SUI, prolapse require an integrated treatment approach

Brisbane, Australia-Female urology is a rapidly changing and wide-ranging specialty that requires special expertise, according to George Webster, MD, professor of urology and head of the section of reconstructive urology, female urology, and urodynamics at Duke University Medical Center, Durham, NC. Because of the high frequency of concomitant stress incontinence and pelvic prolapse, surgeons must take an integrated approach to correcting both conditions.

The current movement to minimally invasive surgeries makes this an attractive time for urologists to enter the field, Dr. Webster said. He also noted that the female urology patient population is different from male urology patients and that surgical skills used in female pelvic reconstruction are not intuitive and cannot be simply transferred from those used in male patients.

The number of incontinence surgeries performed in the United States actually surpassed that of prostate surgeries in 2003 (300,000 vs. 285,000), Dr. Webster told the audience at the Urological Society of Australasia annual meeting here. In addition, urinary incontinence and pelvic organ prolapse occur together so frequently "that the physician taking care of them must understand that you can't do them in total isolation," he said.

A co-surgeon role with a gynecologist is common, but it sometimes produces difficulties with respect to responsibilities. Certainly, a collaborative approach to pelvic surgery rather than a turf war is preferable and collaborative training programs are underway in some U.S. centers, he said.

Considerations for carrying out stress incontinence surgery include the extent of the patient's complaint of incontinence, examination showing stress incontinence, bladder diary findings, the number of pads used daily, 24-hour pad weight, a standardized clinic pad test, and urodynamic study of bladder function and urethral competence, Dr. Webster said.

Currently, the most popular procedures for the management of stress incontinence are minimally invasive, using synthetic or biologic "slings in a box."

"Results are comparable to those achieved with the classic pubovaginal sling, and they are here to stay, their use having swept the U.S.," he said.

Consider patient's needs

The most important question to address in patients with vaginal prolapse is whether or not the condition is symptomatic and requires management, Dr. Webster said. In some women with stress incontinence and associated asymptomatic cystocele, the performance of sling surgery alone may be complicated by postoperative voiding problems due to distortion of the cystocele over the sling. If this appears to be a risk, both should be addressed at the surgery. The patient needs to be asked if they want to be sexually active and every precaution should then be made to avoid excessively reducing the vaginal caliber. The treating surgeon must ensure that all prolapse defects have been identified preoperatively and that he/she has the skills to deal with each of them.

A proper preoperative vaginal examination using appropriate lighting is essential. Up to 20% of prolapse cases are under-diagnosed, he said. The pelvic organ prolapse quantification (POP-Q) staging system, which describes the exact degree and location of prolapse, is quickly becoming the standard for identifying the extent of prolapse, Dr. Webster noted.

The most common condition managed is a cystocele often associated with incontinence, and this may be addressed by simple repair or by the use of reinforcing allograft fascia or mesh if the patient's own tissues are poor. Rectoceles, causing fecal soiling and need for perineal splinting to defecate, are the second most common condition when incontinence and prolapse are integrated into a practice, Dr. Webster said.

"These are relatively straightforward surgeries but you have to understand that the combination of an anterior repair and sling with a rectocele repair runs a greater risk of reducing vaginal caliber," he explained.

Although good anatomic repair is achieved in 75% to 90% of patients undergoing rectocele repair, poor functional outcomes occur in up to 30% of patients.