Treatment of Pelvic organ prolapse (POP) associated with stress urinary incontinence (SUI) is a surgical challenge. Surgeons may perform combined prolapse and incontinence surgery or may correct prolapse first and evaluate incontinence afterwards. We present a prospective study to evaluate the effect of ASC on urethral anatomy and continence using Dynamic MRI

Twenty females with concomitant apical prolapse and SUI due to urethral hypermobility were included. Patients with fixed urethra or ISD were excluded. All patients underwent ASC operation as a sole treatment without anti-incontinence procedure. Patients were informed that they may need anti-incontinence procedure afterwards. 
Symptom-specific questionnaires were administered in the form of Urogenital Distress Inventory (UDI-6), International Consultation on Incontinence Questionnaire short form (ICIQ-UI-SF) to evaluate incontinence, and Pelvic Organ Prolapse and Incontinence Sexual Function questionnaire (PISQ-12) short form to evaluate sexual function. All patients underwent urodynamic study (UDS) in the form of free uroflowmetry with PVR estimation, and pressure flow study with estimation of Valsalva leak point pressure (VLPP) before and after surgery.
The following parameters were assessed in the MRI:
1-Degree of bladder descent: which is the vertical distance between PCL & the bladder base. 
2-Posterior urethro-vesical angle (PUV): It is the angle between the urethral axis & the posterior border of the bladder base or the trigone (15), normally it is less than 115º 
3-Angle of urethral inclination (UI): It is the angle of the urethral axis in relation to the vertical plane, normally it is less than 30º (17).
4-Leading edge of the vaginal cuff (in cases of previous hysterectomy) or the location of the cervix (in cases of preserved uterus) in relation to the PCL
5-The anorectal junction in relation to the PCL

Mean age was 53 years. All patients had apical prolapse; 4 with cystocele, and 5 with rectocele. Urethral hypermobility was positive in all patients. After performing ASC, all patients reported significant improvement of all prolapse and incontinence questionnaires as well as QoL and sexual function. Significant improvement of incontinence parameters on dynamic MRI (bladder neck descent, posterior urethrovesical angle and urethral inclination angle) was observed after ASC. Similarly, significant change in the position of the leading edge of prolapse and the anorectal junction was observed.

18 patients had no leak postoperatively (cured from SUI). They had a mean of 86.16 ± 13.76 cmH2O. Only two patients had postoperative SUI; however, they both reported improvement of their SUI. They showed improvement of their VLPP (mean of 86 ± 2 pre-operatively, which became 101 ± 8.49cmH2O). One of them underwent TOT insertion as she was bothered by her symptoms and she was continent after TOT. The other patient refused to undergo TOT insertion as her SUI symptoms were occasional and were of no bother to her.

In patients with prolapse and urethral hypermobility, ASC may return the bladder neck and urethral anatomy towards normal as proved by dynamic MRI. However, further studies on a larger number of patients with a longer follow up period are required