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Abdominal sacrocolpopexy and urinary incontinence: surgical planning based on urodynamics
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UROGYNECOLOGY
Abdominal sacrocolpopexy and urinary incontinence: surgical planning based on urodynamics Denise M. Elser, MD; Michael D. Moen, MD; Edward J. Stanford, MD; Kristinell Keil, MD; Catherine A. Matthews, MD; Neeraj Kohli, MD; Fleming Mattox, MD; Janet Tomezsko, MD; on behalf of the Urogynecology Network OBJECTIVE: The objective of the study was to evaluate the use of uro-
RESULTS: At a mean follow-up of 46.6 weeks, the overall rate of incon-
dynamics to determine the need for incontinence surgery at the time of abdominal sacrocolpopexy (ASC).
tinence was low and similar for both groups (13.4% in group 1 and 13.3% in group 2 [P ⫽ .967]), as was new-onset UF: 18.6% in group 1 and 11.5% in group 2 (P ⫽ .195).
STUDY DESIGN: The records of 441 women undergoing ASC during
2005-2007 were reviewed. Group 1 consisted of 204 women (46.3%) with urodynamic stress incontinence (USI), including occult USI, who underwent incontinence surgery with ASC. Group 2 consisted of 237 women (53.7%) without USI who underwent ASC alone. Primary outcome measures were any complaint of postoperative incontinence (stress or urge) or new-onset urgency/frequency (UF).
CONCLUSION: Urodynamic evaluation appears to be useful in deter-
mining the need for incontinence surgery at the time of ASC. Key words: abdominal sacrocolpopexy, Burch urethropexy, midurethral sling, pelvic organ prolapse surgery, stress incontinence
Cite this article as: Elser DM, Moen MD, Stanford EJ, et al. Abdominal sacrocolpopexy and urinary incontinence: surgical planning based on urodynamics. Am J Obstet Gynecol 2010;202:375.e1-5.
G
ynecologic surgeons have long realized that the surgical correction of advanced prolapse will render some continent women incontinent. Gynecologic surgeons also realize that surgical treatment of stress incontinence can cause obstruction or new-onset symptoms of urgency, frequency, urge incontinence, and recurrent urinary tract infection. The goal, of course, is to prevent or treat stress incontinence and not cause obstruction or new-onset symptoms. The ideal method to achieve this goal and manage incontinence in
women undergoing surgery for pelvic organ prolapse (POP) remains a subject of debate. Options in this situation range from not treating stress incontinence at the time of prolapse surgery to performing an incontinence procedure during each and every prolapse repair. Almost a decade ago, in an editorial titled, “What is the optimal anti-incontinence procedure in women with advanced prolapse and potential stress incontinence,” Karram commented, “ѧ we have been overaggressive in the surgical correction of these patients specifically
From Illinois Urogynecology, Ltd, Oak Lawn (Dr Elser) and Park Ridge (Dr Moen), IL; the Division of Urogynecology, Department of Obstetrics and Gynecology, University of Tennessee, Memphis, TN (Dr Stanford); Keil Urogynecology, Denver, CO (Dr Keil); the Division of Urogynecology, Department of Obstetrics and Gynecology, Virginia Commonwealth University, Richmond, VA (Dr Matthews); Division of Urogynecology, Department of Obstetrics and Gynecology, Brigham and Womens Hospital, Boston, MA (Dr Kohli); Carolina Continence Center, Greenville, SC (Dr Mattox); and the Division of Urogynecology, Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL (Dr Tomezsko). The Urogynecology Network is located in Park Ridge, IL. Presented at the 29th Annual Scientific Meeting of the American Urogynecologic Society, Chicago, IL, Sept. 4-6, 2008, and the 33rd Annual Meeting of the International Urogynecological Association, Taipei, Taiwan, Sept. 15-17, 2008. Received Jan. 15, 2009; revised April 20, 2009; accepted June 5, 2009. Reprints not available from the authors. 0002-9378/$36.00 • © 2010 Published by Mosby, Inc. • doi: 10.1016/j.ajog.2009.06.022
See Journal Club, page 403
regarding the fear of development of stress incontinence.”1 Most urogynecologists have relied on urodynamic evaluation (UDS) to assess each woman’s lower urinary tract function prior to surgery to determine an individual’s need for an incontinence procedure. The result is a more selective use of incontinence surgery at the time of prolapse surgery. More recently, Brubaker et al2 published the results of the Colpopexy and Urinary Reduction Efforts (CARE) trial in which continent women with prolapse undergoing abdominal sacrocolpopexy (ASC) were randomized to undergo Burch or no incontinence procedure. Study enrollment was ended early when significantly more women in the no-Burch group were found to have stress incontinence at 12 weeks postoperatively than those in the Burch group. (44.1% vs 23.8%). Based on their results, they concluded all women should undergo Burch urethropexy at the time of ASC. This approach represents a significant deviation from the common practice of using UDS to determine the need for incontinence surgery. In an era when patient safety is the most important concern in gynecologic surgery, surgeons
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and their patients must weigh the risks and benefits of performing prophylactic procedures during reconstructive surgery. The significantly higher rates of incontinence seen in the CARE trial compared with previously published reports also raised questions over whether this approach should be utilized. The CARE trial was a carefully planned, prospective trial by respected investigators, and it received a great deal of attention in the gynecologic community. Although the authors carefully concluded that their recommendations applied only to the combination of ASC and Burch, in women with advanced POP, without stress incontinence at baseline, many in the gynecologic community quickly adopted the mantra that all women undergoing any type of surgical correction of prolapse must undergo a concomitant incontinence procedure. Our interpretation of the CARE trial was that it seemed to expose the majority of women to an unnecessary incontinence surgery without any resultant benefit in reducing postoperative stress incontinence compared with published rates. Our current practice is to use urodynamics to determine the need for incontinence surgery, based on our hypothesis that selective use of incontinent procedures in women with demonstrable stress incontinence will result in optimal outcomes in regard to bladder function after prolapse repair. The current study is an analysis of the results of this approach in a similar number of patients studied in the CARE trial.
