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Effects of sacrocolposuspension on the lower urinary tract
Effects of sacrocolposuspension on the lower urinary tract R. Edward Varner, MD," KirbyJ. Plessala, MD," and HoUey Richter, MD, PhD b Birmingham and Mobile, Alabama OBJECTIVE: Urinary incontinence and micturition disorders have been reported to be common in patients who have had sacrocolposuspension procedures for vaginal vault prolapse. From interviews with 213 patients who had this procedure in Birmingham from 1986 to 1992, it was found that 53% related complaints of some urine leakage and 44% related other comPlaints, including frequency, urgency, and voiding dysfunction. It is also well known that frequently urinary symptoms accompany severe defects in pelvic support. Our purpose was to determine whether sacrocolposuspension and cul-de-sac obliteration, with or without retropubic suspension and posterior colporrhaphy, had a causal relationship to lower urinary tract dysfunction or symptoms. STUDY DESIGN: Forty-five patients who had the procedures were felt to be evaluable on the basis of preoperative documentation of a history of lower urinary tract symptoms and an evaluation. Four to eighty months after surgery (mean 31 months, median 24 months) these patients were interviewed by use of a verbally administered questionnaire assessing symptoms, and 24 patients underwent urodynamic testing. Preoperative and postoperative data collected subjectively and objectively were analyzed with Fisher's exact test (two-tailed) or paired t test analysis. RESULTS: Lower urinary tract symptoms or dysfunction occurred in 87% of patients before and 49% of patients after sacrocolposuspension for vaginal vault prolapse in spite of correction of bladder support defects. Stress urinary incontinence was effectively treated in 92% of patients who underwent appropriate bladder neck suspension procedures. There was no evidence that subjective or objective voiding dysfunction, urinary frequency, urgency or urge incontinence, or subjective and objective stress incontinence increased after the above procedures. None of the seven patients who had no urinary symptoms preoperatively had new-onset lower urinary tract symptoms postoperatively that could be attributed to the surgery. CONCLUSIONS: (1) Lower urinary tract dysfunction is common in patients with significant pelvic relaxation. (2) Careful evaluation of the lower urinary tract is essential for treatment choice and to effectively counsel patients with total prolapse. (3) Sacrocolposuspension in itself does not significantly affect lower urinary tract function or symptoms. (AMJ OBSTETGYNEGOL1995;173:1684-9.)
Key words: Sacrocolposuspension, urinary incontinence, vaginal vault prolapse, urinary frequency/urgency
Since Soichet 1 first advocated sacral colpopexy for correction of vaginal vault prolapse in 1970, various modifications that use homologous and heterologous graft material have become widely used. The procedures have been shown to effectively suspend the vagina while preserving sexual function and have been especially useful when vault prolapse occurs after previous vaginal repair procedures in which the vagina may have been narrowed or shortened. A retrospective chart review and questionnaire of 213 patients who had undergone sacrocolposuspension pro-
From the Division of Medical and Surgical Gynecology,~Department of Obstetrics and Gynecology,b The University of Alabama at Birmingham, and the Mobile OB/GYN PC. c Presented at the Twentyfirst Annual Meeting of the Society of Gynecologic Surgeons, Orlando, Florida, March 6-8, 1995. Reprint requests: R. Edward Varner, MD, Division of Medical and Surgical Gynecology, Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, 618 S. 20th St., Birmingham, AL 35233-7333. Copyright © 1995 by Mosby-Year Book, Inc. 0002-9378/95 $5.00+ 0 6/6/68499 1684
cedures by five different surgeons in Birmingham revealed that 53% of all patients related some urinary leakage, and 44% had some other urinary complaints postoperatively. Snyder and Krantz, 2 from a series of 147 procedures, and Timmons et al., 3 from a series of 160 procedures, reported the occurrence of persistent or worsening incontinence in 38 (26%) and 18 (11%) patients, respectively. Afte r evaluating and managing three patients who had significant urinary incontinence after the procedures, we felt that further investigation was indicated. It might be speculated that sacrocolposuspension could affect bladder and urethral function by two mechanisms. First, part of the nerve supply to and from the lower urinary tract could be disturbed when the presacral space is dissected and implanted with graft material. Second, there is potential for obliterating the urethrovesical angle by tightening the pubocervical fascia and orienting it in a more cephalad-caudad direction. Lower urinary tract symptoms appear to be common in patients with vaginal vault prolapse. Several studies, in-
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Varner, Plessala, and Richter 1685
Table L Operative procedures performed with sacrocolposuspension Abdominal culdoplasty Reu'opubic suspension Modified Burch procedure Marshall-Marchetti-Krantz with paravaginal defect repair Paravaginal defect repair Urethral sling Posterior colporrhaphy Anterior colporrhaphy
Fig. 1. Sacrocolposuspension with Y-shaped graft, GIA (United States Surgical Corporation, Norwalk, Conn.) intestinal sizer, and Halban-type cul-de-sac obliteration.
cluding the two mentioned, 26 reported incidences of incontinence and other urinary tract symptoms to be 30% to 80% before surgery. Symptoms are even more comm o n in patients who have large anterior defects with protrusion of the anterior vaginal wall and the bladder through the introitus. In one study7 32 of 33 women who had large anterior defects had urodynamic evidence of stress incontinence when the prolapse was reduced. To our knowledge, no study has specifically addressed whether lower urinary tract dysfunction or symptoms persist or occur de novo after surgery for vaginal vault prolapse when all anatomic defects are addressed. The purpose of the study was to determine whether abdominal repair of posthysterectomy vaginal vault prolapse with sacrocolposuspension has an adverse effect on lower urinary tract function and symptoms. The study was designed to compare preoperative and postoperative lower urinary tract symptoms and objective findings on urodynamic evaluation.
