INTRODUCTION
Pelvic organ prolapse (POP) involves the descent of pelvic organs through the vaginal canal and is associated with urinary, sexual, and defecatory dysfunction, leading to reduced quality of life (QoL). Studies suggest that approximately 50% of women over 50 years old, especially those with multiple births, experience POP [1].
POP can be treated through non-mesh procedures (e.g., colporrhaphy and vaginal hysterectomy) or mesh-based surgeries, including transvaginal mesh surgery (TVM) and laparoscopic sacrocolpopexy (LSC). Although non-mesh procedures have higher recurrence rates, mesh-based surgeries offer improved long-term outcomes [2, 3]. TVM, LSC, and robot-assisted sacrocolpopexy have lower recurrence rates [4].
However, mesh-based procedures, including LSC, can lead to stress urinary incontinence (SUI) and mesh exposure [5, 6]. SUI, characterized by involuntary urine leakage during exertion or sneezing, occurs in 15%–80% of patients with POP [7, 8]. After POP surgery, excessive tension in the mesh placed beneath the bladder can result in urethral kinking and dynamic obstruction, potentially leading to new-onset postoperative SUI (de novo SUI) [9, 10]. Although reported rates of postoperative SUI vary considerably, the incidence following LSC ranges from 7.5% to 23% [11]. On the other hand, urge urinary incontinence (UUI) is defined as a urine leak that is either preceded or accompanied by an intense desire to urinate. In addition, mixed urinary incontinence (MUI) is characterized by involuntary urine leakage that is linked to urgency, exertion, effort, coughing, or sneezing [12, 13]. Incontinence of any of the types described above occurs in a certain percentage even after POP surgery [14, 15].
However, it is essential to identify the underlying causes of postoperative UI and develop contingency plans to manage this distressing complication [15-17]. In this study, we analyzed data from patients with POP who underwent LSC at our institution to identify potential factors—including mesh-related factors—that may contribute to postoperative UI including SUI, UUI, and MUI affecting patients’ QoL.
MATERIALS AND METHODS
Patients
The medical records of 96 patients who underwent LSC between June 2016 and September 2023 were retrospectively reviewed. The surgical indication was POP of stage ≥2 with symptoms, such as a feeling of vaginal protrusion, or complications like hydronephrosis and/or hydroureter caused by POP, even in asymptomatic cases.
Patients who underwent LSC during the specified period were included in this study, while those who declined to participate were excluded.
The median postoperative observation period was 12.4 months (interquartile range [IQR], 12.2–18.9). The median operative time calculated from all patients was 183 minutes (IQR, 153–252 minutes). Table 1 presents clinical data, including age, body mass index (BMI), presence of diabetes mellitus, POP-Q stage, history of hysterectomy, blood loss, operative time, preoperative and postoperative voiding dysfunction, preoperative and postoperative UI, International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) scores at 1 year postoperatively, mesh products used, and intraoperative complications. Variables following a normal distribution are expressed as mean±standard deviation, while those not following a normal distribution are expressed as median (IQR).
Surgical Methods
The LSC procedure followed the method described by Wattiez et al. [18]. After port placement, the patient was positioned in a 15° Trendelenburg position to improve visualization of the pelvic cavity by shifting the bowel cranially. The key steps were as follows:
(1) Anterior vaginal wall dissection: The space between the anterior vaginal wall and bladder was dissected, and anterior wall mesh—either Polyform (Boston Scientific Japan, Tokyo, Japan) or ORIHIME (Kono Seisakusho, Tokyo, Japan)—was fixed.
(2) Subtotal hysterectomy and adnexectomy: These procedures were performed if the uterus and adnexa were present. Subtotal hysterectomy and bilateral adnexectomy are not always necessary in LSC, but since preservation of the uterus requires separate retroperitonealization of the anterior and posterior wall meshes, we perform subtotal hysterectomy and bilateral adnexectomy to simplify the procedure. In this setting, the presence or absence of hysterectomy was added as a preoperative factor because the ligation of the uterine artery might have affected the blood supply to the vaginal wall.
(3) Posterior wall dissection: The posterior vaginal wall was separated from the rectum, and posterior wall mesh was fixed.
(4) Mesh retroperitonealization: The mesh was covered, and the pelvic peritoneum was closed.
(5) Peritoneal closure: The peritoneum was completely closed after securing the mesh to the anterior longitudinal ligament.
Assessment of Pre- and Postoperative UI
In our previous study, we found a significant correlation between daily life-impairing UI and the total ICIQ-SF score [15]. Similarly, in this study, the ICIQ-SF score was significantly associated with daily life-impairing UI at 1 year postoperatively. Receiver operator characteristic analysis identified an ICIQ-SF score of ≥6 as indicative of daily life-impairing UI (Fig. 1). Daily life-impairing UI was defined as UI that interferes with daily life because of urine leakage regardless of whether it is SUI, UUI, or MUI.
Statistical Analysis
The Pearson chi-square test was performed to evaluate the correlation between preoperative plus intraoperative factors and postoperative UI. The multiple logistic regression model and the Cox proportional hazards model were used to determine the independent factors that contribute to postoperative UI. Statistical analysis was conducted using JMP PRO ver. 17 (SAS institute, Cary, NC, USA). A P-value <0.05 was considered statistically significant.