M ATERIALS AND M ETHODS This was a retrospective case series analyzing the subjective bladder function of women who had undergone an ASC during the years 2005-2007. This collaborative endeavor included 11 surgeons from 7 sites. Surgeons were chosen based on their practice pattern of using UDS to diagnose stress incontinence and only performing incontinence surgery at the time of abdominal prolapse repair in women with documented urodynamic stress incontinence (USI). Although a power analysis was not performed, the initial 375.e2
www.AJOG.org goal was to match the number of patients treated in the CARE trial.2 Data collected included baseline information, such as age, and urinary symptoms; preoperative evaluation including the stage of prolapse and urodynamics results; and surgical details, specifically if incontinence surgery was performed and, if so, which procedure. All patients underwent urodynamic testing preoperatively. Diagnoses of USI, occult USI, detrusor overactivity (DO), mixed incontinence, or no incontinence during testing were noted. Prolapse reduction was performed for patients with advanced prolapse. The reduction method was determined by the individual centers and included use of large swabs placed at the apices, posterior blade of a bivalve speculum, Sims speculum, or vaginal pessary. This population assumedly included patients with the diagnosis of intrinsic sphincteric deficiency; however, specific urodynamic parameters, such as maximal urethral closure pressure or Valsalva leak point pressure, were not collected in this database. Urgency/frequency was defined as a patient’s perception that she suffered from frequent urination or uncomfortable urgency to void. Patients diagnosed with urodynamic stress incontinence, either with or without prolapse reduction, underwent incontinence surgery at the time of ASC. The decision to perform a Burch, a retropubic synthetic midurethral sling, or a transobturator synthetic midurethral sling was determined by the individual surgeon. Group 1 consisted of patients with USI who underwent an incontinence procedure at time of ASC. Group 2 consisted of patients with no evidence of USI during testing who did not undergo an incontinence procedure at time of ASC. A subanalysis of the outcomes of Burch with ASC vs synthetic midurethral sling with ASC is the subject of another paper and will not be reported here. The sacrocolpopexies were all performed with a Y-shaped piece of polypropylene mesh including an anterior arm placed along the anterior vaginal wall between bladder and vagina and a posterior mesh arm placed along the posterior vaginal wall.
American Journal of Obstetrics & Gynecology APRIL 2010
Because it is our philosophical belief to consider USI and occult USI to be 1 entity, patients demonstrating stress incontinence during urodynamic testing were considered to have urodynamic stress incontinence whether this incontinence occurred only with prolapse reduction, or not and these patients were not analyzed separately. Data regarding time to void after ASC alone or ASC with incontinence procedure were not collected. The surgeons participating in this study routinely evaluate postoperative patients at 6 weeks and at varying intervals thereafter, so charts were examined to determine patient status at the 6 week postoperative visit and at the last visit recorded for each patient. Although all patients in these practices were asked at each postoperative visit about bladder symptoms, including stress, urge, and frequency, not all practices used the same standardized questionnaires, and the retrospective nature of the study did not allow us to ensure that these questions were asked in the same way for each patient. It was not always clear when a chart stated “⫹ incontinence” whether this represented stress or urge or even the frequency or severity of the problem. Therefore, to capture the worst-case scenario, we noted a patient as having incontinence if there was any comment of incontinence on the chart as recorded by any health care practitioner. Similarly, a patient was considered to have urgency/ frequency (UF) if she subjectively reported having UF either volunteering the information on intake or responding positively when questioned. This study was approved by the Advocate Health Care Institutional Review Board (Park Ridge, IL). Data were analyzed through a central data coordinating center utilizing Pearson 2 analysis performed with SPSS version 14.0 (SPSS, Inc., Chicago, IL).
R ESULTS The women in this study had a mean age of 59.3 years (range, 29 – 89 years). The majority of women in this study had stage 3 prolapse by either the Pelvic Or-
Urogynecology
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TABLE 1
Demographics, baseline urodynamics data, and concomitant surgical procedures
Variable Age, mean age (y) (range)
Group 1, women with preoperative USI (n ⴝ 204) 57.65 (32–83)
Group 2, women without preoperative USI (n ⴝ 237) Total
P value
59.3 (29–89) ⬍ .01a
60.73 (29–89)
.............................................................................................................................................................................................................................................. a
Stage 2 prolapse
n ⫽ 161 55 (34.2%)
n ⫽ 142 16 (11.3%)
n ⫽ 303 71 (23.4%)
n ⫽ 161 74 (46.0%)
n ⫽ 142 59 (41.5%)
n ⫽ 303 133 (43.9%)
n ⫽ 161 32 (19.9%)
n ⫽ 142 67 (47.2%)
n ⫽303 99 (32.7%)
⬍ .01
..............................................................................................................................................................................................................................................
Stage 3 prolapse
.440
.............................................................................................................................................................................................................................................. a
Stage 4 prolapse
⬍ .01
..............................................................................................................................................................................................................................................
Urodynamic diagnoses
.....................................................................................................................................................................................................................................
USI
122 (59.8%)
0
151 (34.2%)
NA
82 (40.2%)
0
82 (18.6%)
NA
.....................................................................................................................................................................................................................................
Occult USI
.....................................................................................................................................................................................................................................
DO
42 (20.7%)
46 (19.4%)
88 (20.0%)
.74
PVR ⬎100 mL
23 (12.6%)
47 (21.2%)
70 (15.9%)
.023
..................................................................................................................................................................................................................................... a ..............................................................................................................................................................................................................................................
Concomitant surgeries
..................................................................................................................................................................................................................................... a
152 (34.5%)
⬍ .01
29 (12.2%)
79 (18.0%)
⬍ .01
82 (34.6%)
136 (31.1%)
.08
Hysterectomy
91 (44.8%)
61 (25.7%)
Cystocele repair
50 (24.9%)
Rectocele repair
54 (26.9%)
..................................................................................................................................................................................................................................... a ..................................................................................................................................................................................................................................... ..............................................................................................................................................................................................................................................
Data for stage of prolapse were available for 161 women in group 1 and 142 women in group 2. DO, detrusor overactivity; PVR, postvoid residual; USI, urodynamic stress incontinence. a
Statistically significant.