Material and methods Charts of patients who were managed with sacrocolposuspension by the primary author for posthysterectomy vaginal vault prolapse between September 1987 and January 1994 were reviewed. Forty-five patients were thought to be evaluable on the basis of documentation of subjective and objective lower urinary tract evaluation before surgery. These evaluations included detailed histories including specific, verbally administered questionnaires about lower urinary tract symptoms and past medical histories, a thorough pelvic examination noting all support structures and defects, and urodynamic studies including urinalysis, a postvoid residual volume, cotton
45 (100%) 36 (80%) 28 4 2 2 33 (73%) 4 (9%)
swab test, stress test, cystometrics, and uroflometry. Patients found to have stress urinary incontinence had urethral pressure profilometry as well, and, when indicated, cystoscopy or urethroscopy was performed. Patients were examined both in supine and upright positions, at rest, and straining with a birthing chair and Sims speculum. Stress tests and urethral pressure profilometry were performed with the prolapse reduced by use of ring forceps with 100 ml in the bladder with the patient supine and at bladder capacity with the patient upright. A dual microtip pressure transducer catheter and muhichannel recorder were used for cystometrics and urethral pressure measurements. Ages of patients ranged from 37 to 81 years (median 66 years, mean 64 years). All patients were parous with mean parity of 2.7. All had undergone previous hysterectomy (28 transabdominally, 17 transvaginally). Sixty percent had previous repair procedures, and (40%) had undergone prior retropubic suspension procedures. All patients had evidence of protrusion of the vaginal vault through the introitus. Thirty-six (80%) had accompanying cystoceles and 34 (76%) had demonstrable rectoceles. All patients either declined pessary use or had some problem with using various pessaries. All were treated preoperatively with an estrogen regimen. The senior author (R.E.V.) was the primary surgeon in all cases. Sacrocolposuspension was performed with a Gore-Tex (W.L. Gore and Associates, Flagstaff, Ariz.) graft constructed to create two flaps, one to be fixed anteriorly to the paravaginal fascia just cephalad to the vesicovaginal reflection and one to be fixed posteriorly to the paravaginal fascia, likewise above the vaginal rectosigmoid reflection (Fig. 1). The free end was secured to the anterior sacral ligament or the sacral periosteum at the level of S-1 to S-2. In all cases the peritoneum was removed from the vaginal cuff before flap fixation, and cul-de-sac obliteration was performed with either a Halban or Moschowitz-type procedure. In all cases the peritoneum was incised just below the sacral prominence, and exposure of the anterior sacral ligament was accomplished with a spreading technique of the scissors and careful blunt dissection. Hemoclips were applied to the middle sacral vessels below and above the point at which the graft was attached to the anterior sacral ligament or
1686 Varner,Plessala, and Richter
December 1995 AmJ ObstetGynecol
Table II. Lower urinary tract symptoms (n = 45 patients)
Symptom Voiding complaints Urinary urgency Frequency (more than seven times daily) Nocmria (more than two times) Subjective urge incontinence Subjective stress incontinence
Preoperative 12 22 9 8 13 15
Postoperative
(27%) (49%) (20%) (18%) (29%) (33%)
11 17 2 9 9 8
Significance
(24%) (38%) (4%) (20%) (20%) (18%)t
NS* NS* NS* (p< 0.049) NS* NS* NS*
NS, Not significant. *Two-tailed Fisher's exact test. tSix of these eight were significantly improved.
Table III. Objective evaluations
Evalua~on
Preoperative (n = 45)
Postoperative (n = 24)
Peak flow rates (ml/sec) (mean) Residual volume (ml) (mean) Bladder capacity (ml) (mean) Detrusor instability Positive stress test results
26 46 365 4 (9%) 27 (60%)
29 39 351 3 (12%) 3 (12%)
I
Significance NS* NS* NS* NSt p=0.0015 t
NS, Not significant. *Paired t tests. tTwo-tailed fisher's exact test.
periosteum with p e r m a n e n t suture material. In some cases in which the paravaginal fascia was particularly attenuated and the vagina was elongated the exposed cuff fascia was plicated by use of imbricating structures of polyglycolic acid before graft placement. Care was taken in each case to avoid oversuspending the vault, thereby promoting excess tension on the graft, sutures, and paravaginal tissues. When other pelvic support defects or stress urinary incontinence were present, other procedures were performed as well (Table I). The two patients who underwent urethral sling procedures had been noted to have combined extrinsic and intrinsic urethral defects. Follow-up of these patients ranged from 4 to 84 months, with a mean of 31 months and median of 24 months. Forty-five patients were contacted by telephone and interviewed by questionnaire. Twenty-four of these were seen for an objective evaluation with a complete examination and the same urodynamic evaluations, which were performed preoperatively. Twenty-one of the patients preferred not to present for repeat objective evaluations for various reasons, including travel distance, problems with transportation, and health problems. All postoperative evaluations were performed by the second and third authors to minimize surgeon bias. Data collected subjectively and objectively were analyzed to attempt to discover whether the procedures had significant effects on micturition, urge incontinence, or stress incontinence. Paired t tests were used to compare
preoperative and postoperative numeric values, and Fisher's exact tests were used to compare subjective data, The study was approved by the Institutional Review Board for H u m a n Use at the University of Alabama at Birmingham.
