Midurethral Sling Lowers Incontinence Rates After Pelvic Organ Prolapse Repair

Each year, an estimated 200,000 women have surgery to correct pelvic organ prolapse; of these, about 50,000 women will experience incontinence postoperatively. Both conditions can greatly reduce quality of life. In a new study, researchers have found that placement of a midurethral sling-a mesh hammock inserted underneath the urethra and attached to the abdominal wall-can halve the rate of incontinence after prolapse surgery.¹

The study involved 337 women, most of whom were in their early 60s, who needed surgical repair of pelvic organ prolapse. Women were randomized to receive either vaginal prolapse surgery with a midurethral sling or vaginal prolapse surgery with sham incisions. The rate of incontinence in each group was then analyzed 3 months and 12 months after surgery. Of the 337 participants, 327 completed a 12-month follow-up.

At 3 months, 23.6% of the women in the sling group experienced incontinence, compared with 49.4% of women in the sham group. At 12 months, incontinence had developed or had been treated in 27.3% of the women in the sling group, compared with 43.0% of women in the sham group.
 Although adding a midurethral sling reduced the rate of incontinence, it increased the risk of complications, such as urinary tract infections, major bleeding, bladder perforation, and difficulty emptying the bladder. Because of complications, the midurethral sling had to be removed in 2% of cases. Among those in the sham group, approximately 5% underwent additional surgery to have a midurethral sling inserted within 12 months of the initial pelvic organ prolapse repair.

Some physicians try to predict whether incontinence will develop by having the patient cough or sneeze while her bladder is full and the uterus is repositioned to the top of the vaginal cavity.² If urine leaks, then incontinence is more likely to develop after surgery. How accurately this test predicts incontinence is unknown.

Pertinent Points:
- Placement of a midurethral sling during surgery to correct pelvic organ prolapse can half the risk of postoperative incontinence, adds only minutes to the surgery, and avoids the need for a second surgery.
- Insertion of a midurethral sling is not without risk, and physicians should inform patients that there is an increased risk of urinary tract infections, bleeding, perforation of the bladder, and difficulty emptying the bladder. Waiting for incontinence to develop before placing the sling remains a sound treatment option, even if it means an additional surgery.

References:

1. Wei JT, Nygaard I, Richter HE, et al, for the Pelvic Floor Disorders Network. A midurethral sling to reduce incontinence after vaginal prolapsed repair. N Engl J Med. 2012;366:2358-2367.
2. National Institutes of Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development. Extra treatment during prolapse repair reduced incontinence rate. Available at: http://www.nih.gov/news/health/jun2012/nichd-20a.htm. Accessed June 21, 2012.