Elser. Abdominal sacrocolpopexy and urinary incontinence. Am J Obstet Gynecol 2010.
gan Prolapse Quantification System3 or Halfway grading system.4 Women in group 1 were significantly younger, had a higher percentage of patients with stage 2 prolapse, and were more likely to have undergone concurrent hysterectomy
and cystocele repair than group 2. These results are summarized in Table 1. A total of 463 patients underwent ASC, either open or laparoscopic, during the years 2005-2007; however, 441 charts (95%) were available for review. The pre-
Research
operative urodynamic diagnoses were as follows: 204 USI (46.3%) (122 [59.8%] USI and 82 [40.2%] occult USI), 88 DO (20%), and 237 no USI (53.7%). In the group with preoperative stress incontinence (group 1), all underwent an incontinence procedure at the time of ASC: 157 patients (77%) underwent synthetic midurethral sling, either retropubic or transobturator; and 47 patients (23%) underwent Burch urethropexy. Charts for 441 patients (204 in group 1, 237 in group 2) were available for the 6 week preoperative analysis and 375 patients (85%) (164 in group 1, 211 in group 2) for the last visit of record analysis (mean time of 46.6 weeks). At 6 weeks, 178 patients in group 1 (87.3%) and 220 patients in group 2 (92.8%) reported no incontinence. At the last visit of record, 142 patients in group 1 (86.6%) and 183 patients in group 2 (86.7%) reported no incontinence. At 6 weeks, 158 women in group 1 (77.8%) reported no UF compared with 217 patients in group 2 (91.6%). At the last visit, 128 women in group 1 (78.0%) reported no UF, as did 178 women in group 2 (86.0%). This difference in UF at 6 weeks and at the last visits reached statistical significance, with women who had undergone an incontinence procedure more likely to experience these symptoms. Table 2 compares the rates of incontinence and UF between the 2 groups. The majority of women with preexisting UF with or without DO experienced resolution of their UF symptoms after
TABLE 2
Rates of postoperative incontinence and UF in women undergoing abdominal sacrocolpopexy
Variable
Group 1, women with USI who received incontinence procedure
Group 2, women without USI who did not receive incontinence procedure 7.2% (17/237)
Total 9.8% (43/441)
P value, group 1 vs group 2 a
.049
OR (95% CI) 1.890 (0.994–3.594)
Any symptoms of incontinence, 6 wk visit
12.7% (26/204)
UF, 6 wk visit
22.2% (45/203)
8.4% (20/237)
14.8% (65/440)
⬍ .001
3.090 (1.756–5.438)
Any symptoms of incontinence last visit (mean, 46.6 wks)
13.4% (22/164)
13.3% (28/211)
13.4% (50/375)
.967
1.013 (0.556–1.845)
UF, last visit
22.0% (36/164)
................................................................................................................................................................................................................................................................................................................................................................................ a ................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................ a
14.0% (29/207)
17.5% (65/371)
.046
1.726 (1.007–2.960)
................................................................................................................................................................................................................................................................................................................................................................................
CI, confidence interval; OR, odds ratio; UF, urgency/frequency. a
Statistically significant.
Elser. Abdominal sacrocolpopexy and urinary incontinence. Am J Obstet Gynecol 2010.
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TABLE 3
Resolution of irritative bladder symptoms in patients with preoperative UF and/or DO
Preoperative urgency and/or preoperative DO
Group 1, women with USI who received incontinence procedure
Group 2, women without USI who did not receive incontinence procedure
Total
P value
OR (95% CI)
No UF at 6 wk postoperative visit
84/115 (73.0%)
104/114 (91.2%)
188/229 (82.1%)
⬍ .001a
3.838 (1.7802–8.278)
Any UF at last postoperative visit (mean, 46.6 wks)
71/94 (75.5%)
86/103 (83.5%)
157/197 (79.7%)
................................................................................................................................................................................................................................................................................................................................................................................
.165
1.639 (0.813–3.304)
................................................................................................................................................................................................................................................................................................................................................................................
CI, confidence interval; DO, detrusor overactivity; OR, odds ratio; UF, urgency/frequency; USI, urodynamic stress incontinence. a
Statistically significant.
Elser. Abdominal sacrocolpopexy and urinary incontinence. Am J Obstet Gynecol 2010.
ASC, regardless of whether they had an incontinence procedure, with a difference between groups noted at 6 weeks but not at the last visit. Table 3 reports the percentage of women in each group with resolution of UF at 6 weeks and the last visit. Eighteen percent of women with UF and/or DO had persistent UF at 6 weeks with relative stability of this rate (20%) at the last visit. The rate of newonset UF of any degree in women without preexisting UF or DO was low for both groups and is reported in Table 4. Perioperative and postoperative morbidity was low in both groups. In follow-up over the study period, 12 patients reported stress incontinence. Of these 12 patients, 9 had not undergone an incontinence surgery, 3 had undergone Burch, and none had undergone sling at the time of ASC. Three of these patients had resolution of their symptoms without treatment by 1 year, 4 had a sling performed as an interval procedure after the ASC, and 1 had a periurethral injection of bulking procedure. Ten patients had symptomatic recurrent prolapse in the
preoperative period. Four opted for vaginal repair, 4 chose vaginal pessary, and 2 were not retreated. Of the women with recurrent prolapse, 6 were in group 1 and 4 were in group 2. One patient developed an intraabdominal abscess that was treated with computed tomography– guided drainage and intravenous antibiotics. Five patients developed mesh erosion: 4 were treated in the office with vaginal excision of exposed mesh, and 1 woman underwent a laparoscopic excision of mesh. Four patients were described as having granulation tissue treated topically. One patient developed an incisional hernia. One patient experienced an enterotomy during surgery with excision of the injured segment and end-to-end anastomosis performed.
C OMMENT Urodynamic testing is commonly used to evaluate lower urinary tract symptoms and assist in directing treatment for
women with incontinence. Because of the morbidity associated with surgical treatment, most gynecologic surgeons do not perform incontinence procedures in patients who have no symptoms of stress urinary incontinence (SUI) or objective diagnosis of SUI based on urodynamics. Recently it has been suggested that surgeons take a different approach when treating women with prolapse who are undergoing surgical treatment. The suggestion is based on the results of the CARE trial, which found a higher-than-expected rate of de novo SUI in patients undergoing ASC and showed that the addition of Burch in this group of patients significantly reduced the rate of SUI postoperatively. Their conclusion was to suggest performing a Burch procedure in all patients undergoing ASC, regardless of objective findings on urodynamics. In their study, such an approach reduced de novo SUI from 44.1% to 23.8% at 12 weeks postoperatively.2
TABLE 4
New irritative bladder symptoms in patients without symptoms of urgency preoperatively and no preexisting DO
No preoperative urgency and no preoperative DO
Group 1, women undergoing incontinence procedure
Group 2, women not undergoing incontinence procedure
Total
P value
OR (95% CI)
Any UF at 6 wk postoperative visit
14/88 (15.9%)
10/123 (8.1%)
24/211 (11.4%)
.079
2.138 (0.902–5.066)
Any UF at last postoperative visit (mean, 46.6 wks)
13/70 (18.6%)
12/104 (11.5%)
25/174 (14.4%)
.195
1.749 (0.746–4.096)
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
CI, confidence interval; DO, detrusor overactivity; OR, odds ratio; UF, urgency/frequency. Elser. Abdominal sacrocolpopexy and urinary incontinence. Am J Obstet Gynecol 2010.
