Study design, materials and methods
This prospective study assessed women with concomitant anterior vaginal wall defect and SUI (Group 1), patients with only anterior vaginal wall defect (Group 2), and subjects with only SUI (Group 3). All women were naïve for vaginal surgery, all the patients with POP were symptomatic. Surgical procedures were: anterior vaginal wall repair (AVWR) by native tissue technique, middle urethral sling (MUS) placement. In Group 1 both the surgical treatments were performed. Allocation of women in Group 1 was based on share decision during counselling. Exclusion criteria were: previous POP/SUI surgery, previous pelvic surgery and/or radiotherapy, neurological diseases. All patients underwent preoperative physical examination, with Pelvic Organ Prolapse Quantification system (POP-Q) and stress test, urodynamics (UDS). POP objective success was defined by POP-Q stage < 2, while objective SUI success by negative stress test. Complications were ranked by Clavien-Dindo scale. Follow-up was scheduled by outpatient clinical evaluation at 1-3-6-12 months, and then yearly, with physical examination, urinalysis, abdominal ultrasound (AUS) with post-void residual (PVR) urine. Data were analysed with a 2-years follow-up.
Patients were recruited from January 2014 to January 2018, 197 completed 2-years follow-up and were eligible for the study. Group 1 was comprised by 42 women (21.3%) with mean age of 66.4 yrs, group 2 by 76 (38.6%) with mean age of 68.2 yrs, and group 3 by 79 (40.1%) with mean age of 64.3 yrs.
Patients characteristics are reported in table 1. In table 2 are listed mean operative time and blood loss, outcomes and complications. As expected, mean operative time was higher in concomitant surgical procedures (83 minutes), and mean hospital stay was longer in group 1 and 2 than group 3. No significant difference was found in terms of blood loss, two patients who needed blood transfusions were in group 2. POP and SUI outcomes were similar between group 1 and the control groups. The rate of de novo urgency was higher in group 1 but did not reach significant difference with the control groups. Groin pain was comparable in group 1 and 3 (MUS placement). Re-operation rate was low in all groups. Outcomes are reported in table 2.
Interpretation of results
Women underwent concomitant POP and SUI surgical correction had success rate not inferior than control groups without higher complications rate. Thus, concomitant treatment of POP and SUI was effective and safe as the single procedures. This study showed that the association of these two surgical treatments did not mean an increase of the complications. Due to the longer operating time, also blood loos were higher when both the surgical techniques were associated. Anyway, this finding did not negatively impact on the post-operative course and on the outcomes. Furthermore, the only blood transfusions were performed in women underwent a single surgical procedure (group 2). Thus, the management of POP and SUI with a single surgical step was suitable in patients who preferred complete resolution of these conditions. Counselling was a crucial step in these women.