Urodynamic outcome after surgery for severe prolapse and potential stress incontinence

OBJECTIVE: Women with severe prolapse may be paradoxically continent because of kinking of the urethra. It is currently a common practice to perform urethropexy in women who demonstrate stress incontinence on preoperative reduction of the prolapse with a pessary. We compared the urodynamic outcomes after reconstructive operations that included suspending urethropexy with outcomes after those that did not. STUDY DESIGN: A review was performed of the charts of the Gynecologic Urology Clinic at Los Angeles County-University of Southern California Women's and Children's Hospital from 1991-1997 of patients with grade III uterovaginal prolapse or procidentia in whom the pessary test was used to determine whether urethropexy was included in the reconstructive operation. Urodynamic outcomes were compared statistically with the Fisher exact test, and P less than or equal to .05 denoted statistical significance. RESULTS: Fifty-five patients underwent urethropexy in addition to repair of the prolapse, and 70 underwent reconstruction alone. Twenty-three patients in the first group and 20 in the second were available for a mean urodynamic follow-up of 3.5 years. In the urethropexy group 7 (30%) patients had de novo detrusor instability and 1 (4%) had stress incontinence. In the reconstruction-only group 1 (5%) patient had detrusor instability and none had stress incontinence. CONCLUSIONS: Preoperative barrier testing is useful in identifying patients who do not require an anti-incontinence procedure. Prophylactic Burch retropubic urethropexy increases the incidence of bladder instability.