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www.AJOG.org However, the addition of an incontinence procedure at the time of POP surgery also adds the risk of developing new symptoms of lower urinary tract dysfunction with new-onset urgency or DO being reported in 18-27% of women undergoing Burch urethropexy.5,6 Burgio et al7 reported 12 month data for women undergoing ASC with or without Burch and found urge incontinence in 14.5% with Burch and 26.8% without. The development of new overactive bladder symptoms can lead to significant dissatisfaction for a patient who was previously asymptomatic. According to Mallett et al,8 women undergoing either fascial sling or Burch for stress incontinence, who did not also experience resolution of their urgency and frequency, were dissatisfied with the surgical outcome, regardless of whether they were counseled preoperatively that the surgery was intended to affect only the stress leakage. Several studies suggest that the incidence of de novo SUI after ASC is much lower than the rate reported in the CARE trial, ranging from 1.9% to 13%.9-12 Whether the true risk of de novo SUI is as low as 1.9% or as high as 44.1%, performing Burch urethropexy in all stress continent patients undergoing ASC would result in performing an unindicated Burch procedure in more than half of patients undergoing ASC, subjecting them to the unnecessary additional risks of complications, including de novo lower urinary tract symptoms. Because of this and the low rate of postoperative stress incontinence in their patients undergoing prolapse repair, Roovers and Oelke13 recommended only treating the POP and reevaluating the patients postoperatively, with the option of performing an incontinence operation separately if needed. The current study analyzed data on 441 patients undergoing sacrocolpopexy collected from 11 urogynecologists across the United States, providing a snapshot of results of common clinical urogynecologic practice. USI was diagnosed in almost half of these women (46.3%), with occult USI accounting for 40.2% of those with stress incontinence. In this study population, the addition of
an incontinence procedure was based on the objective urodynamic findings of USI. The most commonly performed procedure was a minimally-invasive suburethral sling (77% of patients), whereas a Burch was performed in 23%. Utilizing this approach, the rate of postoperative incontinence was low and, more importantly, significantly lower than the rates seen in the CARE trial. Irritative voiding symptoms were also low, despite the fact that a large number of these women with advanced pelvic floor disorders also had preoperative DO. The major weakness of this study is its retrospective design. This did not allow for standardization in assessing preoperative and postoperative data and resulted in variation in assessment of symptoms related to bother. In an attempt to account for this weakness, we used a low threshold for assessment of lower urinary tract symptoms, including any complaints, regardless of quantity or severity. The strengths of this study are the uniform, evidence-based approach used by 11 urogynecologists independently at multiple centers with similar results. This is the largest trial to date focusing on the evaluation and performance of incontinence surgery at the time of apical vault repair by sacrocolpopexy. Within the limits of our study, our results show that urodynamic testing is useful in determining the need for incontinence surgery at the time of abdominal sacrocolpopexy, and utilizing this approach results in a low incidence of postoperative incontinence and irritative bladder symptoms. Based on our data, we recommend that results of urodynamic testing should be used to selectively treat incontinent women with a sling or Burch at the time of ASC. We further recommend that patients without stress incontinence should not undergo an antiincontinence procedure at the time of ASC. Adding an unindicated procedure to benefit a minority of patients seems unacceptable in an era in which patient safety is of utmost importance in gynecologic surgery, particularly for treat-
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ing conditions that are not life f threatening. ACKNOWLEDGMENT We thank Christopher Blair (Advocate Healthcare, Oakbrook, IL) for statistical analysis.
REFERENCES 1. Karram M. What is the optimal anti-incontinence procedure in women with advanced prolapse and potential stress incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1999;10:1-2. 2. Brubaker L, Cundiff GW, Fine P, et al. Abdominal sacrocolpopexy with Burch colposuspension to reduce urinary stress incontinence. N Engl J Med 2006;354:1557-66. 3. Bump RC, Mattiasson A, Bø K, et al. The standardisation of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10-7. 4. Baden W, Walker T. Surgical repair of vaginal defects. Philadelphia, PA: Lippincott; 1992. 5. Cardozo LD, Stanton SL, Williams JE. Detrusor instability following surgery for genuine stress incontinence. Br J Urol 1979;51:204-7. 6. Langer R, Ron-El R, Newman M, Herman A, Caspi E. Detrusor Instability following colposuspension for urinary stress incontinence. BJOG 1988;5:607-10. 7. Burgio KL, Nygaard IE, Richter HE, et al. Bladder symptoms 1 year after abdominal sacrocolpopexy with and without Burch colposuspension in women without preoperative stress incontinence symptoms. Am J Obstet Gynecol 2007;197:647.e1-6. 8. Mallett VT, Brubaker L, Stoddard AM, et al. The expectations of patients who undergo surgery for stress incontinence. Am J Obstet Gynecol 2008;198:308.e1-6 9. Roovers JP, van Laar JO, Loffeld C, Bremer GL, Mol BS, Bonger MY. Does urodynamic investigation improve outcome in patients undergoing prolapse surgery? Neurourol Urodyn 2007;26:170-5. 10. Kleeman S, Vassallo B, Segal J, Hungler M, Karram M. The ability of history and a negative cough stress test to detect occult stress incontinence in patients undergoing surgical repair of advanced pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2006;17:27-9. 11. Costantini E, Zucchi A, Giannantoni A, Mearini L, Bini V, Porena M. Must colposuspension be associated with sacropexy to prevent postoperative urinary incontinence? Eur Urol 2007;51:788-94. 12. Misraï V, Rouprêt M, Cour F, Chartier-Kastler E, Richard F. De novo urinary stress incontinence after laparoscopic sacral colpopexy. BJU Int 2008;101:594-7. 13. Roovers JPWR, Oelke M. Clinical relevance of urodynamic investigation tests prior to surgical correction of genital prolapse: a literature review. Int Urogynecol J 2007;18:455-60.