Results Preoperative and postoperative subjective complaints and objective evaluations are compared in Tables II and III. Overall, 87% had lower urinary tract symptoms before surgery compared with 49% after operation. Importantly, none of the seven patients who had no anterior segment defect and no urinary complaints had incontinence or new symptoms after surgery. Micturition. Preoperatively 12 patients (27%), when specifically asked, related some difficulty voiding, described as hesitancy, incomplete voiding, slow voiding, or postvoid dribbling. Three (6.4%) had abnormal residual volumes >75 ml (none >160 ml). All patients had peak flow rates >20 ml/sec, but 9 (20%) had prolonged voiding times with intermittent flow patterns. Postoperatively 11 patients complained of voiding difficulty. Nine of these had the same complaints preoperatively. Seven related some improvement and two reported no change. The only two patients with new-onset complaints had retropubic suspension procedures, and of those patients who did not undergo retropubic suspension none had de novo micturition complaints. The three patients with increased residual volumes preoperatively
Volume 173, Number 6 AmJ Obstet Gynecol
retained these volumes postoperatively. Again, all peak flow rates were >20 ml/sec, and only four patients had intermittent flow patterns. The mean residual volumes and flow" rates did not change significantly from preoperative values, although the changes were in favorable directions. Frequency-volume diaries, when available, confirmed the above and showed no obvious difference between preoperative and postoperative voiding patterns although patients verbally reported less urinary frequency. Urgency and detrusor dysfunction. Twenty-two patients (49%) complained of urgency preoperatively and 13 related leakage with urge. However, only four patients (9%) had detrusor instability confirmed by cystometric studies. Nineteen of the patients with urgency and three of the four patients with stated urge incontinence also had stress urinary incontinence diagnosed by urodynamic evaluation. All patients had bladder capacities >300 ml. Seventeen patients (38 %) complained of urgency postoperatively. Nine reported some improvement and five reported no real change in urge symptoms. Two patients related worsening of urgency postoperatively. One of these had stress incontinence 2 years after procedure and one had problems with recurrent urinary tract infections. Two other patients had new-onset urgency, neither having the symptom in the immediate postoperative period but rather 1 to 2.5 years later. Three of nine patients who reported urge incontinence were found to have detrusor instability on postoperative cystometric evaluation. One of these had instability before surgery that had not changed. The remaining two patients had had retropubic suspensions (8% of patients in this series who had retropubic suspensions thus had detrusor instability). This 8% of new-onset detrusor instability after the retropubic procedure is equal to that seen in other series examining the effect of retropubic suspension on bladder stability. Stress incontinence. Preoperatively 27 patients (60%) were found to have urodynamically documented stress incontinence with the prolapse reduced; however, only 15 (33%) complained of leakage with stress. Ten of the patients with stress incontinence had had previous retropubic suspension procedures. Two patients who complained of this had no urodynamically demonstrable leakage. The remainder all had documented positive stress tests, and all had at least some evidence of bladder neck descent as evidenced by cotton swab rotation with cough. Two patients had intrinsic urethral defects and underwent sling procedures concurrently with colposuspension. Postoperatively eight patients (18%) complained of some stress incontinence. No patient had de novo stress incontinence early after the procedure, but one had this 2 years later. Six of the eight patients stated the leakage with stress was much improved after surgery, and all of
Varner, Plessala, and Richter
1687
these had negative stress test results and negative cotton swab test results when studied. The overall subjective cure and improvement rate for stress incontinence was 96%. Two patients had worsening of leakage with stress; both had undergone a prior retropubic suspension. Neither of the two were noted on physical examination to have excess tension applied to the anterior wall by the graft, which might ablate the urethrovesical angle, and both had intrinsic urethral incompetence evidenced by low urethral pressures and abdominal leak point pressures without evidence of bladder neck descent. One patient who did not complain of incontinence had a weakly positive stress test result on evaluation. Comparison of preoperatively and postoperatively measured peak urethral pressures in 11 patients showed a decrease in the two patients who had intrinsic urethral defects and an increase in five patients, two of whom had sling procedures. Urethral pressure was measured preoperatively in three patients who did not have stress urinary incontinence or retropubic procedures. Postoperative measurements showed no change. Comment
It can be concluded that uncomplicated, correctly performed sacrocolposuspension does not in itself adversely affect lower urinary tract function or symptoms. It is apparent from this study and from the literature that lower urinary tract dysfunction and pelvic prolapse frequently coexist. A total of 14% to 39% of patients with significant prolapse have difficulty with voiding, 20% to 50% have increased urgency and frequency, and 60% to 80%, when studied with the prolapse reduced, have evidence of urethral incontinence. Several studies 8ql have demonstrated with urodynamic investigation that urethral mechanics may be affected by anterior vaginal and bladder prolapse and that an apparent kinking effect may conceal urethral incompetence. Careful evaluation with the prolapse reduced in this series of patients allowed for successful treatment of stress incontinence in most patients. This study illustrates that some of the dysfunction (defects in bladder emptying, sensory urgency, and functional nocturia) may not be effectively treated by"correction" of the prolapse. This indicates that mechanical factors of the prolapse are not the only cause of the dysfunction. In addition, retropubic suspension procedures, which should accompany correction of the vault prolapse in patients with anterior defects, carry some risk of subsequent problems, including detrusor instability, voiding dysfunction, and the occasional production of intrinsic urethral incompetence, particularlywhen prior retropubic procedures have been performed. Careful preoperative evaluation of the lower urinary tract and the specific pelvic support structures is essential for planning treatment and strategy and for effectively counseling patients.
