Outcomes of a Staged Midurethral Sling Strategy for Stress Incontinence and Pelvic Organ Prolapse

Abstract

OBJECTIVE: To evaluate the proportion of women who experienced resolution of stress urinary incontinence (SUI) symptoms after surgery for pelvic organ prolapse (POP) without a concomitant incontinence procedure. METHODS: We conducted a retrospective observational study of women with preoperative subjective and objective SUI who underwent minimally invasive sacrocolpopexy or uterosacral ligament suspension from 2009 to 2015. We excluded cases with incontinence procedures. The primary outcome was the proportion of women with subjective resolution of SUI postoperatively, defined as the absence of patient reported SUI symptoms during follow-up. Secondary outcomes included the proportion of women who underwent a subsequent staged midurethral sling (MUS) procedure and factors associated with resolution of SUI and staged MUS placement. RESULTS: Of 93 women, most were white (n=90, 98%) with stage III POP (n=55, 59%). Mean age was 59.5±8.9 years and body mass index 28.7±4.7. Seventy-three patients (78%) underwent minimally invasive sacrocolpopexy, and 20 (22%) underwent uterosacral ligament suspension. Median follow-up was 8.3 months (interquartile range 3.4–26.7). Postoperatively, 28 (30%) patients reported resolution of SUI, and 65 (70%) reported persistent SUI. Of the 93 patients, 47 (51%) were treated for persistent SUI and 34 (37%) underwent a staged MUS procedure. Among the staged MUS procedures, 27 (79%) were placed within 12 months. Median time to staged MUS procedure was 5.5 months (interquartile range 4.2–9.9). After controlling for degree of preoperative SUI bother, obese women were less likely to experience resolution of SUI after prolapse repair (odds ratio 0.28, 95% CI 0.08–0.95). We did not identify any factors that were significantly associated with undergoing a staged MUS procedure on univariate analyses (P>.05). CONCLUSION: Preoperative SUI resolved in nearly a third of women after prolapse surgery without a concomitant incontinence procedure. In a population typically offered a concomitant MUS procedure at the time of prolapse repair, a staged approach may result in nearly two-thirds fewer patients undergoing MUS procedures. This information may be helpful during preoperative shared decision making.

Long-term Urinary Outcomes After Transvaginal Uterovaginal Prolapse Repair With and Without Concomitant Midurethral Slings

“…In a multicenter randomized trial comparing vaginal prolapse repair with and without MUS among women with preoperative SUI, 26% reported complete resolution of SUI without an MUS, whereas 56% of women with a concomitant MUS had persistent SUI at 1-year follow-up 5 . Other nonrandomized studies of women with prolapse and SUI symptoms undergoing prolapse surgery, including other approaches such as sacrocolpopexy, demonstrated similar findings; resolution of SUI was seen in 30–69% of those without an MUS 6,20 . On the basis of our findings and the previously mentioned summary of the literature, it is plausible that the efficacy of concomitant MUS differs in the setting of anterior vaginal hysteropexy mesh for apical suspension.…”

“…A staged MUS strategy is one in which the determination to treat SUI is delayed until after prolapse repair. Both prospective and retrospective studies have reported placement of proportionately fewer MUSs with a staged approach, although follow-up was limited 5–7 …”

Therapeutic Effects of 17β-Estradiol on Pelvic Organ Prolapse by Inhibiting Mfn2 Expression: An In Vitro Study

“…In the current research, when estrogen was used to stimulate cells, Mfn2 expression was inhibited at both protein level and mRNA level, indicating that estrogen can play a role by inhibiting Mfn2 expression. Mfn2 is a protein that crosses the mitochondrial bilayer membrane twice (8)(9)(10)(11). It is not only related to the fusion and division of mitochondria, but also cell proliferation, apoptosis, and signal transduction pathway (8)(9)(10)(11).…”

“…Mfn2 is a protein that crosses the mitochondrial bilayer membrane twice (8)(9)(10)(11). It is not only related to the fusion and division of mitochondria, but also cell proliferation, apoptosis, and signal transduction pathway (8)(9)(10)(11). Additionally, Mfn2 is also related to aging (12)(13)(14).…”

“…Mitofusn2 (Mfn2) is a key regulator of mitochondrial fusion and division. It affects cell metabolism, function, proliferation and apoptosis by regulating a variety of signal pathways (8)(9)(10)(11). Previous studies on Mfn2 mostly focused on pulmonary fibrosis (10), breast cancer (9), liver fibrosis (10), and Alzheimer's disease (11), and there was little research on pelvic floor dysfunction.…”