Vaginal prolapse repair and sling surgery significantly reduce UUI

In this interview, Christina M. Mezes, DO and Catherine A. Matthews MD, discuss the background, notable findings, and implications of the Urogynecology study “Effect of Vaginal Prolapse Repair and Midurethral Sling on Urgency Incontinence Symptoms.” Mezes is a female pelvic medicine and reconstructive surgery fellow at Wake Forest University School of Medicine in Winston-Salem, North Carolina and was the primary author on this study. Dr. Matthews is the Division Director and Fellowship Director at Wake Forest and was the senior author.

Please give an overview of this study and its notable findings.

Christina M. Mezes, DO

This was a secondary analysis of a large multi-center, randomized controlled trial, which initially was comparing retropubic vs an adjustable single-incision sling (Altis, Coloplast) in women undergoing concomitant native tissue vaginal repair for symptomatic pelvic organ prolapse and objectively confirmed stress incontinence. We were interested in further exploring what happened to urgency incontinence symptoms in this cohort. To identify women with bothersome urgency UI at baseline and 12 months post-operatively, we dichotomized patients based on responses to the question: "Do you usually experience urine leakage associated with a feeling of urgency, that is a strong sensation of needing to go to the bathroom?" into mild bother, with answers 0 or 1 on that scale, and severe bother, with answers 2, 3, and 4. We then evaluated associations between UUI persistence, regression and de novo symptoms.

Catherine A. Matthews, MD

Our most important finding was that 60% of people who had baseline significant urgency incontinence symptoms had complete resolution of UUI at 1 year after surgery and that sling type didn't make a difference in that success rate. We also found that de novo urgency incontinence was about 11% in patients at 12 months, and that colpocleisis seemed to exert a protective effect against the development of de novo UUI [urgency urinary incontinence] in that population. At baseline, advancing age was the strongest associated factor for urgency incontinence. Age remained associated with persistent and de novo urgency incontinence at 12 months.

Given that 40% of patients experienced persistent UUI at 12 months, how do you recommend clinicians counsel patients preoperatively regarding the expected outcomes of combined native tissue vaginal prolapse repair and midurethral sling procedures for UUI?

The biggest message from this study is that 60% can expect resolution of UUI, simply by fixing the prolapse and placing a sling, which is not normally indicated for UUI. This might prompt a surgeon to consider offering this intervention to a woman with a stage II vaginal prolapse who is very bothered by UUI but is not as bothered by vaginal bulge or SUI symptoms. Based on this evidence, she has a better chance of UUI symptom resolution with surgery than something like an overactive bladder medication. However, our evidence does further assist in counseling older women that they are at higher risk of experiencing bothersome persistent UUI after a sling and prolapse repair unless they had a colpocleisis. Those who experience the persistent UUI tended to be older and have a higher Charlson comorbidity index. The components of the Charleston comorbidity index are things like diabetes, congestive heart failure, peripheral vascular disease, chronic obstructive pulmonary disease, liver disease, renal disease, leukemia, lymphoma, and metastatic tumor. These are all obviously markers of poor health, and so if we know that someone is particularly debilitated, frail, old, that's the kind of person that, if there are any of those factors that could be optimized, like better controlling some of their chronic medical conditions, that may be a way that we could help to prevent them from having worsening UUI or continued UUI.

You identified body mass index (BMI) and symptomatic stress urinary incontinence (SUI) as baseline risk factors for UUI. How do you suggest these factors be incorporated into pre-operative assessments and surgical planning?

BMI and the metabolic syndrome specifically are known risk factors for overactive bladder and UUI, so this was not a surprising association in our study, both at baseline and at 12 months. Weight loss has been shown to reduce both SUI and UUI, and weight loss is always advised pre-operatively. However, exercise is often very challenging for women with pelvic floor disorders. Hopefully, the advent of more effective weight loss medications might help optimize BMI in some patients seeking POP and SUI surgery. Women with SUI often have lower urethral pressure and may be more symptomatic when bladder spasms occur. It is plausible that increasing urethral resistance with a sling decreased UUI symptom bother at 12 months.

The study found age and Charlson Comorbidity Index to be associated with persistent UUI at 12 months. How do you interpret these findings in the context of patient selection for this combined surgical approach, particularly in older or comorbid populations?

As transvaginal native tissue repairs carry very low associated surgical risk, even women who are frail and old may benefit from surgical intervention if they have symptom bother from a vaginal bulge and have objectively demonstrated SUI with relatively normal bladder emptying. Specifically with regards to UUI symptoms, however, this study provides evidence that for these older, sicker women, they are much more likely to suffer from persistent UUI at 12 months post-op. Therefore, if one of these patients was seeking surgery for the primary goal of alleviating UUI symptoms, I would counsel her that she was NOT likely to meet that goal. Surprisingly, however, colpocleisis was associated with a significant reduction in risk of UUI and this is often chosen as the surgical intervention for older, sicker women. Therefore, based on our evidence, I would recommend colpocleisis with a single-incision sling for older women with higher CCI if they were no longer sexually active.

11% of patients experienced de novo UUI. What strategies do you recommend for minimizing the risk of de novo UUI following this combined surgical procedure?

De novo urge UI may occur more frequently in women with slings that are too tight and therefore, ensuring tension-free placement of slings is important. We did not find any difference in de novo urge UI between sling type but other studies have demonstrated a higher risk of voiding dysfunction with retropubic slings. If a patient has this symptom, I would perform a uroflowmetry to ensure there is no evidence of voiding dysfunction that is attributable to the sling. As BMI was associated with urge UI post-operatively, we would encourage weight loss in individuals with a BMI over 30.

This study assessed outcomes at 12 months. What are the potential long-term implications of these findings, and what further research is needed to evaluate UUI outcomes beyond 12 months postoperatively?

If correcting vaginal prolapse and objective SUI with native tissue repair and mid urethral sling results in long-term relief of bothersome urgency UI symptoms without the need for medications or other therapies, that is a major bonus! It would be interesting to follow these patients up to 36 months after surgery to see if with time, there is a return of UI, either from stress or urge. As there is also the rare risks of slings causing future voiding dysfunction, assessing de novo UUI over time is important.

Beyond the PFDI-20, what other patient-reported outcome measures do you believe are essential for comprehensively evaluating the success of combined prolapse and incontinence surgery?

This was highlighted in the original manuscript, but the Patient Global Impression of Improvement, or PGII, is essential, as it really captures a patient’s overall perception of pelvic health. This balances very nicely the competing issues of persistent incontinence versus retention.

Based on the findings of the study, what are the most pressing research questions that need to be addressed to further optimize surgical management of UI in women undergoing vaginal prolapse repair?

The necessary pre-operative assessment of lower urinary tract symptoms in women with pelvic organ prolapse is not clearly defined. We are interested in evaluating urodynamic data from women in the original trial to understand if any predictive urodynamic parameters exit for persistent and de novo UUI and post-operative voiding dysfunction. We don’t have a clear understanding if there is a specific sub-group of patients who benefit more from a retropubic versus single-incision sling in terms of UUI symptoms.

Also, the finding of colpocleisis being protective against UUI needs to be explored further with a larger sample size.