1688 Varner, Plessala, and Richter
REFERENCES
1. Soichet S. Surgical correction of total genital prolapse with retention of sexual function. Obstet Gynecol 1970;36:69-75. 2. Snyder TE, Krantz KE. Abdominal-retroperitoneal sacral colpopexy for the correction of vaginal prolapse. Obstet Gynecol 1991;77:944-9. 3. Timmons Me, Addison WA, Addison SB, Cavenar MG. Abdominal sacral colpopexy in 163 women with posthysterectomy vaginal vault prolapse and enterocele: evolution of operative techniques. J Reprod Med 1992;37:323-7. 4. Hendee AE, Berry CM. Abdominal sacropexy for vaginal vault prolapse. Clin Obstet Gynecol 1981;24:1217-26. 5. Drutz HP, Cha LS. Massivegenital and vaginal vault prolapse treated by abdominal-vaginal sacropexy with use of Marlex mesh: reviewof the literature. AMJ OBSTETG'mECOL1987;156: 387-92. 6. Maloney JC, Dunton CJ, Smith K. Repair Of vaginal vault prolapse with abdominal sacropexy.J Reprod Med 1990;35: 6-10. 7. Grady M, Kozminski M, Delancey J, Elkins T, McGuire EJ. Stress incontinence and cystoceles.J Urol 1991;145:1211-3. 8. Richardson DA, Bent AE, Ostergard DR. The effect of uterovaginal prolapse on ureterovesical pressure dynamics. AMJ OBSTET GYNECOL1983;146:901-5. 9. Bump Re, Fantl JL, Hurt WG. The mechanism of urinary continence m women with severe uterovaginal prolapse: results of barrier studies. Obstet Gynecol 1988;72:291-5. 10. Bergman A, Koonings PB, Ballard CA. Predicting postoperative urinary incontinence development in women undergoing operation for genitourinary prolapse. AMJ OBSTET GYNECOL1988;158:1171-5. 11. Rosenzweig BA, Pushkin S, Blumenfeld D. Prevalence of abnormal urodynamic test results in continent women with severe genitourinary prolapse. Obstet Gynecol 1992;79:53942.
Discussion
D~, ERNESTJ. KOHORN,New Haven, Connecticut. It is puzzling that Soichet 1 is still credited with designing the operation of an abdominal colposacropexy. Arthure performed uterine sarcopexy as far back as 1957 at the suggestion of Savage, 2 and three cases of sacrocolpopexy were included in his report. As a resident I remembered his chagrin when he discovered in one of his patients that preoperative curettage of the uterus showed carcinoma. This was not discovered until 3 days postoperatively, and of course the uterus then had to be removed. How intraoperative sacrocolpopexy is useful in managing uterine carcinoma with total procedentia. Birnbaum3was the second person to perform the procedure in the United States. In 1961 Embrey4 at Oxford first used fascia lata to bridge the gap between the vagina and the cervix. In 1962 Lane s in New York first used synthetic graft for the same purpose. ApproPriately, the authors attend to the question of urinary problems associated with vaginal eversion and rightly report that Krantz and Snyder and Addison and Timmons found worsening symptoms of incontinence although attempts at surgical correction were made (18%, 56/307 patients). Dr. Varner and his colleagues now restrict their discussion to the 45 patients personally operated on by Dr. Varner. In the original presentation at the Society of Gynecologic Surgeons Dr. Varner also mentioned a total of 213 patients; it would have been interesting to see
December 1995 AmJ ObstetGynecol
whether the patients who did not have detailed urodynamic assessment had a different outcome from the 45 patients who had such a precise examination. Dr. Varner and his colleagues theorized that the surgery may interfere with the nerve supply of the presacral space or may obliterate the urethrovesical angle by tightening the endocervical fascia. The nerve supply to the bladder and urethra do r u n in the presacral space, but usually the presacral nerve is pushed to the left side during this operation and is not in fact usually divided. As to obliterating the urethrovesical angle, this seems a new concept and it is difficult to fathom how one can "obliterate an angle." The authors demonstrate that the procedure of colposacropexy does not significantly alter bladder and urethral function objectively or subjectively and in fact demonstrated that if all accompanying defects are dealt with surgically then most patients benefit from the correction of the prolapse and in terms of their urinary symptoms. This is still a difficult article to follow because every investigation was performed, and it is not always clear which is of significance in relation to particular findings. The authors need to clarify which of the 36 patients had a cystocele previously repaired. They do state that 40% of 45 patients had undergone prior retropubic procedures. When the authors state that 45% of the patients were contacted by telephone, it presumably means that all the patients were contacted by telephone. In the Results section the authors state that 80% of patients had lower urinary tract symptoms before surgery and only 49% postoperatively. This then compares with 11 of the 45 patients who had voiding difficulties postoperatively, and only nine had the same complaints preoperatively. Two patients had new onset of urinary symptoms after retropubic procedures, but it is not clear whether in fact this was stress incontinence or other urinary problems. This then needs to be compared with the reSults in the section of stress urinary incontinence, where it is stated that preoperatively 27 patients had urodynamically documented stress incontinence but only 15 complained of urinary leakage. Postoperatively eight patients complained of urinary leakage, so it seems that seven patients were in fact cured of their stress incontinence. These figures need to be compatible. The overall conclusions appear to be acceptable and are in accord with general experience.
REFERENCES
1. Soichet S. Surgical correction of total genital prolapse with retention of sexual function. Obstet Gynecol 1970;36:68-75. 2. Arthure HGE, Savage D. Uterine prolapse and prolapse of the vaginal vault treated by sacropexy. J Obstet Gynaecol Br Comm 1957;64:355-60. 3. Birnbaum SJ. Rational therapy for the prolapsed vagina. AuJ OBSTETGYNECOL1973;115:411-9. 4. Embrey MP. An abdominal sling operation for the repair of enterocele and vault prolapse. J Obstet Gynaecol Br Comm 1961;68:471-4. 5. Lane FE. Repair of posthysterectomy vaginal-vault prolapse. Obstet Gynecol 1962;20:72-7.