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UROGYNECOLOGY
Abdominal sacrocolpopexy and urinary incontinence: surgical planning based on urodynamics Denise M. Elser, MD; Michael D. Moen, MD; Edward J. Stanford, MD; Kristinell Keil, MD; Catherine A. Matthews, MD; Neeraj Kohli, MD; Fleming Mattox, MD; Janet Tomezsko, MD; on behalf of the Urogynecology Network OBJECTIVE: The objective of the study was to evaluate the use of uro-
RESULTS: At a mean follow-up of 46.6 weeks, the overall rate of incon-
dynamics to determine the need for incontinence surgery at the time of abdominal sacrocolpopexy (ASC).
tinence was low and similar for both groups (13.4% in group 1 and 13.3% in group 2 [P ⫽ .967]), as was new-onset UF: 18.6% in group 1 and 11.5% in group 2 (P ⫽ .195).
STUDY DESIGN: The records of 441 women undergoing ASC during
2005-2007 were reviewed. Group 1 consisted of 204 women (46.3%) with urodynamic stress incontinence (USI), including occult USI, who underwent incontinence surgery with ASC. Group 2 consisted of 237 women (53.7%) without USI who underwent ASC alone. Primary outcome measures were any complaint of postoperative incontinence (stress or urge) or new-onset urgency/frequency (UF).
CONCLUSION: Urodynamic evaluation appears to be useful in deter-
mining the need for incontinence surgery at the time of ASC. Key words: abdominal sacrocolpopexy, Burch urethropexy, midurethral sling, pelvic organ prolapse surgery, stress incontinence
Cite this article as: Elser DM, Moen MD, Stanford EJ, et al. Abdominal sacrocolpopexy and urinary incontinence: surgical planning based on urodynamics. Am J Obstet Gynecol 2010;202:375.e1-5.
G
ynecologic surgeons have long realized that the surgical correction of advanced prolapse will render some continent women incontinent. Gynecologic surgeons also realize that surgical treatment of stress incontinence can cause obstruction or new-onset symptoms of urgency, frequency, urge incontinence, and recurrent urinary tract infection. The goal, of course, is to prevent or treat stress incontinence and not cause obstruction or new-onset symptoms. The ideal method to achieve this goal and manage incontinence in
women undergoing surgery for pelvic organ prolapse (POP) remains a subject of debate. Options in this situation range from not treating stress incontinence at the time of prolapse surgery to performing an incontinence procedure during each and every prolapse repair. Almost a decade ago, in an editorial titled, “What is the optimal anti-incontinence procedure in women with advanced prolapse and potential stress incontinence,” Karram commented, “ѧ we have been overaggressive in the surgical correction of these patients specifically
From Illinois Urogynecology, Ltd, Oak Lawn (Dr Elser) and Park Ridge (Dr Moen), IL; the Division of Urogynecology, Department of Obstetrics and Gynecology, University of Tennessee, Memphis, TN (Dr Stanford); Keil Urogynecology, Denver, CO (Dr Keil); the Division of Urogynecology, Department of Obstetrics and Gynecology, Virginia Commonwealth University, Richmond, VA (Dr Matthews); Division of Urogynecology, Department of Obstetrics and Gynecology, Brigham and Womens Hospital, Boston, MA (Dr Kohli); Carolina Continence Center, Greenville, SC (Dr Mattox); and the Division of Urogynecology, Department of Obstetrics and Gynecology, Northwestern University, Chicago, IL (Dr Tomezsko). The Urogynecology Network is located in Park Ridge, IL. Presented at the 29th Annual Scientific Meeting of the American Urogynecologic Society, Chicago, IL, Sept. 4-6, 2008, and the 33rd Annual Meeting of the International Urogynecological Association, Taipei, Taiwan, Sept. 15-17, 2008. Received Jan. 15, 2009; revised April 20, 2009; accepted June 5, 2009. Reprints not available from the authors. 0002-9378/$36.00 • © 2010 Published by Mosby, Inc. • doi: 10.1016/j.ajog.2009.06.022
See Journal Club, page 403
regarding the fear of development of stress incontinence.”1 Most urogynecologists have relied on urodynamic evaluation (UDS) to assess each woman’s lower urinary tract function prior to surgery to determine an individual’s need for an incontinence procedure. The result is a more selective use of incontinence surgery at the time of prolapse surgery. More recently, Brubaker et al2 published the results of the Colpopexy and Urinary Reduction Efforts (CARE) trial in which continent women with prolapse undergoing abdominal sacrocolpopexy (ASC) were randomized to undergo Burch or no incontinence procedure. Study enrollment was ended early when significantly more women in the no-Burch group were found to have stress incontinence at 12 weeks postoperatively than those in the Burch group. (44.1% vs 23.8%). Based on their results, they concluded all women should undergo Burch urethropexy at the time of ASC. This approach represents a significant deviation from the common practice of using UDS to determine the need for incontinence surgery. In an era when patient safety is the most important concern in gynecologic surgery, surgeons
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and their patients must weigh the risks and benefits of performing prophylactic procedures during reconstructive surgery. The significantly higher rates of incontinence seen in the CARE trial compared with previously published reports also raised questions over whether this approach should be utilized. The CARE trial was a carefully planned, prospective trial by respected investigators, and it received a great deal of attention in the gynecologic community. Although the authors carefully concluded that their recommendations applied only to the combination of ASC and Burch, in women with advanced POP, without stress incontinence at baseline, many in the gynecologic community quickly adopted the mantra that all women undergoing any type of surgical correction of prolapse must undergo a concomitant incontinence procedure. Our interpretation of the CARE trial was that it seemed to expose the majority of women to an unnecessary incontinence surgery without any resultant benefit in reducing postoperative stress incontinence compared with published rates. Our current practice is to use urodynamics to determine the need for incontinence surgery, based on our hypothesis that selective use of incontinent procedures in women with demonstrable stress incontinence will result in optimal outcomes in regard to bladder function after prolapse repair. The current study is an analysis of the results of this approach in a similar number of patients studied in the CARE trial.
