Should Prophylactic Anti-Incontinence Procedures Be Performed at the Time of Prolapse Repair? Systematic Review

Abstract

Urodynamic studies performed prior to prolapse repair in women with high-grade pelvic organ prolapse (POP) have revealed asymptomatic stress urinary incontinence (SUI) in 36% to 80% of these women. The probable explanation for maintenance of continence prior to surgery in these patients may be urethral kinking or compression of the urethra by the genital prolapse. Once the genital prolapse has been repaired, these women are at high risk of postoperative SUI. Although occult SUI and prolapse repair can be corrected during a single surgery, combining both procedures is highly controversial. Some surgeons question the effectiveness of a single surgery to make both repairs and recommend a second surgical procedure after prolapse repair to correct occult incontinence. However, there are risks associated with a new hospitalization and a second surgery. This systematic literature review was conducted to determine whether performing prophylactic anti-incontinence procedures during surgical POP correction in women with severe genital prolapse and no symptoms of incontinence could prevent postoperative SUI. PubMed, EMBASE, Cochrane Library, and Lilacs databases were searched to identify articles published up to January 12, 2014. The search was limited to randomized trials. All participants had severe POP and no symptoms of SUI prior to prolapse surgery. The primary study outcome was the incidence of SUI or the need of treatment for this condition after the surgical procedure. The initial search identified 5618 studies; 66% of these were selected for full text analysis. Only 7 of these trials met the study inclusion and exclusion criteria. Following the systematic review, a meta-analysis was performed with common variables of studies and the same scale of quantification. Performance of any prophylactic anti-incontinence procedure during prolapse repair reduced the incidence of SUI postoperatively; the relative risk was 0.51, with a 95% confidence interval of 0.38 to 0.68. However, the results were different when the types of anti-incontinence procedure used were analyzed separately. The only anti-incontinence procedure that led to a significant reduction in the incidence of UI was retropubic midurethral sling surgery (relative risk, 0.09; 95% confidence interval, 0.02–0.36). These data show that use of the retropubic midurethral sling concomitantly with prolapse repair in women with severe POP is the only prophylactic anti-incontinence procedure that reduces risk of SUI.