RESULTS
Table 1 summarizes the patient demographics. Intraoperative complications included bladder injury in 4 patients and anterior vaginal wall injury in 7 patients, all classified as Clavien-Dindo classification grade 1 [19]. No major postoperative complications were observed.
The correlation analysis using Pearson chi-square test between preoperative and intraoperative factors and UI at 1 year postoperatively revealed that BMI, POP-Q stage 4, and the presence of preoperative UI were significantly associated with postoperative UI (all P<0.05) (Table 2).
Multivariate logistic regression analysis was conducted to identify independent factors influencing postoperative UI. In the univariate analysis, BMI, POP-Q stage 4, and preoperative UI were significant predictors (P=0.048, P=0.005, and P<0.001, respectively). In the multivariate analysis, only POP-Q stage 4 and preoperative UI remained as significant predictors of postoperative UI (P=0.039 and P=0.003, respectively) (Table 3).
The univariate Cox proportional hazards model showed that patients with POP stage 4 and those with preoperative UI had significantly higher risks of developing postoperative UI (P=0.042 and P=0.007, respectively). The multivariate analysis identified preoperative UI as the strongest predictor of postoperative UI, with a hazard ratio of 3.56 (95% confidence interval [95% CI], 1.29–11.58; P=0.016) (Table 4).
Kaplan-Meier curves and the log-rank test indicated significant differences in UI-free survival rates between patients with and without POP-Q stage 4 as well as between those with and without preoperative UI (P=0.036 and P=0.003, respectively) (Fig. 2A and B).
DISCUSSION
Multivariate logistic regression analysis revealed that POP-Q stage 4 and preoperative UI are independent predictors of postoperative UI (Table 3). Similarly, the Cox proportional hazards model confirmed that preoperative UI is an independent factor affecting the development of postoperative UI (Table 4). The Kaplan-Meier analysis with the log-rank test also demonstrated a significant difference in outcomes based on POP-Q stage 4 and the presence of preoperative UI (Fig. 2). These results suggest that preoperative UI is a key determinant of daily life-impairing UI following LSC. Although LSC generally has a lower incidence of postoperative UI than TVM procedures, it is still associated with a risk of UI, occurring in a few percent of cases [20, 21].
One study reported that postoperative SUI was associated with an increased point Ba measurement and the presence of preoperative SUI. Point Ba represents the most dependent position of the upper anterior vaginal wall (between the vaginal cuff or fornix and point Aa). Point Aa is located on the anterior vaginal wall 3 cm proximal to the external urethral meatus [22]. Their findings, consistent with ours, indicated that patients with advanced POP are at risk of developing postoperative UI. Severe prolapse can obscure preexisting SUI by exerting external pressure on the bladder neck or urethra. Once the prolapse is corrected through LSC, the underlying SUI may become apparent. This scenario is particularly common in women who experience no or mild SUI symptoms preoperatively but develop significant symptoms postoperatively. Preoperative assessments to identify occult SUI are therefore essential to plan appropriate anti-incontinence treatments [23].
Postoperative UI after LSC may also result from anatomical misalignment. Overcorrection or excessive mesh tension can displace the bladder neck or urethra, leading to de novo or worsened SUI. Such misalignment can impair the urethral closure mechanism, contributing to bladder outlet obstruction or increased urethral mobility. Cystoscopic observations during LSC have shown bladder neck opening and abnormal tension along the trigone and posterior wall because of mesh traction [24]. Additionally, some studies suggest that LSC might not address functional sphincter deficiencies, as maximal urethral closure pressure can decrease postoperatively [25]. Careful intraoperative adjustments may be needed to avoid overcorrection, and postoperative monitoring is essential to evaluate whether the anatomical realignment affects continence outcomes [26].
Overactive bladder (OAB) and urgent urinary incontinence (UUI) may also persist after LSC, potentially because of unresolved detrusor overactivity. Although LSC restores normal pelvic anatomy, it may not fully address the underlying bladder dysfunction. In some cases, surgical inflammation or nerve irritation might exacerbate OAB symptoms, resulting in de novo UUI. Pharmacologic management with antimuscarinics or β3 agonists may be necessary to control urgency and frequency issues in these patients [27]. In this study, the rate of patients with OAB among enrolled patients before surgery was 77 of 96 (80.2%), and the rate of de novo OAB 1 year postoperatively was 5 of 19 (26.3%). The cure rate of OAB 1 year after surgery was 30 of 77 (39.0%). This cure rate appeared to be in need of improvement.
This study has several limitations. First, it is a retrospective study conducted at a single center, which may limit the generalizability of the findings. Second, the relatively small sample size reduces the statistical power of the results. Third, the median follow-up duration was relatively short, potentially limiting the ability to assess long-term outcomes. Future multicenter studies with larger sample sizes and longer follow-up periods are needed to validate our findings and strengthen the evidence base. Expanding the scope of future studies will enhance the robustness of conclusions and provide insights into the long-term effects of LSC on UI outcomes.
In conclusion, preoperative UI was found to be a significant predictor of postoperative UI following LSC. Patients with POP-Q stage 4 should also be carefully monitored for postoperative UI.
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