M ATERIALS AND M ETHODS This was a retrospective case series analyzing the subjective bladder function of women who had undergone an ASC during the years 2005-2007. This collaborative endeavor included 11 surgeons from 7 sites. Surgeons were chosen based on their practice pattern of using UDS to diagnose stress incontinence and only performing incontinence surgery at the time of abdominal prolapse repair in women with documented urodynamic stress incontinence (USI). Although a power analysis was not performed, the initial 375.e2
www.AJOG.org goal was to match the number of patients treated in the CARE trial.2 Data collected included baseline information, such as age, and urinary symptoms; preoperative evaluation including the stage of prolapse and urodynamics results; and surgical details, specifically if incontinence surgery was performed and, if so, which procedure. All patients underwent urodynamic testing preoperatively. Diagnoses of USI, occult USI, detrusor overactivity (DO), mixed incontinence, or no incontinence during testing were noted. Prolapse reduction was performed for patients with advanced prolapse. The reduction method was determined by the individual centers and included use of large swabs placed at the apices, posterior blade of a bivalve speculum, Sims speculum, or vaginal pessary. This population assumedly included patients with the diagnosis of intrinsic sphincteric deficiency; however, specific urodynamic parameters, such as maximal urethral closure pressure or Valsalva leak point pressure, were not collected in this database. Urgency/frequency was defined as a patient’s perception that she suffered from frequent urination or uncomfortable urgency to void. Patients diagnosed with urodynamic stress incontinence, either with or without prolapse reduction, underwent incontinence surgery at the time of ASC. The decision to perform a Burch, a retropubic synthetic midurethral sling, or a transobturator synthetic midurethral sling was determined by the individual surgeon. Group 1 consisted of patients with USI who underwent an incontinence procedure at time of ASC. Group 2 consisted of patients with no evidence of USI during testing who did not undergo an incontinence procedure at time of ASC. A subanalysis of the outcomes of Burch with ASC vs synthetic midurethral sling with ASC is the subject of another paper and will not be reported here. The sacrocolpopexies were all performed with a Y-shaped piece of polypropylene mesh including an anterior arm placed along the anterior vaginal wall between bladder and vagina and a posterior mesh arm placed along the posterior vaginal wall.
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Because it is our philosophical belief to consider USI and occult USI to be 1 entity, patients demonstrating stress incontinence during urodynamic testing were considered to have urodynamic stress incontinence whether this incontinence occurred only with prolapse reduction, or not and these patients were not analyzed separately. Data regarding time to void after ASC alone or ASC with incontinence procedure were not collected. The surgeons participating in this study routinely evaluate postoperative patients at 6 weeks and at varying intervals thereafter, so charts were examined to determine patient status at the 6 week postoperative visit and at the last visit recorded for each patient. Although all patients in these practices were asked at each postoperative visit about bladder symptoms, including stress, urge, and frequency, not all practices used the same standardized questionnaires, and the retrospective nature of the study did not allow us to ensure that these questions were asked in the same way for each patient. It was not always clear when a chart stated “⫹ incontinence” whether this represented stress or urge or even the frequency or severity of the problem. Therefore, to capture the worst-case scenario, we noted a patient as having incontinence if there was any comment of incontinence on the chart as recorded by any health care practitioner. Similarly, a patient was considered to have urgency/ frequency (UF) if she subjectively reported having UF either volunteering the information on intake or responding positively when questioned. This study was approved by the Advocate Health Care Institutional Review Board (Park Ridge, IL). Data were analyzed through a central data coordinating center utilizing Pearson 2 analysis performed with SPSS version 14.0 (SPSS, Inc., Chicago, IL).
R ESULTS The women in this study had a mean age of 59.3 years (range, 29 – 89 years). The majority of women in this study had stage 3 prolapse by either the Pelvic Or-
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TABLE 1
Demographics, baseline urodynamics data, and concomitant surgical procedures
Variable Age, mean age (y) (range)
Group 1, women with preoperative USI (n ⴝ 204) 57.65 (32–83)
Group 2, women without preoperative USI (n ⴝ 237) Total
P value
59.3 (29–89) ⬍ .01a
60.73 (29–89)
.............................................................................................................................................................................................................................................. a
Stage 2 prolapse
n ⫽ 161 55 (34.2%)
n ⫽ 142 16 (11.3%)
n ⫽ 303 71 (23.4%)
n ⫽ 161 74 (46.0%)
n ⫽ 142 59 (41.5%)
n ⫽ 303 133 (43.9%)
n ⫽ 161 32 (19.9%)
n ⫽ 142 67 (47.2%)
n ⫽303 99 (32.7%)
⬍ .01
..............................................................................................................................................................................................................................................
Stage 3 prolapse
.440
.............................................................................................................................................................................................................................................. a
Stage 4 prolapse
⬍ .01
..............................................................................................................................................................................................................................................
Urodynamic diagnoses
.....................................................................................................................................................................................................................................
USI
122 (59.8%)
0
151 (34.2%)
NA
82 (40.2%)
0
82 (18.6%)
NA
.....................................................................................................................................................................................................................................
Occult USI
.....................................................................................................................................................................................................................................
DO
42 (20.7%)
46 (19.4%)
88 (20.0%)
.74
PVR ⬎100 mL
23 (12.6%)
47 (21.2%)
70 (15.9%)
.023
..................................................................................................................................................................................................................................... a ..............................................................................................................................................................................................................................................
Concomitant surgeries
..................................................................................................................................................................................................................................... a
152 (34.5%)
⬍ .01
29 (12.2%)
79 (18.0%)
⬍ .01
82 (34.6%)
136 (31.1%)
.08
Hysterectomy
91 (44.8%)
61 (25.7%)
Cystocele repair
50 (24.9%)
Rectocele repair
54 (26.9%)
..................................................................................................................................................................................................................................... a ..................................................................................................................................................................................................................................... ..............................................................................................................................................................................................................................................
Data for stage of prolapse were available for 161 women in group 1 and 142 women in group 2. DO, detrusor overactivity; PVR, postvoid residual; USI, urodynamic stress incontinence. a
Statistically significant.
