Outcomes of Prophylactic Mid-Urethral Sling at the Time of Robotic Sacrocolpopexy - Beyond the Abstract

Although de novo stress urinary incontinence (SUI) with surgical correction of pelvic organ prolapse (POP) is a well-recognized phenomenon, the role of a prophylactic anti-incontinence procedure at the time of POP repair is a controversial topic for urologists and urogynecologists. Large clinical trials have reported that 43%-57% of women will suffer from de novo SUI.1,2 Proponents of a prophylactic procedure advocate that prophylactic anti-incontinence procedure can reduce the associated risks and costs of additional surgery. In addition, some patients may not seek care for their de novo incontinence and needlessly suffer. Opponents to this strategy argue that a prophylactic procedure is often unnecessary and can increase patient morbidity, including mesh-related complications, intra-operative bleeding, de novo urgency, and urge incontinence and voiding difficulty. To date, there are limited data on the efficacy and outcomes of a mid-urethral sling (MUS) at the time of robotic sacrocolpopexy (RSC). 



In this study, we performed a retrospective review to compare outcomes of women without prior incontinence procedures who underwent a robotic sacrocolpopexy (RSC) with and without a mid-urethral sling (MUS) with one of three surgeons with specialty training in female pelvic medicine and reconstructive surgery (FPMRS).3 In our practice, we routinely counsel patients about the risks and benefits of a prophylactic MUS at RSC. We identified three cohorts of patients from 2012 to 2017: those who had a MUS placed for either a history of SUI or documented physical exam findings of SUI (n=58), those who had a MUS placed for prophylaxis (n=43), and those who underwent RSC without MUS (n=33). 

Baseline characteristics were similar between all three groups. We found that there were no differences in operative times, length of stay, or rates of post-operative urinary retention between groups. Patients who did not have a concurrent sling placed had statistically less estimated blood loss, although this was clinically insignificant (76.4 vs 63.8 vs 36.9 mL, p=0.018). The rate of post-operative SUI was 7% (4/58) for those with pre-existing incontinence, 5% (2/43) for those with a prophylactic sling, and 12% (4/33) for those who did not have a sling. There were no differences in the rate of other post-operative urinary symptoms. This data suggests that concurrent MUS placement appears to be safe and does not prolong hospitalization. 

We do not routinely provide validated questionnaires or perform a provocation test on follow up visits. Thus, we may not be capturing all patients with some degree of SUI that was not mentioned on follow up visits. In addition, some patients could have had predominantly apical or posterior compartment prolapse prior to surgery, and would be less susceptible to developing de novo SUI. Nevertheless, these results may be representative of real-world practice and can be useful in counseling future patients who undergo RSC with or without MUS. Further studies, ideally with randomization, are needed to better understand and further guide a risk-benefit analysis of these procedures. 

Written by: Hanson Zhao, Karyn Eilber, Jennifer T. Anger, Division of Urology, Cedars-Sinai Medical Center, Los Angeles, California

References:
  1. Wei JT, Nygaard I, Richter HE, Nager CW, Barber MD, Kenton K, et al. A midurethral sling to reduce incontinence after vaginal prolapse repair. N Engl J Med. 2012;366(25):2358-67.
  2. Brubaker L, Cundiff GW, Fine P, Nygaard I, Richter HE, Visco AG, et al. Abdominal sacrocolpopexy with Burch colposuspension to reduce urinary stress incontinence. N Engl J Med. 2006;354(15):1557-66.
  3. Stewart CA, Popat S, Zhao H, Dallas K, Gonzalez G, Gonzales-Alabastro C, et al. Outcomes of Prophylactic Mid-Urethral Sling at the Time of Robotic Sacrocolpopexy. Urology. 2020.
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