Patients with pelvic prolapse may develop de novo urinary incontinence after surgical repair.
While pressure-flow urodynamic studies with a pessary may predict postoperative incontinence, the need for a prophylactic anti-incontinence procedure at the time of prolapse repair has not been studied in a randomized fashion.
In the April 12th issue of the New England Journal of Medicine, Brubaker and colleagues from the Pelvic Floor Disorders Network present results from a randomized trial designed to determine whether adding a Burch procedure to abdominal sacrocolpopexy for prolapse repair reduces the risk of de novo incontinence.
A total of 322 women with pelvic prolapse and no preoperative incontinence were randomized to sacrocolpolexy alone (165 patients) or sacrocolpopexy with a concurrent Burch procedure. The outcomes of the study included the development of urinary incontinence and symptoms of urinary urgency.
At the time of evaluation 3 months postoperatively, urinary incontinence was identified in 24% of patients in the Burch group and 44% of the control group. Furthermore, of all patients with stress incontinence, patients in the Burch groups were less likely to complain of report bothersome symptoms than those in the control group (25% vs. 6%, P<0.001). There was no difference in the incidence of urge incontinence between groups.
These data from a randomized trial suggest that a Burch colposuspension at the time of prolapse repair reduces the risk of de novo bothersome urinary incontinence. While the authors are to be congratulated for performing a controlled, randomized trial, several questions remain: what should be our accepted risk of de novo incontinence after prolapse surgery? Isn’t 24% too high? Wouldn’t a vaginal approach for prolapse repair with a concurrent sling procedure be associated with better results? How accurate are urodynamics studies with a pessary in predicting de novo incontinence in these patients?
By Ricardo Sánchez-Ortiz, MD
Reference:
NEJM, April 12; 354 (15): 1557– 1566, 2006
http://www.ncbi.nlm.nih.gov/entrez/
Brubaker L, Cundiff GW, Fine P, Nygaard I, Richter HE, Visco AG, Zyczynski H, Brown MB, Weber AM; Pelvic Floor Disorders Network.
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