Prolapse surgery with or without stress incontinence surgery for pelvic organ prolapse: a systematic review and meta‐analysis of randomised trials

• Published in: BJOG : an international journal of obstetrics and gynaecology 2014-04, Vol.121 (5), p.537-547
• Main Authors: Ploeg, JM, Steen, A, Oude Rengerink, K, Vaart, CH, Roovers, JP
• Format: Article
• Language: English
• Subjects: Burch colposuspension; Female; Gynecologic Surgical Procedures; Gynecology; Humans; meta‐analysis; midurethral sling; pelvic organ prolapse; Pelvic Organ Prolapse - surgery; Postoperative Complications - prevention & control; Randomized Controlled Trials as Topic; Reproductive system; review; stress urinary incontinence; Suburethral Slings; Surgical outcomes; Surgical techniques; Urinary Catheterization; Urinary incontinence; Urinary Incontinence, Stress - prevention & control; Urinary Incontinence, Stress - surgery; Urination
• ISSN: 1470-0328; 1471-0528
• DOI: 10.1111/1471-0528.12509

Objectives The combination of prolapse surgery with an incontinence procedure can reduce the incidence of stress urinary incontinence (SUI) after surgery, but may increase adverse events. We compared the effectiveness and safety of prolapse surgery versus combined prolapse and incontinence surgery in women with pelvic organ prolapse. Design and setting Pubmed, EMBASE, DARE, the Cochrane Library and the register of Current Controlled Trials were searched for randomised trials (restricted to Burch colposuspension and midurethral sling as incontinence procedure) from 1995 to 2013 limited to the English literature. Methods Two reviewers selected eligible articles and extracted the data. Pooling for SUI was based on three patient groups: (1) women with coexisting SUI; (2) women asymptomatic for SUI; and (3) women with occult SUI. For adverse events, pooling was based on incontinence procedure. Main outcome measures The primary outcome was SUI. The secondary outcomes were treatment for SUI, bladder storage symptoms, obstructive voiding and adverse events. Results Seven trials were included. Pooling for women with coexisting SUI was possible for objective SUI with two studies and showed no difference. Statistical (I2 = 95%) and clinical heterogeneity was, however, high. The largest study showed a lower incidence of persisting SUI (5% versus 23%) and treatment for this (0% versus 57%) in women who underwent prolapse repair with a midurethral sling. The second study did not find a difference in women undergoing a sacrocolpopexy with or without Burch colposuspension. In asymptomatic women, combination surgery resulted in a lower incidence of de novo subjective SUI (two studies; 24% versus 41%; relative risk [RR], 0.6; 95% confidence interval [CI], 0.3–0.9; I2 = 36%) and the need for subsequent anti‐incontinence surgery (three studies; 2% versus 7%; RR, 0.4; 95% CI, 0.2–0.8; I2 = 13%). For the outcome objective SUI, pooling was possible for five studies, but statistical heterogeneity was high (I2 = 82%) and the difference was not statistically significant. In the subgroup of women with occult stress incontinence, we found a lower incidence of objective SUI after combination surgery (two studies; 22% versus 52%; RR, 0.4; 95% CI, 0.3–0.8; I2 = 32%). There were no differences in bladder storage symptoms, urgency incontinence or long‐term obstructive voiding symptoms. Adverse events (two studies; 15% versus 10%; RR, 1.6; 95% CI, 1.0–2.5; I2 = 0%) and prolonged catheteris