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AmJ Obstet Gynecol
DR. VaRNER (Closing). I appreciate Dr. Kohorn's comments and his pointing out that Arthure and Savage first discussed vaginal or uterine sacroplexy in 1957 in a journal article that I missed. The 45 patients inlcuded in this study had specific preoperative subjective and objective evaluations, which would allow for better comparison to postoperative data. The 213 patients who were evaluated by postoperative questionnaire were managed by five different surgeons and had variable preoperative evaluations. Many had no specific urologic history documented, and all but 45 had no formal urodynamic studies. Overall, postoperative urinary tract symptoms were present in 49% of the 45 patients who had urodynamic evaluations preoperatively and in 60% of the total group of 213 patients. Stress incontinence symptoms were present in 18% of the former and 44% of the latter. It is thought that overstretching of the pubocervical fascial plane in a posterior cephalad direction may, in effect, obliterate the urethrovesical angle a n d that theoretically any foreign body placed in proximity to a neural
plexus might affect the function of those nerves. The data derived from these patients in which careful operative technique was used would not appear to indicate that these potential problems occur commonly, if at all. There was a large amount of data to present in this study. It was felt that this was best accomplished by comparing subjective and objective data from preoperative and postoperative studies in table format and by using the test to present specific areas of lower urinary tract dysfunction (i.e., disordered micturition, urgency and detrusor instability, urethral incompetence). Significant individual changes from preoperation to postoperation were also specifically noted in the test. Many patients had more than one symptom and more than one abnormal urodynamic finding, possibly explaining some of the difficulty in understanding the data. The two patients which Dr. Kohorn referred to as having new-onset urinary symptoms postoperatively were discussed in the micturition section of the Results. They had new-onset voiding complaints, not stress incontinence, after retropubic procedures. I found no discrepancy in the data presented.
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Key words: Sacrocolposuspension, urinary incontinence, vaginal vault prolapse, urinary frequency/urgency
Since Soichet 1 first advocated sacral colpopexy for correction of vaginal vault prolapse in 1970, various modifications that use homologous and heterologous graft material have become widely used. The procedures have been shown to effectively suspend the vagina while preserving sexual function and have been especially useful when vault prolapse occurs after previous vaginal repair procedures in which the vagina may have been narrowed or shortened. A retrospective chart review and questionnaire of 213 patients who had undergone sacrocolposuspension pro-
From the Division of Medical and Surgical Gynecology,~Department of Obstetrics and Gynecology,b The University of Alabama at Birmingham, and the Mobile OB/GYN PC. c Presented at the Twentyfirst Annual Meeting of the Society of Gynecologic Surgeons, Orlando, Florida, March 6-8, 1995. Reprint requests: R. Edward Varner, MD, Division of Medical and Surgical Gynecology, Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, 618 S. 20th St., Birmingham, AL 35233-7333. Copyright © 1995 by Mosby-Year Book, Inc. 0002-9378/95 $5.00+ 0 6/6/68499 1684
cedures by five different surgeons in Birmingham revealed that 53% of all patients related some urinary leakage, and 44% had some other urinary complaints postoperatively. Snyder and Krantz, 2 from a series of 147 procedures, and Timmons et al., 3 from a series of 160 procedures, reported the occurrence of persistent or worsening incontinence in 38 (26%) and 18 (11%) patients, respectively. Afte r evaluating and managing three patients who had significant urinary incontinence after the procedures, we felt that further investigation was indicated. It might be speculated that sacrocolposuspension could affect bladder and urethral function by two mechanisms. First, part of the nerve supply to and from the lower urinary tract could be disturbed when the presacral space is dissected and implanted with graft material. Second, there is potential for obliterating the urethrovesical angle by tightening the pubocervical fascia and orienting it in a more cephalad-caudad direction. Lower urinary tract symptoms appear to be common in patients with vaginal vault prolapse. Several studies, in-
Volume 173, Number 6 AmJ Obstet Gynecol
Varner, Plessala, and Richter 1685
Table L Operative procedures performed with sacrocolposuspension Abdominal culdoplasty Reu'opubic suspension Modified Burch procedure Marshall-Marchetti-Krantz with paravaginal defect repair Paravaginal defect repair Urethral sling Posterior colporrhaphy Anterior colporrhaphy
Fig. 1. Sacrocolposuspension with Y-shaped graft, GIA (United States Surgical Corporation, Norwalk, Conn.) intestinal sizer, and Halban-type cul-de-sac obliteration.
cluding the two mentioned, 26 reported incidences of incontinence and other urinary tract symptoms to be 30% to 80% before surgery. Symptoms are even more comm o n in patients who have large anterior defects with protrusion of the anterior vaginal wall and the bladder through the introitus. In one study7 32 of 33 women who had large anterior defects had urodynamic evidence of stress incontinence when the prolapse was reduced. To our knowledge, no study has specifically addressed whether lower urinary tract dysfunction or symptoms persist or occur de novo after surgery for vaginal vault prolapse when all anatomic defects are addressed. The purpose of the study was to determine whether abdominal repair of posthysterectomy vaginal vault prolapse with sacrocolposuspension has an adverse effect on lower urinary tract function and symptoms. The study was designed to compare preoperative and postoperative lower urinary tract symptoms and objective findings on urodynamic evaluation.
