Prophylactic midurethral sling insertion during transvaginal pelvic reconstructive surgery for advanced prolapse patients with high-risk predictors of postoperative de novo stress urinary incontinence.

INTRODUCTION AND HYPOTHESIS: Our aim was to evaluate the clinical outcome of continent women with high-risk predictors for de novo stress urinary incontinence (SUI) offered prophylactic midurethral sling (MUS) insertion during vaginal pelvic reconstructive surgery (PRS) for advanced pelvic organ prolapse (POP). MATERIALS AND METHODS: This was a prospective cohort study in patients with POP stage ≥ 3 and maximum urethral closure pressure (MUCP) <60 cmH2O and functional urethral length (FUL) <2 cm. Patients were divided into PRS and PRS + MUS groups. Surgery commenced with vaginal hysterectomy, application of Uphold® and insertion of MUS to the PRS + MUS group. Main outcome measures were incidence of de novo urodynamic stress incontinence (USI), lower urinary tract symptoms (LUTS), quality of life (QoL), and topographic and anatomical relationship of implanted mesh. RESULTS: Based on sample size calculation, 40 patients were recruited-20 in each group. Rate of de novo USI in PRS + MUS was 5% objectively and 10% subjectively, while in the PRS it was 50% objectively and 60% subjectively. No significant difference was noted in patient demographics. Intraoperative blood loss was greater for PRS + MUS but was not statistically significant. No organ injuries, mesh exposure, or infections occurred. Postoperatively, MUCP significantly increased from 43.3 ± 8.9 to 58.5 ± 19.2 cmH2O and FUL from 17.2 ± 1.9 to 20.3 ± 3.1 mm in the PRS + MUS group. Residual urine significantly decreased. No patient had bladder outlet obstruction (BOO). Sonographic assessment showed no difference in mesh mobility with urethral kinking observed in 11 (55%) patients with MUS. CONCLUSION: Based on a validated small sample, prophylactic MUS for continent women at high risk for postoperative USI with advanced POP lowers its incidence to 5%. Continence is achieved in 95%. Concern for complications, LUTS, and QoL did not significantly differ.