Hypothesis / aims of study
Pelvic organ prolapse (POP) and overactive bladder (OAB) symptoms are frequently encountered in the same patient. The correlation between POP and OAB remains unclear. A potential cause of OAB may result from mechanical bladder outlet obstruction (BOO). POP may have an obstructive action on the female urethra creating the base to develop OAB symptoms. Indeed, patients may present a spectrum of voiding complaints and symptoms of OAB. Pelvic organ prolapse repair usually resolves the mechanical BOO but the effect on OAB symptoms may be unpredictable. Pelvic organ prolapse surgery may cure or improve OAB, but in some cases it can result in de novo OAB. The effect on OAB of different surgical techniques to repair the upper vaginal compartment prolapses -the vaginal vault prolapse or the uterine prolapse- is reported tin literature. Data on the influence of laparoscopic lateral suspension (LLS) on OAB are lacking. The aim of this study was to assess the anatomical results and the effect on OAB symptoms in a cohort of women who underwent laparoscopic lateral suspension for POP.
Study design, materials and methods
This prospective study included all women with apical POP underwent surgical repair with LLS from January 2016 to December 2017. The baseline and the 1-year follow-up included: post-void residual measurement, urinalysis, vaginal examination, OAB symptoms and evaluation and administration of questionnaires (Pelvic Floor Distress Inventory 20 - PFDI20; Urinary Distress Inventory 6 - UDI 6). Other questionnaires used were: the Colorectal-anal Distress Inventory 6 (CRADI6) and the Pelvic Organ Prolapse Distress Inventory 6 (POPDI6). Exclusion criteria were: post void residual volume >150ml, posterior vaginal wall defects, previous prolapse or incontinence surgery, previous hysterectomy, neurological conditions, uncontrolled diabetes, bladder pain syndrome. To make a correlation between the different stages of POP and OAB, we divided the population in three groups: (i) Group 1 women with anterior vaginal wall and Cervix defect both Stage II; (ii) Group 2 women with anterior vaginal wall defect Stage III and Cervix defect Stage II; (iii) Group 3 women with anterior vaginal wall and Cervix defect both Stage III. Statistical evaluation was done by Pearson’s correlation and Student t-test (p value less than 0.001 was considered statistically significant).
64 women underwent LLS for uterine prolapse, 78.1% had concomitant anterior vaginal wall defect. Mean age was 59.4 y.o. (+/-9.3). At 1-year follow up the anatomic success rates was 84.4% for the apical and 76.2% for the anterior compartment (table 1). Total recurrences rate was 12.5%: anterior vaginal wall 3.1%; apical 4.7%; enterocele 1.6%; posterior vaginal wall 3.1%. Need for reoperation was 10.9%. None patient had vaginal exposure of the polypropylene mesh. The comparison between OAB symptoms before and after the surgical procedure showed a statistically significant improvement with the resolution of OAB in 76% of the women, while de-novo OAB was present in 2.6%. Both stress and urgency urinary incontinence significant positively changed (p<0.001). Female sexual functions did not show significant changes. Table 2 reports the symptoms before surgery, and at the 12 months follow-up. Considering preoperative and postoperative OAB, in all the three groups we documented a trend in ameliorating of OAB regardless of the POP-Q stage. However, statistically significant correlation was achieved only in Group 2. Group 1 was composed by 11 women with preoperative OAB in 2 patients and postoperative OAB in 1 patient (p <0.34). Group 2 was composed by 31 women with preoperative OAB in 13 patients and postoperative OAB in 2 subjects (p<0.0003). Group 3 was composed by 22 women with preoperative OAB in 10 patients and postoperative OAB in 4 cases (p<0.03). Patient satisfied after POP repair were 95.3% (61/64). Mean PFDI20 changed from a preoperative score 99.2 (+/-33.4) to postoperative 16.5 (21.6). Mean POPDI6 lowered to a score 4.2 (+/-10.7) from a preoperative score 51 (+/-18.3). Mean preoperative CRADI8 score was 9.1 (9.8) and postoperative 4.8 (+/-7.6). Mean UDI6 score decreased to 7.4 (+/-3.3) from 39.1 (+/-22.3).
Interpretation of results
Our data showed that LLS was a feasible, safe and effective procedure for apical and anterior vaginal wall defects with a high objective and subjective success rate at 1-year follow-up. As reported in literature for other surgeries for POP, a great cure rate of OAB symptoms was evidenced specially in women with anterior vaginal wall defect stage III and Cervix stage II POP (Group 2).1-2 However, the low sample size may have affected the results in other groups. Another possible hypothesis could be that the lower POP stage of patients in Group 1 had only a limited influence on the OAB. Conversely, women in Group 3 with a higher POP stage could not gain advantages from the surgery due to its severity and prolonged condition. Anyway, women may benefit from a resolution of OAB and POP symptoms with the improvement of patient's quality of life.