Commented Abstracts

The Effect of Concomitant Prolapse Repair on Sling Outcomes.
The Journal of Urology, 180, 1003-6, 2008.

Jennifer T. Anger, Mark S. Litwin, Qin Wang, Chris L. Pashos and Larissa V. Rodríguez
From the Departments of Urology (JTA, MSL, LVR) and Health Services (MSL),
David Geffen School of Medicine and School of Public Health,
University of California, Los Angeles, Los Angeles, California, and
Abt Associates, Inc., Cambridge, Massachusetts (QW, CLP)

Purpose: We analyzed the effect of concomitant prolapse surgery performed at the time of sling surgery on short-term postoperative outcomes in women with urinary incontinence.

Materials and Methods: We analyzed 1999 to 2001 Medicare claims data on a 5% national random sample of female beneficiaries who underwent sling procedures. Subjects were tracked for 12 months after surgery to assess short-term complications. Concomitant prolapse repairs and prolapse repairs performed in the first 12 months after sling surgery were identified by CPT-4 procedure codes. Postoperative complications and treatments were identified by ICD-9 diagnosis codes and CPT-4 procedure codes, respectively. Bivariate and multivariate analyses were performed to measure the effect of concomitant prolapse surgery on sling outcomes.

Results: Concomitant prolapse repairs were performed in 34.4% of sling cases. Women who underwent prolapse repair at the time of the sling surgery were significantly more likely to be diagnosed with postoperative outlet obstruction (9.4% vs 5.5%, p<0.007) than those who did not. Women who underwent concomitant prolapse repair were less likely to undergo a repeat procedure for stress incontinence in postoperative year 1 (4.7% vs 10.2%, p=0.0005). Multivariate analysis revealed that women who underwent prolapse repair at the time of the sling surgery were significantly less likely to undergo a reoperation for prolapse within 1 year after the sling surgery (OR 0.31, 95% CI 0.22– 0.44).

Conclusions: Our findings suggest that addressing prolapse at the time of stress incontinence surgery may avoid an early repeat operation for either prolapse or stress incontinence. However, rates of postoperative outlet obstruction are higher.

Key Words: pelvis, prolapse, treatment outcome, sub urethral slings, female


Editor’s comment

The authors used a somewhat controversial methodology to assess the impact the concurrent prolapse repair would have in patients with SUI. The data analyzed was obtained from medical charts of the health care system (Medicare) which are omissive in numerous aspects: symptom severity and complications, preoperative classification of the prolapse or even its prior existence. Regardless of these remarks, we observed that concurrent prolapse repair reduced the likelihood of reoperation for dystopia and SUI. It is likely that a considerable number of these patients had a prolapse that was neglected by the surgeon. The drop in new surgical procedures rate for UI could be related to providing a better support for the bladder neck and a reduction to its mobility during stress or, simply, a higher experience by the surgeon in the surgical treatment of female UI and, therefore, a more careful observation regarding the repair of all existing defects. On the other hand, post-operative obstruction rates were greater in the group submitted to the simultaneous correction of UI and dystopia, very likely because of its greater complexity, anatomical alteration and the need for a broad intervention in order to correct the problems. This paper shows clearly the need for a surgeon who treats UI not to neglect the prolapses associated with this occurrence and correct all the anatomical defects during the incontinence surgery.

Aparecido Donizeti Agostinho