endopelvic fascia plication in women with genital prolapse and occult stress urinary incontinence. Am J Obstet Gynecol 2004;90:609–13.
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