AUA 2019: Outcomes of Prophylactic Sling at the Time of Robotic Assisted Sacrocolpopexy

Chicago, IL (UroToday.com) Occult stress urinary incontinence (SUI) is the unmasking of SUI that occurs after repair of pelvic organ prolapse (POP), and it is thought to be caused by the change in the angle of the urethra and bladder neck. This unkinking of the bladder neck can lead to de novo urinary incontinence after surgery for POP. The outcomes of the CARE trial revealed that more than 50% of women who undergo abdominal sacrocolpopexy without a concomitant anti-incontinence procedure will have de novo stress urinary incontinence (SUI) after surgery.¹ To avoid this, some surgeons choose to place a prophylactic mid-urethral sling (MUS) at the time of abdominal sacrocolpopexy, regardless of whether patients demonstrate SUI by history or physical examination. However, MUS can be associated with complications, such as mesh exposure or voiding dysfunction, and prophylactic MUS may unnecessarily put patients at risk of these complications. In this study, the authors aimed to compare outcomes of patients who underwent robotic-assisted abdominal sacrocolpopexy with MUS placed either prophylactically or due to SUI.

The authors performed a retrospective review to evaluate 101 patients at their institution who underwent abdominal sacrocolpopexy with concomitant MUS placement. The decision on whether to perform a concurrent MUS at their institution is patient-driven after a discussion of the risks and benefits. They performed a chart review to divide these patients into two groups: 1) patients who underwent a prophylactic MUS (n=43), and 2) patients who underwent a MUS for SUI on examination or by history (n=58). They compared demographic and clinical characteristics as well as surgical outcomes between the two groups.

The two groups were found to be demographically similar, and surgical characteristics were the same, though preoperative prolapse stage was slightly higher in the prophylactic group. The authors found no significant difference in the incidence of de novo urinary urgency or urgency incontinence between the two groups. In regard to the incidence of MUS mesh extrusion there was no difference between groups, with 2 patients in the SUI group and 1 patient in the prophylactic group requiring a surgical procedure for this complication. Post-operative SUI was seen in 2 patients in each group.

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Overall this study highlights some important findings in POP surgery. Based on this data, the placement of a prophylactic sling at the time of abdominal sacrocolpopexy did not confer an increased risk of complications as compared to those patients who had MUS for SUI. Although useful, the data would benefit from an assessment of patient-reported outcomes. In addition, inclusion of a comparison of patients who underwent a sacrocolpopexy without a prophylactic MUS would provide further insight into this question. Despite these limitations, this study demonstrated that in prophylactic sling at the time of abdominal sacrocolpopexy was safe and effective in their patient population as compared to patients who underwent a MUS for SUI.

Presented by: Carrie Stewart, MD, Urology specialist, Tulane University Medical Group, New Orleans, Louisiana

Written by: Dena Moskowitz, MD; Assistant Professor of Clinical Urology, University of California Irvine; @demoskowitz at the American Urological Association's 2019 Annual Meeting (AUA 2019), May 3 – 6, 2019 in Chicago, Illinois

Reference:

Brubaker L, Cundiff GW, Fine P, et al. Abdominal sacrocolpopexy with Burch colposuspension to reduce urinary stress incontinence. N Engl J Med. 2006;354(15):1557–1566.

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