Material and methods Charts of patients who were managed with sacrocolposuspension by the primary author for posthysterectomy vaginal vault prolapse between September 1987 and January 1994 were reviewed. Forty-five patients were thought to be evaluable on the basis of documentation of subjective and objective lower urinary tract evaluation before surgery. These evaluations included detailed histories including specific, verbally administered questionnaires about lower urinary tract symptoms and past medical histories, a thorough pelvic examination noting all support structures and defects, and urodynamic studies including urinalysis, a postvoid residual volume, cotton
45 (100%) 36 (80%) 28 4 2 2 33 (73%) 4 (9%)
swab test, stress test, cystometrics, and uroflometry. Patients found to have stress urinary incontinence had urethral pressure profilometry as well, and, when indicated, cystoscopy or urethroscopy was performed. Patients were examined both in supine and upright positions, at rest, and straining with a birthing chair and Sims speculum. Stress tests and urethral pressure profilometry were performed with the prolapse reduced by use of ring forceps with 100 ml in the bladder with the patient supine and at bladder capacity with the patient upright. A dual microtip pressure transducer catheter and muhichannel recorder were used for cystometrics and urethral pressure measurements. Ages of patients ranged from 37 to 81 years (median 66 years, mean 64 years). All patients were parous with mean parity of 2.7. All had undergone previous hysterectomy (28 transabdominally, 17 transvaginally). Sixty percent had previous repair procedures, and (40%) had undergone prior retropubic suspension procedures. All patients had evidence of protrusion of the vaginal vault through the introitus. Thirty-six (80%) had accompanying cystoceles and 34 (76%) had demonstrable rectoceles. All patients either declined pessary use or had some problem with using various pessaries. All were treated preoperatively with an estrogen regimen. The senior author (R.E.V.) was the primary surgeon in all cases. Sacrocolposuspension was performed with a Gore-Tex (W.L. Gore and Associates, Flagstaff, Ariz.) graft constructed to create two flaps, one to be fixed anteriorly to the paravaginal fascia just cephalad to the vesicovaginal reflection and one to be fixed posteriorly to the paravaginal fascia, likewise above the vaginal rectosigmoid reflection (Fig. 1). The free end was secured to the anterior sacral ligament or the sacral periosteum at the level of S-1 to S-2. In all cases the peritoneum was removed from the vaginal cuff before flap fixation, and cul-de-sac obliteration was performed with either a Halban or Moschowitz-type procedure. In all cases the peritoneum was incised just below the sacral prominence, and exposure of the anterior sacral ligament was accomplished with a spreading technique of the scissors and careful blunt dissection. Hemoclips were applied to the middle sacral vessels below and above the point at which the graft was attached to the anterior sacral ligament or
1686 Varner,Plessala, and Richter
December 1995 AmJ ObstetGynecol
Table II. Lower urinary tract symptoms (n = 45 patients)
Symptom Voiding complaints Urinary urgency Frequency (more than seven times daily) Nocmria (more than two times) Subjective urge incontinence Subjective stress incontinence
Preoperative 12 22 9 8 13 15
Postoperative
(27%) (49%) (20%) (18%) (29%) (33%)
11 17 2 9 9 8
Significance
(24%) (38%) (4%) (20%) (20%) (18%)t
NS* NS* NS* (p< 0.049) NS* NS* NS*
NS, Not significant. *Two-tailed Fisher's exact test. tSix of these eight were significantly improved.
Table III. Objective evaluations
Evalua~on
Preoperative (n = 45)
Postoperative (n = 24)
Peak flow rates (ml/sec) (mean) Residual volume (ml) (mean) Bladder capacity (ml) (mean) Detrusor instability Positive stress test results
26 46 365 4 (9%) 27 (60%)
29 39 351 3 (12%) 3 (12%)
I
Significance NS* NS* NS* NSt p=0.0015 t
NS, Not significant. *Paired t tests. tTwo-tailed fisher's exact test.
periosteum with p e r m a n e n t suture material. In some cases in which the paravaginal fascia was particularly attenuated and the vagina was elongated the exposed cuff fascia was plicated by use of imbricating structures of polyglycolic acid before graft placement. Care was taken in each case to avoid oversuspending the vault, thereby promoting excess tension on the graft, sutures, and paravaginal tissues. When other pelvic support defects or stress urinary incontinence were present, other procedures were performed as well (Table I). The two patients who underwent urethral sling procedures had been noted to have combined extrinsic and intrinsic urethral defects. Follow-up of these patients ranged from 4 to 84 months, with a mean of 31 months and median of 24 months. Forty-five patients were contacted by telephone and interviewed by questionnaire. Twenty-four of these were seen for an objective evaluation with a complete examination and the same urodynamic evaluations, which were performed preoperatively. Twenty-one of the patients preferred not to present for repeat objective evaluations for various reasons, including travel distance, problems with transportation, and health problems. All postoperative evaluations were performed by the second and third authors to minimize surgeon bias. Data collected subjectively and objectively were analyzed to attempt to discover whether the procedures had significant effects on micturition, urge incontinence, or stress incontinence. Paired t tests were used to compare
preoperative and postoperative numeric values, and Fisher's exact tests were used to compare subjective data, The study was approved by the Institutional Review Board for H u m a n Use at the University of Alabama at Birmingham.
