Multioperated Recurrent Incontinence/Prolapse

Abstract

Pelvic organ prolapse (POP) is a major health care problem. It was reported to be present in 50% of parous women [1] , with aggregated rates of prolapse surgery estimated to be between 15 and 49 per 10,000 women/ years [2] . Olsen et al., reporting data from the Kaiser Permanent Group, a large health maintenance organization with nearly 393,000 members which draws epidemiological data from a service area of more than 2 million people from North America, showed that the lifetime risk of surgery for POP or stress urinary incontinence (SUI) was 11.1% for a woman with an average life expectancy of 79 years [3] . In the United States, each year approximately 300,000 women require inpatient surgery for POP or SUI [4, 5] and about 100,000 more procedures are performed on an outpatient basis [6] . Moreover, Olsen's study highlighted that 29% of the patients experienced surgical failure and required repeated surgical procedures and that the time interval between reoperation decreased with each successive repair [3] . Consequently, each year about 116,000 operations are repeated surgical procedures, showing that the current available treatments for pelvic floor dysfunction are suboptimal [6] . The pathophysiology of recurrent POP and SUI is not clearly understood. Obviously, many risk factors for pelvic floor dysfunction, such as age, parity, obstetrical factors, cognitive impairment, or genetic factors, are unmodifiable and other relevant ones, such as obesity, smoking habits, or lower urinary tract dysfunction, can persist after the primary surgery and can be regarded as possible causes of recurrence [7] . On the other hand, the effect of multiple surgeries and dissections on sphincter function, as well as the chance of neural injuries, can contribute to the occurrence of further pelvic floor dysfunction. Specifically, Kenton et al. showed by the use of urethral electromyography that women with previous continence surgery had more neural injury to their striated urethral sphincter than women without previous surgery after controlling for age and parity [8] . Other studies hypothesized that pudendal neuropathy or lesions to the somatic urethral innervation can be caused during vaginal dissection in case of anterior colporrhaphy, needle suspension, and paravaginal repair [9, 10, 11, 12] . In the treatment of recurrent pelvic floor dysfunction, the available evidence is largely insufficient due to the lack of long-term results from randomized controlled trials. Moreover, most of the low-quality pieces of evidence provide data only at shortor intermediate-term follow-up. The present review focuses on the currently available data and recommendations on diagnostic workup and treatment of recurrent POP and SUI.