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Hysterectomy and stress urinary incontinence
Correspondence
Daniel Altman and colleagues (Oct 27, p 1494)1 found an increased risk of surgery for stress urinary incontinence after hysterectomy for benign indications, irrespective of surgical technique. However, an increased risk of surgery for stress urinary incontinence does not necessarily mean that these women also have an increased risk of stress urinary incontinence. The continence status of the investigated women is unknown. Does hysterectomy itself predispose to stress urinary incontinence, or are women who undergo hysterectomy for benign indications just more disposed to surgery than are those who have not had (or are perhaps not willing to have) hysterectomies? Although Altman and colleagues used hallux valgus surgery and varicose-vein stripping as indicators of propensity for elective surgery, this cannot exclude (how could it?) an increased disposition to surgery for stress urinary incontinence of women who agree to hysterectomy. Notwithstanding the fact that hysterectomy is undoubtedly associated with an at least statistically increased risk of surgery for stress urinary incontinence, this does not imply an increased risk of stress urinary incontinence. Thus, whether hysterectomy itself really predisposes to stress urinary incontinence remains to be elucidated. I declare that I have no conflict of interest.
Thomas M Kessler [email protected] Department of Urology, University of Bern, 3010 Bern, Switzerland 1
Altman D, Granath F, Cnattingius S, Falconer C. Hysterectomy and risk of stressurinary-incontinence surgery: nationwide cohort study. Lancet 2007; 370: 1494–99.
because of uterine prolapse and surgery for pelvic organ prolapse (POP) at the time of hysterectomy were the greatest risk factors for a second surgical procedure. From January, 1999, to July, 2006, we did 43 uterus-sparing procedures (abdominal hysterocolposacropexy) in patients (mean age 59 years [SD 12]) with symptomatic POP. POP was associated with stress urinary incontinence in 24 patients (58%). At a mean follow-up of 52·7 months (range 12–133), urinary incontinence was present in 15 (36%) patients, 11 of whom underwent Burch colposuspension. Four of the 15 patients showed de novo urinary incontinence (three had stress urinary incontinence and one urgency incontinence); the remaining 11 had persistent stress urinary incontinence. Altman’s data and ours do not clarify whether there is a real link between hysterectomy and stress urinary incontinence, but open a new debate on uterus preservation in young women undergoing POP surgery. In recent decades, attitudes to sexuality and the psychological and emotional value of the sexual organs have changed in western countries. The uterus has been shown to contribute positively to the patient’s self-esteem, body image, confidence, and sexuality.2 One of our main goals should be to permit all women who keep their uterus to be satisfied with their image of body integrity, while always advising them about the risks of pregnancy and delivery and the need for long-term follow-up to rule out malignant disease. We declare that we have no conflict of interest.
Elisabetta Costantini, Massimo Lazzeri, *Massimo Porena [email protected]
Daniel Altman and colleagues1 report that hysterectomy, irrespective of route or mode of surgery, substantially increases the risk of subsequent surgery for stress urinary incontinence. They also found that hysterectomy www.thelancet.com Vol 371 February 2, 2008
Department of Medical-Surgical Specialties and Public Health, Section of Urology and Andrology, Via Brunamonti 51, 06100 Perugia, Italy 1
Altman D, Granath F, Cnattingius S, Falconer C. Hysterectomy and risk of stressurinary-incontinence surgery: nationwide cohort study. Lancet 2007; 370: 1494–99.
2
Neuman M, Lavy Y. Conservation of the prolapsed uterus is a valid option: medium term results of a prospective comparative study with the posterior intravaginal slingplasty operation. Int Urogynecol J 2007; 18: 889–93.
Authors’ reply We agree with Thomas Kessler that propensity for elective surgery is difficult to measure. To provide an estimate of the magnitude of such potential bias in our study (not to refute its possible existence), we studied associations between hysterectomy and risks of hallux valgus and varicose vein surgery (hazard ratios were 1·4 and 1·2, respectively). These results suggest that failure to adjust for propensity for elective surgery might result in an overestimate, but cannot explain the considerably higher risks of surgery for urinary incontinence related to hysterectomy (hazard ratios ranging from 2·1 to 2·7 depending of time of follow-up). We find it hard to believe that surgery for stress urinary incontinence and symptoms are somehow unrelated, as suggested by Kessler. Several studies have shown that women with more severe incontinence symptoms are more likely to seek and receive surgical treatment.1 Thus, surgery for stress urinary incontinence might to some extent be viewed as a measure of severity. Kessler, and also the Comment2 accompanying our Article, ignores the substantial body of evidence showing that hysterectomy is associated with stress urinary incontinence and put forth that hysterectomy is unlikely to adversely affect bladder function. Biological mechanisms for the detrimental association have repeatedly been confirmed by objective assessments,3,4 and in a systematic review of 12 studies comparing women who had and had not had hysterectomies, the summary estimate was consistent with increased odds for incontinence in women with hysterectomy.5 Our study adds a new, population-based, dimension to the already existing data, further strengthening the notion that hyster-
Science Photo Library
Hysterectomy and stress urinary incontinence
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
383
Daniel Altman and colleagues (Oct 27, p 1494)1 found an increased risk of surgery for stress urinary incontinence after hysterectomy for benign indications, irrespective of surgical technique. However, an increased risk of surgery for stress urinary incontinence does not necessarily mean that these women also have an increased risk of stress urinary incontinence. The continence status of the investigated women is unknown. Does hysterectomy itself predispose to stress urinary incontinence, or are women who undergo hysterectomy for benign indications just more disposed to surgery than are those who have not had (or are perhaps not willing to have) hysterectomies? Although Altman and colleagues used hallux valgus surgery and varicose-vein stripping as indicators of propensity for elective surgery, this cannot exclude (how could it?) an increased disposition to surgery for stress urinary incontinence of women who agree to hysterectomy. Notwithstanding the fact that hysterectomy is undoubtedly associated with an at least statistically increased risk of surgery for stress urinary incontinence, this does not imply an increased risk of stress urinary incontinence. Thus, whether hysterectomy itself really predisposes to stress urinary incontinence remains to be elucidated. I declare that I have no conflict of interest.
