There is a lack of data on the outcome of laparoscopic sacrocolpopexy (LASC) with concomitant or delayed midurethral sling (MUS) insertion in women with POP and symptomatic SUI or occult SUI.

The combination of prolapse surgery with an incontinence procedure can reduce the incidence of stress urinary incontinence (SUI) after surgery, but may increase adverse events. [1]

The aim of this study was therefore to assess the short-term results of stress urinary incontinence in women undergoing laparoscopic sacrocolpopexy with and without midurethral sling (MUS).

This retrospective study was conducted from July 2012 to Dec. 2017. We recruited women with Pelvic Organ Prolapse Quantification (POP-Q) stage 3 or 4 and received laparoscopic sacrocolpopexy (LASC).  

All women underwent multichannel urodynamicstudies in order to clarify the symptoms. Urodynamic studies included a conventional filling-cystometry (with maximal bladder filling up to 500 ml) and a pressure-flow-study according to the recommendations of the International Continence Society (ICS)

Women were operated with combined LASC and MUS or LASC alone based on published criteria, data and after extensive counselling. We offered the MUS as a treatment option in these patients with preoperative stress urinary incontinence (SUI). Some decided to received concomitant MUS, but some did not. 

Assessments included the pre- and postoperative Pelvic Organ Prolapse Quantification (POP-Q) stage, urodynamic parameters, peri- and postoperative complications and symptoms .

The primary outcome measure was the presence of SUI after surgery. The secondary outcomes were treatment for SUI, bladder storage symptoms, obstructive voiding and adverse events.

We enrolled 118 women received LASC surgery. The Median follow-up period is 16.9 months.

40 patients (33.9%) had symptomatic SUI before surgery. In this this group, 20 patients received concomitant urethral sling. After MUS, 3 had post-op urine retention and 2 had overactive bladder symptoms. 5 patients received MUS later.

19 patients had occult SUI (16.9%). In this this group, 3 patients received concomitant urethral sling. 4 patient developed SUI symptoms after LASC surgery.

Comparison of the pre- and postoperative urodynamic studies in concomitant sling group, the result of pad test was significant improved (12.9 gm-->0.1 gm, P=0.035).

The postoperative complications included mesh extrusion 6.8%, recurrent prolapse 2.5%, transient urine retention 0.8%, dyspareunia 1.7%, low back pain 2.5%,  thigh numbness 1.7%, de novo SUI 14.4% and de novo OAB 6.8%.

In this study, for women undergoing laparoscopic sacrocolpopexy with concomitant MUS for preoperative SUI, about 15 % had voiding difficulty with urine retention and 10 % had postoperative OAB symptoms. 

For those who had occult SUI without concomitant MUS, about 25 % developed postoperative SUI with no further surgical intervention during the follow-up period in this study.

Our prospective study showed over 45.7% (27/59) of the pre-operatively incontinent women did not suffer from SUI after prolapse surgery alone and only 13.8% (5/36) women required additional anti-incontinence procedures in a second step. 

Combination surgery reduces the risk of postoperative stress incontinence, but short‐term voiding difficulties and adverse events were more frequent after combination surgery with a midurethral sling.

Several studies support the better outcome of combined prolapse and incontinence surgery with regards to persisting SUI. However, it should be considered that women may undergo unnecessary additional surgery. [3]

Furthermore, a most recent systematic review and meta-analysis reported that concomitant MUS reduce the risk of postoperative incontinence in women with preoperative symptomatic or occult SUI. However, serious adverse events are more frequently seen. [2]

All women who are considering pelvic reconstructive surgery should have a comprehensive evaluation for both prolapse and urinary incontinence before treatment and well counseled before surgery.

In women with POP and SUI (symptomatic or occult), a concurrent MUS probably reduces postoperative SUI and should be discussed in counselling. 

Informed decision should be well-balanced the pros and cons of combined laparoscopic prolapse surgery with concurrent MUS in women with concomitant incontinence. It should be individualized.

Ploeg, JM, Steen, A, Oude Rengerink, K, Vaart, CH, Roovers, JP. Prolapse surgery with or without stress incontinence surgery for pelvic organ prolapse: a systematic review and meta-analysis of randomised trials. BJOG 2014; 121: 537– 547.
Van der Ploeg JM, van der Steen A, Zwolsman S, van der Vaart CH, Roovers J. Prolapse surgery with or without incontinence procedure: a systematic review and meta-analysis. BJOG 2018;125(February (3))289–97, doi:http://dx.doi.org/ 10.1111/1471-0528.14943 Epub 2017 Nov 13.
Van der Ploeg JM, Oude Rengerink K, van der Steen A, van Leeuwen JH, van der Vaart CH, Roovers JP. Dutch urogynaecology consortium. Vaginal prolapse repair with or without a midurethral sling in women with genital prolapse and occult stress urinary incontinence: a randomized trial. Int Urogynecol J 2016;27(July (7))1029–38, doi:http://dx.doi.org/10.1007/s00192-015-2924-1 Epub 2016 Jan 6.