Bladder outlet obstruction after laparoscopic sacrocolpopexy for advanced pelvic organ prolapse

Illiano E1, Trama F1, Fabi C2, Natale F3, Costantini E1

Research Type


Abstract Category

Female Lower Urinary Tract Symptoms (LUTS) / Voiding Dysfunction

Abstract 190
On Demand Female Lower Urinary Tract Symptoms (LUTS) / Voiding Dysfunction
Scientific Open Discussion Session 17
Bladder Outlet Obstruction Voiding Dysfunction Pelvic Organ Prolapse Surgery
1. Andrology and Urogynecology Clinic ,Santa Maria Hospital,University of Perugia, 2. Department of Experimental Medicine, University of Perugia, 3. Gemelli Hospital,Rome

Ester Illiano



Hypothesis / aims of study
Pelvic organ prolapse (POP), leads frequently to voiding dysfunction by kinking of the urethra-related bladder outlet obstruction (BOO), and prolonged, untreated BOO may lead to detrusor failure. The aim of this study was to evaluate the impact of laparoscopic sacrocolpopexy (LSC) on the bladder outlet obstruction.
Study design, materials and methods
This was a single-center prospective study in women with stage III–IV POP according to the POP Quantification system and BOO who underwent LSC and in whom functional outcomes were evaluated using pre- and postoperative urodynamic tests. Preoperative evaluation included medical history, clinical examination, multichannel urodynamics, and transperineal ultrasound. Patients were followed up at 1, 3, 6, and 12 months postoperatively and annually thereafter, with history, clinical examination, uroflowmetry, and postvoid residual (PVR) volume measurement. Voiding dysfunction was defined for the presence of one or more of these symptoms: slow stream, splitting or spraying of the stream, intermittent stream, hesitancy, straining. Six months after surgery, all patients underwent clinical evaluation and performed a urodynamic test. Bladder outlet obstruction was defined according to Defreitas nomogram [maximum flow (Qmax) at uroflowmetry ≤12 ml/s and a detrusor pressure at Qmax during pressure-flow study ≥25 cm H2O defining BOO] . Detrusor underactivity (DU) was defined according to the Projected Isovolumetric Pressure (PIP) index and calculated as Qmax + maximum detrusor pressure (Pdet) Qmax (normal range 30–75 cmH2O). Detrusor overactivity (DO) was defined according to current recommendations as involuntary detrusor contractions during filling cystometry, spontaneous or provoked, phasic or terminal, that produce a wave form on the cystometrogram of variable duration and amplitude
Forty-two consecutive patients with advanced POP and BOO underwent LSC and were included in the study. Table 1 showed their demographic and clinical characteristics at baseline. Median follow-up study was 22 months (range 8–48). The urodynamic cure rate of BOO six months after surgery was 85.7%; it persisted in six (14.3%) women. However in only three (7%) women the PVR was 30% of voided volume (Table 2). They had stage II cystocele and they refused further treatments. One of 6 women with BOO also presented dry detrusor overactivity. She complained of some urgency episodes and increased daytime frequency but were not bothered by these symptoms. The subjective voiding symptoms cure rate was 83.3%. Infact the voiding symptoms persisted in 7 women, six of which had persisted BOO and detrusor underactivity (DU), while one had only persisted DU. At 6 months after surgery, free uroflowmetry data showed that Qmax significantly improved compared with baseline (10.30 ± 1.0 vs 17.38 ± 3.4 ml/s; p <0.0001), and the percentage of patients with PVR >30% of voided volume significantly decreased (31% vs 7%; p <0.0001). Pre- and postoperative pressure-flow studies showed significant improvements in Qmax (from 9.68 ± 1.4 ml/s to 14.8 ± 2.5 ml/s; p <0.0001) in the percentage of patients with PVR >30% of voided volume (p < 0.0001). DO disappeared in 30.9 % of the cases.Apical prolapse was corrected to stage 0–I in all (100%) cases with LSC. Anatomical correction success rates (prolapse stage 0 or I) for the anterior and posterior vaginal compartments were 92% and 95%, respectively.
Interpretation of results
Pelvic organ prolapse is recognized as a possible cause of mechanical BOO, which is a possible aetiology for DU and both BOO and DU can lead to difficulty with bladder emptying. The preoperative rate of BOO in women with DO was higher than in women without DO, suggesting that some degree of obstruction during voiding may play a role in DO pathogenesis. Prolapse surgery corrected the obstruction in 85.7% of patients and the persistence of voiding symptoms could be explained by the persistence of DU. DU improvement could be explained by removal of the obstruction, while persistence could be related to several factors: time of obstruction due to POP, aging, denervation, ischemia, and inflammation
Concluding message
This study showed that the cure rate of BOO is high after laparoscopic sacrocolpopexy, however voiding dysfunctions due to irreversible alterations of the detrusor such as detrusor underactivity may persist
Figure 1 Table 1 Baseline characteristics of the study population
Figure 2 Table 2 Pre- and postoperative urodynamic parameters
Funding None Clinical Trial No Subjects Human Ethics Committee Ceas Umbria Helsinki Yes Informed Consent Yes
11/07/2024 20:28:47