De Novo Stress Urinary Incontinence Common After Laparoscopic Sacrocolpopexy

Women who have surgery for pelvic organ prolapse (POP) can develop de novo stress urinary incontinence (SUI). Prophylaxis against SUI during POP repair reduces the need for future SUI procedures, but it's controversial whether that benefit outweighs the risk of complications.

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To aid shared decision-making, in 2014, the Pelvic Floor Disorders Network (PFDN) developed and validated a calculator for gauging the risk of incontinence after POP surgery, using data from two large clinical trials. However, neither of those trials involved minimally invasive surgery.

Massachusetts General Hospital researchers have now completed the largest-ever study of the incidence of de novo SUI in stress-continent women who underwent laparoscopic sacrocolpopexy. As a secondary objective, they tested the predictability of the PFDN calculator. Youngwu Kim, MD, and Emily Von Bargen, DO urogynecologists in the Division of Female Pelvic Medicine and Reconstructive Surgery, and colleagues report the results in the International Urogynecology Journal.

Methods

Using the patient registry for the Mass General Brigham health system, the researchers performed a chart review from October 2006 through January 2021. They identified 169 stress-continent women who underwent laparoscopic abdominal sacrocolpopexy without a concomitant or prior anti-incontinence procedure for SUI. The average length of follow-up was 6.7 years.

Incidence of Stress Urinary Incontinence

30 (18%) women developed SUI, including 20 who developed bothersome symptoms within six months of surgery. 20 women were diagnosed after developing symptoms, and 10 demonstrated objective SUI on a cough stress test or urodynamic testing.

On multivariate analysis, independent predictors of SUI were:

• Body mass index—adjusted OR (aOR), 1.13; P=0.001
• Preoperative urinary urgency—aOR, 2.82; P=0.030
• Prior transvaginal mesh surgery to treat POP—aOR, 8.92; P=0.007

Complications

Perioperative complications (within 30 days of operation) were:

• Intraoperative ureteral injury (n=1)
• Immediate postoperative hemorrhage requiring reoperation and blood transfusion (n=1)
• Cystotomy (n=1)
• Need for oral antibiotics to treat surgical site infections (n=3)

Over the entire follow-up period, 9 (5%) women had a vaginal mesh exposure, including 5 diagnosed within 12 months of surgery.

Postoperative Treatment of Stress Urinary Incontinence

Of the 30 women who developed SUI:

• 13 (43%) selected expectant management
• 9 (30%) selected pelvic floor physical therapy
• 12 (40%) elected to undergo a midurethral sling

The total is 34 because four women opted for both physical therapy and a midurethral sling.

Risk Calculator

The C-statistic for the PFDN calculator (a measure of its ability to predict SUI) in this cohort was:

• 0.71 (P=0.07) (moderate) for women who developed SUI during the first 12 postoperative months
• 0.69 (P=0.004) (moderate) for women who developed SUI at any point during their follow-up

The mean predicted risk of SUI was higher among women who did develop SUI after surgery than those who remained stress-continent (42% vs. 35%; P=0.003).

Future work to refine the PFDN calculator for women undergoing laparoscopic sacrocolpopexy will aid preoperative counseling and guide clinical management.

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