Elser. Abdominal sacrocolpopexy and urinary incontinence. Am J Obstet Gynecol 2010.
gan Prolapse Quantification System3 or Halfway grading system.4 Women in group 1 were significantly younger, had a higher percentage of patients with stage 2 prolapse, and were more likely to have undergone concurrent hysterectomy
and cystocele repair than group 2. These results are summarized in Table 1. A total of 463 patients underwent ASC, either open or laparoscopic, during the years 2005-2007; however, 441 charts (95%) were available for review. The pre-
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operative urodynamic diagnoses were as follows: 204 USI (46.3%) (122 [59.8%] USI and 82 [40.2%] occult USI), 88 DO (20%), and 237 no USI (53.7%). In the group with preoperative stress incontinence (group 1), all underwent an incontinence procedure at the time of ASC: 157 patients (77%) underwent synthetic midurethral sling, either retropubic or transobturator; and 47 patients (23%) underwent Burch urethropexy. Charts for 441 patients (204 in group 1, 237 in group 2) were available for the 6 week preoperative analysis and 375 patients (85%) (164 in group 1, 211 in group 2) for the last visit of record analysis (mean time of 46.6 weeks). At 6 weeks, 178 patients in group 1 (87.3%) and 220 patients in group 2 (92.8%) reported no incontinence. At the last visit of record, 142 patients in group 1 (86.6%) and 183 patients in group 2 (86.7%) reported no incontinence. At 6 weeks, 158 women in group 1 (77.8%) reported no UF compared with 217 patients in group 2 (91.6%). At the last visit, 128 women in group 1 (78.0%) reported no UF, as did 178 women in group 2 (86.0%). This difference in UF at 6 weeks and at the last visits reached statistical significance, with women who had undergone an incontinence procedure more likely to experience these symptoms. Table 2 compares the rates of incontinence and UF between the 2 groups. The majority of women with preexisting UF with or without DO experienced resolution of their UF symptoms after
TABLE 2
Rates of postoperative incontinence and UF in women undergoing abdominal sacrocolpopexy
Variable
Group 1, women with USI who received incontinence procedure
Group 2, women without USI who did not receive incontinence procedure 7.2% (17/237)
Total 9.8% (43/441)
P value, group 1 vs group 2 a
.049
OR (95% CI) 1.890 (0.994–3.594)
Any symptoms of incontinence, 6 wk visit
12.7% (26/204)
UF, 6 wk visit
22.2% (45/203)
8.4% (20/237)
14.8% (65/440)
⬍ .001
3.090 (1.756–5.438)
Any symptoms of incontinence last visit (mean, 46.6 wks)
13.4% (22/164)
13.3% (28/211)
13.4% (50/375)
.967
1.013 (0.556–1.845)
UF, last visit
22.0% (36/164)
................................................................................................................................................................................................................................................................................................................................................................................ a ................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................ a
14.0% (29/207)
17.5% (65/371)
.046
1.726 (1.007–2.960)
................................................................................................................................................................................................................................................................................................................................................................................
CI, confidence interval; OR, odds ratio; UF, urgency/frequency. a
Statistically significant.
Elser. Abdominal sacrocolpopexy and urinary incontinence. Am J Obstet Gynecol 2010.
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TABLE 3
Resolution of irritative bladder symptoms in patients with preoperative UF and/or DO
Preoperative urgency and/or preoperative DO
Group 1, women with USI who received incontinence procedure
Group 2, women without USI who did not receive incontinence procedure
Total
P value
OR (95% CI)
No UF at 6 wk postoperative visit
84/115 (73.0%)
104/114 (91.2%)
188/229 (82.1%)
⬍ .001a
3.838 (1.7802–8.278)
Any UF at last postoperative visit (mean, 46.6 wks)
71/94 (75.5%)
86/103 (83.5%)
157/197 (79.7%)
................................................................................................................................................................................................................................................................................................................................................................................
.165
1.639 (0.813–3.304)
................................................................................................................................................................................................................................................................................................................................................................................
CI, confidence interval; DO, detrusor overactivity; OR, odds ratio; UF, urgency/frequency; USI, urodynamic stress incontinence. a
Statistically significant.
Elser. Abdominal sacrocolpopexy and urinary incontinence. Am J Obstet Gynecol 2010.
ASC, regardless of whether they had an incontinence procedure, with a difference between groups noted at 6 weeks but not at the last visit. Table 3 reports the percentage of women in each group with resolution of UF at 6 weeks and the last visit. Eighteen percent of women with UF and/or DO had persistent UF at 6 weeks with relative stability of this rate (20%) at the last visit. The rate of newonset UF of any degree in women without preexisting UF or DO was low for both groups and is reported in Table 4. Perioperative and postoperative morbidity was low in both groups. In follow-up over the study period, 12 patients reported stress incontinence. Of these 12 patients, 9 had not undergone an incontinence surgery, 3 had undergone Burch, and none had undergone sling at the time of ASC. Three of these patients had resolution of their symptoms without treatment by 1 year, 4 had a sling performed as an interval procedure after the ASC, and 1 had a periurethral injection of bulking procedure. Ten patients had symptomatic recurrent prolapse in the
preoperative period. Four opted for vaginal repair, 4 chose vaginal pessary, and 2 were not retreated. Of the women with recurrent prolapse, 6 were in group 1 and 4 were in group 2. One patient developed an intraabdominal abscess that was treated with computed tomography– guided drainage and intravenous antibiotics. Five patients developed mesh erosion: 4 were treated in the office with vaginal excision of exposed mesh, and 1 woman underwent a laparoscopic excision of mesh. Four patients were described as having granulation tissue treated topically. One patient developed an incisional hernia. One patient experienced an enterotomy during surgery with excision of the injured segment and end-to-end anastomosis performed.
C OMMENT Urodynamic testing is commonly used to evaluate lower urinary tract symptoms and assist in directing treatment for
women with incontinence. Because of the morbidity associated with surgical treatment, most gynecologic surgeons do not perform incontinence procedures in patients who have no symptoms of stress urinary incontinence (SUI) or objective diagnosis of SUI based on urodynamics. Recently it has been suggested that surgeons take a different approach when treating women with prolapse who are undergoing surgical treatment. The suggestion is based on the results of the CARE trial, which found a higher-than-expected rate of de novo SUI in patients undergoing ASC and showed that the addition of Burch in this group of patients significantly reduced the rate of SUI postoperatively. Their conclusion was to suggest performing a Burch procedure in all patients undergoing ASC, regardless of objective findings on urodynamics. In their study, such an approach reduced de novo SUI from 44.1% to 23.8% at 12 weeks postoperatively.2
TABLE 4
New irritative bladder symptoms in patients without symptoms of urgency preoperatively and no preexisting DO
No preoperative urgency and no preoperative DO
Group 1, women undergoing incontinence procedure
Group 2, women not undergoing incontinence procedure
Total
P value
OR (95% CI)
Any UF at 6 wk postoperative visit
14/88 (15.9%)
10/123 (8.1%)
24/211 (11.4%)
.079
2.138 (0.902–5.066)
Any UF at last postoperative visit (mean, 46.6 wks)
13/70 (18.6%)
12/104 (11.5%)
25/174 (14.4%)
.195
1.749 (0.746–4.096)
................................................................................................................................................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................................................................................................................................................