Thomas M Kessler [email protected] Department of Urology, University of Bern, 3010 Bern, Switzerland 1
Altman D, Granath F, Cnattingius S, Falconer C. Hysterectomy and risk of stressurinary-incontinence surgery: nationwide cohort study. Lancet 2007; 370: 1494–99.
because of uterine prolapse and surgery for pelvic organ prolapse (POP) at the time of hysterectomy were the greatest risk factors for a second surgical procedure. From January, 1999, to July, 2006, we did 43 uterus-sparing procedures (abdominal hysterocolposacropexy) in patients (mean age 59 years [SD 12]) with symptomatic POP. POP was associated with stress urinary incontinence in 24 patients (58%). At a mean follow-up of 52·7 months (range 12–133), urinary incontinence was present in 15 (36%) patients, 11 of whom underwent Burch colposuspension. Four of the 15 patients showed de novo urinary incontinence (three had stress urinary incontinence and one urgency incontinence); the remaining 11 had persistent stress urinary incontinence. Altman’s data and ours do not clarify whether there is a real link between hysterectomy and stress urinary incontinence, but open a new debate on uterus preservation in young women undergoing POP surgery. In recent decades, attitudes to sexuality and the psychological and emotional value of the sexual organs have changed in western countries. The uterus has been shown to contribute positively to the patient’s self-esteem, body image, confidence, and sexuality.2 One of our main goals should be to permit all women who keep their uterus to be satisfied with their image of body integrity, while always advising them about the risks of pregnancy and delivery and the need for long-term follow-up to rule out malignant disease. We declare that we have no conflict of interest.
Elisabetta Costantini, Massimo Lazzeri, *Massimo Porena [email protected]
Daniel Altman and colleagues1 report that hysterectomy, irrespective of route or mode of surgery, substantially increases the risk of subsequent surgery for stress urinary incontinence. They also found that hysterectomy www.thelancet.com Vol 371 February 2, 2008
Department of Medical-Surgical Specialties and Public Health, Section of Urology and Andrology, Via Brunamonti 51, 06100 Perugia, Italy 1
Altman D, Granath F, Cnattingius S, Falconer C. Hysterectomy and risk of stressurinary-incontinence surgery: nationwide cohort study. Lancet 2007; 370: 1494–99.
2
Neuman M, Lavy Y. Conservation of the prolapsed uterus is a valid option: medium term results of a prospective comparative study with the posterior intravaginal slingplasty operation. Int Urogynecol J 2007; 18: 889–93.
Authors’ reply We agree with Thomas Kessler that propensity for elective surgery is difficult to measure. To provide an estimate of the magnitude of such potential bias in our study (not to refute its possible existence), we studied associations between hysterectomy and risks of hallux valgus and varicose vein surgery (hazard ratios were 1·4 and 1·2, respectively). These results suggest that failure to adjust for propensity for elective surgery might result in an overestimate, but cannot explain the considerably higher risks of surgery for urinary incontinence related to hysterectomy (hazard ratios ranging from 2·1 to 2·7 depending of time of follow-up). We find it hard to believe that surgery for stress urinary incontinence and symptoms are somehow unrelated, as suggested by Kessler. Several studies have shown that women with more severe incontinence symptoms are more likely to seek and receive surgical treatment.1 Thus, surgery for stress urinary incontinence might to some extent be viewed as a measure of severity. Kessler, and also the Comment2 accompanying our Article, ignores the substantial body of evidence showing that hysterectomy is associated with stress urinary incontinence and put forth that hysterectomy is unlikely to adversely affect bladder function. Biological mechanisms for the detrimental association have repeatedly been confirmed by objective assessments,3,4 and in a systematic review of 12 studies comparing women who had and had not had hysterectomies, the summary estimate was consistent with increased odds for incontinence in women with hysterectomy.5 Our study adds a new, population-based, dimension to the already existing data, further strengthening the notion that hyster-
Science Photo Library
Hysterectomy and stress urinary incontinence
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
383