Conservative Approach to Pelvic Organ Prolapse Surgery May Prevent Additional Procedures

October 9, 2018 According to a new study at UPMC Magee-Womens Hospital, taking a staged approach to pelvic organ prolapse and stress urinary incontinence – fixing the prolapse first and following up with a second surgery for the stress urinary incontinence if needed – allows many women to skip the second procedure altogether. This finding goes against the common practice of performing the two procedures during a single surgery and potentially saves women from an unnecessary surgical procedure.

These results, funded in part by the National Institutes of Health (NIH), are being presented at the American Urogynecology Society annual meeting on October 11, 2018 in Chicago.

Stress urinary incontinence is commonly associated with pelvic organ prolapse and involves urine leakage during activities like coughing, laughing, sneezing, lifting or exercising. A common approach to treatment of pelvic organ prolapse with urinary incontinence is to perform two procedures during a single surgery. First, surgeons implant a piece of mesh that acts as a prosthetic ligament to return the vagina and pelvic organs to their normal position. Then they place a sling – a piece of mesh tape under the urethra– to prevent urine leakage. 

Since 2006, Magee has advocated to separate  treatment of prolapse and urine leakage into two surgeries. After the initial prolapse repair, providers reassess the stress urinary incontinence symptoms and decide together with the patient whether to place a sling at a later date if symptoms are still present and bothersome.

“What’s notable at the University of Pittsburgh and Magee is that we’ve taken a much more conservative approach,” said Halina Zyczynski, MD, professor, Department of Obstetrics, Gynecology and Reproductive Sciences at Magee. “Let’s not do any unnecessary surgery, and importantly, we believe you have a good chance that symptoms of incontinence will become less bothersome or even go away with prolapse repair alone. Recent analyses are confirming that and providing objective data.” 

Together with Zyczynski, Lauren Giugale, MD, a fellow in female pelvic medicine and reproductive surgery at Magee, reviewed the records of 93 women who had prolapse surgery. All had symptoms and  described being “moderately” or “quite a bit” bothered by their leakage. 

The researchers found that nearly 1 in 3 women had a complete resolution of their stress urinary incontinence symptoms in the months following prolapse repair surgery, without a midurethral sling. 

Importantly, only about a third of the women elected sling surgery for their incontinence symptoms within two years of their prolapse surgery. This finding suggests that delaying the decision to treat stress urinary incontinence symptoms until after prolapse repair is a reasonable strategy that may avoid the cost and complications of midurethral slings in up to two-thirds of women.

“Slings are our best procedure for women with bothersome leakage associated with activity, but we respect the reality that there are no risk-free procedures,” Giugale said. “The risks of treatment are worth taking if the leakage is disruptive to a woman’s lifestyle, her ability to socialize and to be active.  Our study suggests that bladder leakage symptoms diminish in many women after prolapse repair.  We think it’s worth learning if a patient will benefit from a sling rather than assume she will.”    

The study was funded in part by NIH grant number UL1-TR-001857.