Results Preoperative and postoperative subjective complaints and objective evaluations are compared in Tables II and III. Overall, 87% had lower urinary tract symptoms before surgery compared with 49% after operation. Importantly, none of the seven patients who had no anterior segment defect and no urinary complaints had incontinence or new symptoms after surgery. Micturition. Preoperatively 12 patients (27%), when specifically asked, related some difficulty voiding, described as hesitancy, incomplete voiding, slow voiding, or postvoid dribbling. Three (6.4%) had abnormal residual volumes >75 ml (none >160 ml). All patients had peak flow rates >20 ml/sec, but 9 (20%) had prolonged voiding times with intermittent flow patterns. Postoperatively 11 patients complained of voiding difficulty. Nine of these had the same complaints preoperatively. Seven related some improvement and two reported no change. The only two patients with new-onset complaints had retropubic suspension procedures, and of those patients who did not undergo retropubic suspension none had de novo micturition complaints. The three patients with increased residual volumes preoperatively
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retained these volumes postoperatively. Again, all peak flow rates were >20 ml/sec, and only four patients had intermittent flow patterns. The mean residual volumes and flow" rates did not change significantly from preoperative values, although the changes were in favorable directions. Frequency-volume diaries, when available, confirmed the above and showed no obvious difference between preoperative and postoperative voiding patterns although patients verbally reported less urinary frequency. Urgency and detrusor dysfunction. Twenty-two patients (49%) complained of urgency preoperatively and 13 related leakage with urge. However, only four patients (9%) had detrusor instability confirmed by cystometric studies. Nineteen of the patients with urgency and three of the four patients with stated urge incontinence also had stress urinary incontinence diagnosed by urodynamic evaluation. All patients had bladder capacities >300 ml. Seventeen patients (38 %) complained of urgency postoperatively. Nine reported some improvement and five reported no real change in urge symptoms. Two patients related worsening of urgency postoperatively. One of these had stress incontinence 2 years after procedure and one had problems with recurrent urinary tract infections. Two other patients had new-onset urgency, neither having the symptom in the immediate postoperative period but rather 1 to 2.5 years later. Three of nine patients who reported urge incontinence were found to have detrusor instability on postoperative cystometric evaluation. One of these had instability before surgery that had not changed. The remaining two patients had had retropubic suspensions (8% of patients in this series who had retropubic suspensions thus had detrusor instability). This 8% of new-onset detrusor instability after the retropubic procedure is equal to that seen in other series examining the effect of retropubic suspension on bladder stability. Stress incontinence. Preoperatively 27 patients (60%) were found to have urodynamically documented stress incontinence with the prolapse reduced; however, only 15 (33%) complained of leakage with stress. Ten of the patients with stress incontinence had had previous retropubic suspension procedures. Two patients who complained of this had no urodynamically demonstrable leakage. The remainder all had documented positive stress tests, and all had at least some evidence of bladder neck descent as evidenced by cotton swab rotation with cough. Two patients had intrinsic urethral defects and underwent sling procedures concurrently with colposuspension. Postoperatively eight patients (18%) complained of some stress incontinence. No patient had de novo stress incontinence early after the procedure, but one had this 2 years later. Six of the eight patients stated the leakage with stress was much improved after surgery, and all of
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these had negative stress test results and negative cotton swab test results when studied. The overall subjective cure and improvement rate for stress incontinence was 96%. Two patients had worsening of leakage with stress; both had undergone a prior retropubic suspension. Neither of the two were noted on physical examination to have excess tension applied to the anterior wall by the graft, which might ablate the urethrovesical angle, and both had intrinsic urethral incompetence evidenced by low urethral pressures and abdominal leak point pressures without evidence of bladder neck descent. One patient who did not complain of incontinence had a weakly positive stress test result on evaluation. Comparison of preoperatively and postoperatively measured peak urethral pressures in 11 patients showed a decrease in the two patients who had intrinsic urethral defects and an increase in five patients, two of whom had sling procedures. Urethral pressure was measured preoperatively in three patients who did not have stress urinary incontinence or retropubic procedures. Postoperative measurements showed no change. Comment
It can be concluded that uncomplicated, correctly performed sacrocolposuspension does not in itself adversely affect lower urinary tract function or symptoms. It is apparent from this study and from the literature that lower urinary tract dysfunction and pelvic prolapse frequently coexist. A total of 14% to 39% of patients with significant prolapse have difficulty with voiding, 20% to 50% have increased urgency and frequency, and 60% to 80%, when studied with the prolapse reduced, have evidence of urethral incontinence. Several studies 8ql have demonstrated with urodynamic investigation that urethral mechanics may be affected by anterior vaginal and bladder prolapse and that an apparent kinking effect may conceal urethral incompetence. Careful evaluation with the prolapse reduced in this series of patients allowed for successful treatment of stress incontinence in most patients. This study illustrates that some of the dysfunction (defects in bladder emptying, sensory urgency, and functional nocturia) may not be effectively treated by"correction" of the prolapse. This indicates that mechanical factors of the prolapse are not the only cause of the dysfunction. In addition, retropubic suspension procedures, which should accompany correction of the vault prolapse in patients with anterior defects, carry some risk of subsequent problems, including detrusor instability, voiding dysfunction, and the occasional production of intrinsic urethral incompetence, particularlywhen prior retropubic procedures have been performed. Careful preoperative evaluation of the lower urinary tract and the specific pelvic support structures is essential for planning treatment and strategy and for effectively counseling patients.
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REFERENCES
1. Soichet S. Surgical correction of total genital prolapse with retention of sexual function. Obstet Gynecol 1970;36:69-75. 2. Snyder TE, Krantz KE. Abdominal-retroperitoneal sacral colpopexy for the correction of vaginal prolapse. Obstet Gynecol 1991;77:944-9. 3. Timmons Me, Addison WA, Addison SB, Cavenar MG. Abdominal sacral colpopexy in 163 women with posthysterectomy vaginal vault prolapse and enterocele: evolution of operative techniques. J Reprod Med 1992;37:323-7. 4. Hendee AE, Berry CM. Abdominal sacropexy for vaginal vault prolapse. Clin Obstet Gynecol 1981;24:1217-26. 5. Drutz HP, Cha LS. Massivegenital and vaginal vault prolapse treated by abdominal-vaginal sacropexy with use of Marlex mesh: reviewof the literature. AMJ OBSTETG'mECOL1987;156: 387-92. 6. Maloney JC, Dunton CJ, Smith K. Repair Of vaginal vault prolapse with abdominal sacropexy.J Reprod Med 1990;35: 6-10. 7. Grady M, Kozminski M, Delancey J, Elkins T, McGuire EJ. Stress incontinence and cystoceles.J Urol 1991;145:1211-3. 8. Richardson DA, Bent AE, Ostergard DR. The effect of uterovaginal prolapse on ureterovesical pressure dynamics. AMJ OBSTET GYNECOL1983;146:901-5. 9. Bump Re, Fantl JL, Hurt WG. The mechanism of urinary continence m women with severe uterovaginal prolapse: results of barrier studies. Obstet Gynecol 1988;72:291-5. 10. Bergman A, Koonings PB, Ballard CA. Predicting postoperative urinary incontinence development in women undergoing operation for genitourinary prolapse. AMJ OBSTET GYNECOL1988;158:1171-5. 11. Rosenzweig BA, Pushkin S, Blumenfeld D. Prevalence of abnormal urodynamic test results in continent women with severe genitourinary prolapse. Obstet Gynecol 1992;79:53942.