CI, confidence interval; DO, detrusor overactivity; OR, odds ratio; UF, urgency/frequency. Elser. Abdominal sacrocolpopexy and urinary incontinence. Am J Obstet Gynecol 2010.
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www.AJOG.org However, the addition of an incontinence procedure at the time of POP surgery also adds the risk of developing new symptoms of lower urinary tract dysfunction with new-onset urgency or DO being reported in 18-27% of women undergoing Burch urethropexy.5,6 Burgio et al7 reported 12 month data for women undergoing ASC with or without Burch and found urge incontinence in 14.5% with Burch and 26.8% without. The development of new overactive bladder symptoms can lead to significant dissatisfaction for a patient who was previously asymptomatic. According to Mallett et al,8 women undergoing either fascial sling or Burch for stress incontinence, who did not also experience resolution of their urgency and frequency, were dissatisfied with the surgical outcome, regardless of whether they were counseled preoperatively that the surgery was intended to affect only the stress leakage. Several studies suggest that the incidence of de novo SUI after ASC is much lower than the rate reported in the CARE trial, ranging from 1.9% to 13%.9-12 Whether the true risk of de novo SUI is as low as 1.9% or as high as 44.1%, performing Burch urethropexy in all stress continent patients undergoing ASC would result in performing an unindicated Burch procedure in more than half of patients undergoing ASC, subjecting them to the unnecessary additional risks of complications, including de novo lower urinary tract symptoms. Because of this and the low rate of postoperative stress incontinence in their patients undergoing prolapse repair, Roovers and Oelke13 recommended only treating the POP and reevaluating the patients postoperatively, with the option of performing an incontinence operation separately if needed. The current study analyzed data on 441 patients undergoing sacrocolpopexy collected from 11 urogynecologists across the United States, providing a snapshot of results of common clinical urogynecologic practice. USI was diagnosed in almost half of these women (46.3%), with occult USI accounting for 40.2% of those with stress incontinence. In this study population, the addition of
an incontinence procedure was based on the objective urodynamic findings of USI. The most commonly performed procedure was a minimally-invasive suburethral sling (77% of patients), whereas a Burch was performed in 23%. Utilizing this approach, the rate of postoperative incontinence was low and, more importantly, significantly lower than the rates seen in the CARE trial. Irritative voiding symptoms were also low, despite the fact that a large number of these women with advanced pelvic floor disorders also had preoperative DO. The major weakness of this study is its retrospective design. This did not allow for standardization in assessing preoperative and postoperative data and resulted in variation in assessment of symptoms related to bother. In an attempt to account for this weakness, we used a low threshold for assessment of lower urinary tract symptoms, including any complaints, regardless of quantity or severity. The strengths of this study are the uniform, evidence-based approach used by 11 urogynecologists independently at multiple centers with similar results. This is the largest trial to date focusing on the evaluation and performance of incontinence surgery at the time of apical vault repair by sacrocolpopexy. Within the limits of our study, our results show that urodynamic testing is useful in determining the need for incontinence surgery at the time of abdominal sacrocolpopexy, and utilizing this approach results in a low incidence of postoperative incontinence and irritative bladder symptoms. Based on our data, we recommend that results of urodynamic testing should be used to selectively treat incontinent women with a sling or Burch at the time of ASC. We further recommend that patients without stress incontinence should not undergo an antiincontinence procedure at the time of ASC. Adding an unindicated procedure to benefit a minority of patients seems unacceptable in an era in which patient safety is of utmost importance in gynecologic surgery, particularly for treat-
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ing conditions that are not life f threatening. ACKNOWLEDGMENT We thank Christopher Blair (Advocate Healthcare, Oakbrook, IL) for statistical analysis.
REFERENCES 1. Karram M. What is the optimal anti-incontinence procedure in women with advanced prolapse and potential stress incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1999;10:1-2. 2. Brubaker L, Cundiff GW, Fine P, et al. Abdominal sacrocolpopexy with Burch colposuspension to reduce urinary stress incontinence. N Engl J Med 2006;354:1557-66. 3. Bump RC, Mattiasson A, Bø K, et al. The standardisation of terminology of female pelvic organ prolapse and pelvic floor dysfunction. Am J Obstet Gynecol 1996;175:10-7. 4. Baden W, Walker T. Surgical repair of vaginal defects. Philadelphia, PA: Lippincott; 1992. 5. Cardozo LD, Stanton SL, Williams JE. Detrusor instability following surgery for genuine stress incontinence. Br J Urol 1979;51:204-7. 6. Langer R, Ron-El R, Newman M, Herman A, Caspi E. Detrusor Instability following colposuspension for urinary stress incontinence. BJOG 1988;5:607-10. 7. Burgio KL, Nygaard IE, Richter HE, et al. Bladder symptoms 1 year after abdominal sacrocolpopexy with and without Burch colposuspension in women without preoperative stress incontinence symptoms. Am J Obstet Gynecol 2007;197:647.e1-6. 8. Mallett VT, Brubaker L, Stoddard AM, et al. The expectations of patients who undergo surgery for stress incontinence. Am J Obstet Gynecol 2008;198:308.e1-6 9. Roovers JP, van Laar JO, Loffeld C, Bremer GL, Mol BS, Bonger MY. Does urodynamic investigation improve outcome in patients undergoing prolapse surgery? Neurourol Urodyn 2007;26:170-5. 10. Kleeman S, Vassallo B, Segal J, Hungler M, Karram M. The ability of history and a negative cough stress test to detect occult stress incontinence in patients undergoing surgical repair of advanced pelvic organ prolapse. Int Urogynecol J Pelvic Floor Dysfunct 2006;17:27-9. 11. Costantini E, Zucchi A, Giannantoni A, Mearini L, Bini V, Porena M. Must colposuspension be associated with sacropexy to prevent postoperative urinary incontinence? Eur Urol 2007;51:788-94. 12. Misraï V, Rouprêt M, Cour F, Chartier-Kastler E, Richard F. De novo urinary stress incontinence after laparoscopic sacral colpopexy. BJU Int 2008;101:594-7. 13. Roovers JPWR, Oelke M. Clinical relevance of urodynamic investigation tests prior to surgical correction of genital prolapse: a literature review. Int Urogynecol J 2007;18:455-60.
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