4th Annual Jefferson Urology Symposium: Focus on Urinary Incontinence

© The Canadian Journal of Urology TM : International Supplement, August 2021 Selection of suture type and placement has also been shown to contribute to complications of ASC and presents a valuable lesson in the application of surgical technique. Recent observations suggest that postoperative discitis has increased as a more ASC procedures are performed using a minimally invasive technique. 39 Durdag et al described L5-S1 discitis 3 months following ASC, with likely contribution from penetration of the L5-S1 diskwith sutures. The authors of this study recommended careful placement of suture only to the depth of the anterior longitudinal ligament using monofilament sutures. 40 Similar to other POP repairs, ASC has been found to have degradation of success rates over time. Up to 95% of women enrolled in the CARE trial were eligible for the extended CARE (ECARE) trial, of which 84% and 59% completed 5 and 7 year follow up, respectively. By year 7, the probabilities of failure (including POP, stress urinary incontinence (SUI), urinary incontinence (UI) between urethropexy and no urethropexy groups were 0.27 and 0.22 for anatomic POP, and 0.29 and 0.24 for symptomatic POP. By this time, probability of mesh erosion is up to 10.5%. Interestingly, the same study found that 95% of patients did not seek retreatment for POP. This could reflect that patients found the treatment adequate, or that other health and social concerns took precedence over seeking retreatment. 28 Prevention and management of post- cystectomy prolapse Radical cystectomy is the standard of care for recurrent high grade or muscle invasive bladder cancer, and includes removal of the bladder, uterus, ovaries, and anterior vagina. This results in the loss of three levels of vaginal support: the cardinal-uterosacral ligaments hysterectomy), paravaginal attachments (anterior vaginectomy and cystectomy, periurethral fascia and ligamentous support to the pubic symphysis (anterior vaginectomy and urethrectomy). 41 There is a surprising deficiency of information for functional and sexual outcomes for women with muscle invasive bladder cancer who undergo radical cystectomy and urinary diversion. This is important, especially considering the attention to these outcomes inmen undergoing urologic procedures. 42 It is critical that in initiating treatment for women with bladder cancer, postoperative sexual function and goals for quality of life must be a part of the conversation. Routine screening for POP can play an important role in the prevention and treatment of this condition and can be done simply through performing a history and genitourinary exam. The single validated question, “Do you ever feel a bulge or that something 25 Surgical management of vaginal prolapse: current surgical concepts References 1. Barber MD. Symptoms and outcome measures of pelvic organ prolapse. Clin Obstet Gynecol 2005;48(3):648-661. 2. Swift SE. The distribution of pelvic organ support in a population of female subjects seen for routine gynecologic health care. Am J Obstet Gynecol 2000;183(2):277-285. 3. Mant J, Painter R, Vessey M. Epidemiology of genital prolapse: observations from the Oxford family planning association study. Br J Obstet Gynaecol 1997;104(5):579-585. is falling out of your vagina?” has an 81% positive predictive value for clinically significant POP. 13 In light of the substantial decreases in quality of life, which can occur following cystectomy, it is important to consider preventative measures when performing this procedure. This may include techniques such as vaginal and uterine sparing when feasible, the inclusion of omental or peritoneal flaps between a neobladder and vagina, or prophylactic apical repair. 43,44 Prophylactic repair would make use of measures discussed through this article, such as ASC or transvaginal sacrospinous ligament fixation. Additional measures such as round ligament preservation and abdominal uterosacral plication also represent potential preventative measures. As with prevention, the discussion of post-cystectomy repair of POP and other complications requires the consideration of numerous factors such as oncologic status, desired sexual outcome, vaginal length, and tissue quality. Conservative interventions such as pessaries are probably suboptimal, as the patient population often has poorer tissue quality, damaged musculature, and shorter vaginal length. 45 Conclusions When patients undergo a POP repair, all prolapsed compartments should be addressed simultaneously. The success rate of POP repairs varies considerably depending upon the definition of success used. When strict anatomic criteria are used, the success rates of POP repairs, especially anterior repairs, is lower compared to when a composite definition is utilized. When more clinically relevant criteria, such as the presence of symptoms, are incorporated into the definition of success, then success rates improve. As our understanding of POP has grown over time, it has become clear that proper apical support is required for successful repair. Surgical approach for a POP repair must be tailored to the patient’s needs and functional status. Finally, thorough preoperative counseling is paramount in managing expectations and increasing patient satisfaction in the postoperative setting.