Discussion
D~, ERNESTJ. KOHORN,New Haven, Connecticut. It is puzzling that Soichet 1 is still credited with designing the operation of an abdominal colposacropexy. Arthure performed uterine sarcopexy as far back as 1957 at the suggestion of Savage, 2 and three cases of sacrocolpopexy were included in his report. As a resident I remembered his chagrin when he discovered in one of his patients that preoperative curettage of the uterus showed carcinoma. This was not discovered until 3 days postoperatively, and of course the uterus then had to be removed. How intraoperative sacrocolpopexy is useful in managing uterine carcinoma with total procedentia. Birnbaum3was the second person to perform the procedure in the United States. In 1961 Embrey4 at Oxford first used fascia lata to bridge the gap between the vagina and the cervix. In 1962 Lane s in New York first used synthetic graft for the same purpose. ApproPriately, the authors attend to the question of urinary problems associated with vaginal eversion and rightly report that Krantz and Snyder and Addison and Timmons found worsening symptoms of incontinence although attempts at surgical correction were made (18%, 56/307 patients). Dr. Varner and his colleagues now restrict their discussion to the 45 patients personally operated on by Dr. Varner. In the original presentation at the Society of Gynecologic Surgeons Dr. Varner also mentioned a total of 213 patients; it would have been interesting to see
December 1995 AmJ ObstetGynecol
whether the patients who did not have detailed urodynamic assessment had a different outcome from the 45 patients who had such a precise examination. Dr. Varner and his colleagues theorized that the surgery may interfere with the nerve supply of the presacral space or may obliterate the urethrovesical angle by tightening the endocervical fascia. The nerve supply to the bladder and urethra do r u n in the presacral space, but usually the presacral nerve is pushed to the left side during this operation and is not in fact usually divided. As to obliterating the urethrovesical angle, this seems a new concept and it is difficult to fathom how one can "obliterate an angle." The authors demonstrate that the procedure of colposacropexy does not significantly alter bladder and urethral function objectively or subjectively and in fact demonstrated that if all accompanying defects are dealt with surgically then most patients benefit from the correction of the prolapse and in terms of their urinary symptoms. This is still a difficult article to follow because every investigation was performed, and it is not always clear which is of significance in relation to particular findings. The authors need to clarify which of the 36 patients had a cystocele previously repaired. They do state that 40% of 45 patients had undergone prior retropubic procedures. When the authors state that 45% of the patients were contacted by telephone, it presumably means that all the patients were contacted by telephone. In the Results section the authors state that 80% of patients had lower urinary tract symptoms before surgery and only 49% postoperatively. This then compares with 11 of the 45 patients who had voiding difficulties postoperatively, and only nine had the same complaints preoperatively. Two patients had new onset of urinary symptoms after retropubic procedures, but it is not clear whether in fact this was stress incontinence or other urinary problems. This then needs to be compared with the reSults in the section of stress urinary incontinence, where it is stated that preoperatively 27 patients had urodynamically documented stress incontinence but only 15 complained of urinary leakage. Postoperatively eight patients complained of urinary leakage, so it seems that seven patients were in fact cured of their stress incontinence. These figures need to be compatible. The overall conclusions appear to be acceptable and are in accord with general experience.
REFERENCES
1. Soichet S. Surgical correction of total genital prolapse with retention of sexual function. Obstet Gynecol 1970;36:68-75. 2. Arthure HGE, Savage D. Uterine prolapse and prolapse of the vaginal vault treated by sacropexy. J Obstet Gynaecol Br Comm 1957;64:355-60. 3. Birnbaum SJ. Rational therapy for the prolapsed vagina. AuJ OBSTETGYNECOL1973;115:411-9. 4. Embrey MP. An abdominal sling operation for the repair of enterocele and vault prolapse. J Obstet Gynaecol Br Comm 1961;68:471-4. 5. Lane FE. Repair of posthysterectomy vaginal-vault prolapse. Obstet Gynecol 1962;20:72-7.
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DR. VaRNER (Closing). I appreciate Dr. Kohorn's comments and his pointing out that Arthure and Savage first discussed vaginal or uterine sacroplexy in 1957 in a journal article that I missed. The 45 patients inlcuded in this study had specific preoperative subjective and objective evaluations, which would allow for better comparison to postoperative data. The 213 patients who were evaluated by postoperative questionnaire were managed by five different surgeons and had variable preoperative evaluations. Many had no specific urologic history documented, and all but 45 had no formal urodynamic studies. Overall, postoperative urinary tract symptoms were present in 49% of the 45 patients who had urodynamic evaluations preoperatively and in 60% of the total group of 213 patients. Stress incontinence symptoms were present in 18% of the former and 44% of the latter. It is thought that overstretching of the pubocervical fascial plane in a posterior cephalad direction may, in effect, obliterate the urethrovesical angle a n d that theoretically any foreign body placed in proximity to a neural
plexus might affect the function of those nerves. The data derived from these patients in which careful operative technique was used would not appear to indicate that these potential problems occur commonly, if at all. There was a large amount of data to present in this study. It was felt that this was best accomplished by comparing subjective and objective data from preoperative and postoperative studies in table format and by using the test to present specific areas of lower urinary tract dysfunction (i.e., disordered micturition, urgency and detrusor instability, urethral incompetence). Significant individual changes from preoperation to postoperation were also specifically noted in the test. Many patients had more than one symptom and more than one abnormal urodynamic finding, possibly explaining some of the difficulty in understanding the data. The two patients which Dr. Kohorn referred to as having new-onset urinary symptoms postoperatively were discussed in the micturition section of the Results. They had new-onset voiding complaints, not stress incontinence, after retropubic procedures. I found no discrepancy in the data presented.
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