Laparoscopic Sacrocolpopexy Can Alleviate Postoperative Overactive Bladder Symptoms With or Without Urinary Incontinence in Patients With Both Preoperative Symptoms

Kenji Kuroda; Koetsu Hamamoto; Kazuki Kawamura; Ayako Masunaga; Hiroaki Kobayashi; Keiichi Ito

doi:10.5213/inj.2550002.001

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Kuroda, Hamamoto, Kawamura, Masunaga, Kobayashi, and Ito: Laparoscopic Sacrocolpopexy Can Alleviate Postoperative Overactive Bladder Symptoms With or Without Urinary Incontinence in Patients With Both Preoperative Symptoms

Original Article

Clinical Investigations

Int Neurourol J 2025; 29(3): 164-171.

Published online: September 30, 2025

DOI: https://doi.org/10.5213/inj.2550002.001

Laparoscopic Sacrocolpopexy Can Alleviate Postoperative Overactive Bladder Symptoms With or Without Urinary Incontinence in Patients With Both Preoperative Symptoms

Kenji Kuroda, Koetsu Hamamoto, Kazuki Kawamura, Ayako Masunaga, Hiroaki Kobayashi

, Keiichi Ito

Department of Urology, National Defense Medical College, Tokorozawa, Japan

Corresponding author: Kenji Kuroda Department of Urology, National Defense Medical College, 3-2 Namiki, Tokorozawa, Saitama 359-8513, Japan
Email: kksmy@sa2.so-net.ne.jp

Submitted: November 30, 2024 Accepted after revision: March 23, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Purpose

Pelvic organ prolapse (POP) and overactive bladder (OAB) symptoms frequently coexist. Most patients with POP may present with at least one OAB symptom of any grade, and OAB symptoms can be alleviated by conservative or surgical treatments for POP. This study investigated data from patients with POP who underwent laparoscopic sacrocolpopexy (LSC) at our institution to determine the factors that led to the emergence of postoperative OAB symptoms or its improvement after LSC.

Methods

This retrospective study enrolled 97 patients who underwent LSC at our institution between June 2016 and October 2023. The Pearson chi-square test and multiple logistic regression analysis were performed to determine the independent factors that contribute to postoperative OAB symptoms or OAB improvement. The OAB symptom score was used to assess the change in OAB symptoms before and after LSC. OAB symptoms were considered improved if the OAB symptom score total score improved compared to the preoperative score.

Results

In the correlation analysis, the presence of preoperative OAB and/or urinary incontinence (UI) was significantly associated with postoperative OAB symptoms (both P<0.05). In addition, both symptoms were significantly associated with postoperative OAB (P=0.010). In another correlation analysis, the presence of preoperative OAB and that of either symptom were significantly associated with postoperative OAB improvement (both P<0.05). In the multiple logistic regression analysis, the presence of both symptoms was an independent factor for postoperative OAB symptoms among the factors including operative time and preoperative postvoid residual urine volume, and the presence of either symptoms could be associated with postoperative OAB improvement besides operative time.

Conclusions

LSC could improve OAB symptoms postoperatively in patients with preoperative OAB or UI, or both better than in those without such symptoms.

Keywords: Pelvic organ prolapse; Laparoscopic sacrocolpopexy; Urinary bladder, Overactive

INTRODUCTION

Pelvic organ prolapse (POP) is defined as the downward displacement of one or more pelvic organs, such as the bladder, uterus, bowel, or rectum. POP can cause symptoms such as pelvic pressure, vaginal bulging, and incomplete emptying of urine or feces [1]. POP may be caused by weak or damaged pelvic floor muscles because of obesity, persistently high abdominal pressure, and birth trauma. POP-induced pelvic organ displacement and decline greatly affect the daily lives and careers of women. At some point in the lives of these women, approximately 20% have undergone POP surgery [2].

Patients with POP also experience symptoms of an overactive bladder (OAB), which is characterized by frequency or nocturia with urinary urgency with or without urge urinary continence (UUI) [1, 3]. The EPIC (Epidemiology Urinary Incontinence and Comorbidities) study demonstrated that 13% of women suffer from OAB symptoms regardless of age [4]. However, the pathophysiology of OAB is not well known.

POP and OAB symptoms frequently coexist. A recent population-based study reported that 40% of women with POP experienced at least one troublesome OAB symptom, and 82% had at least one OAB symptom of any grade [5]. Among other proposed mechanisms, the integral theory explains the correlation of OAB symptoms with POP, which designates that OAB is caused by anatomical defects and damage to the pelvic floor musculoligamentous system [6]. Therefore, conservative or surgical treatments for POP could improve OAB symptoms after treatment.

POP can be treated with pelvic floor exercises, pessary, and surgery. Typically, transvaginal mesh surgery (TVM) and laparoscopic sacrocolpopexy (LSC) are performed for the treatment of POP. Over the past several years in Japan, POP has been treated with LSC or TVM [7]. A randomized controlled trial that compared LSC with TVM for POP repair showed higher success rates and lower reoperation rates after LSC than after TVM [8]. Both procedures appear to offer favorable results for the surgical treatment of POP [7, 9]. However, LSC has several benefits owing to its correlation with reduced recurrence rates, lower incidence of dyspareunia, shorter length of postoperative hospital stay, and faster recovery period [10, 11]. Accordingly, it has long been considered the gold standard for POP treatment, and robot-assisted sacrocolpopexy is now becoming the new gold standard technique.

This study analyzed data of patients with POP who underwent LSC using Polyform (Boston Scientific, Japan) or ORIHIME (Kono Seisakusho, Japan) at our institution to determine the factors leading to the presence of postoperative OAB symptoms or its improvement after LSC.

MATERIALS AND METHODS

Patients

The medical records of 97 patients who underwent LSC between June 2016 and October 2023 were retrospectively reviewed. Surgery is indicated for stage ≥2 POP with symptoms, such as hydronephrosis and/or hydroureter caused by POP, or even in asymptomatic cases.

This study included patients who underwent LSC for POP using Polyform or ORIHIME throughout the research period; those who chose not to participate or those who underwent LSC using Gynemesh PS (Johnson and Johnson, Japan) were excluded.

The median postoperative observation period was 12.3 months (interquartile range [IQR], 12.1–18.2 months). The median operative time calculated from all patients was 3.03 hours (IQR, 2.55–4.16 hours). Table 1 presents clinical data such as age, body mass index, presence of diabetes mellitus, pelvic organ prolapse quantification stage, past history of hysterectomy, blood loss, operative time, mesh products used, preoperative voiding dysfunction, preoperative OAB, preoperative urinary incontinence (UI), and intraoperative complications.

Surgical Methods

The LSC technique essentially used the method by Wattiez et al. [12]. Briefly, after placing all ports, the patient was tilted 15° from the horizontal in a Trendelenburg position, and to obtain a clear view of the pelvic cavity, the bowel was moved toward the head. Thereafter, the following steps were then performed: (1) dissection between the anterior vaginal wall and the bladder plus fixation of the anterior wall mesh Polyform or ORIHIME, (2) subtotal hysterectomy and bilateral adnexectomy when the uterus and adnexa are present, (3) dissection between the posterior vaginal wall and the rectum plus fixation of the posterior wall mesh, (4) mesh retroperitonealization and partial closure of the pelvic floor peritoneum, and (5) mesh fixation on the anterior longitudinal ligament at the promontory level, and (6) total closure of the peritoneum.

Assessment Methods for Postoperative OAB Symptoms

The overactive bladder symptom score (OABSS) was employed to assess OAB symptoms and evaluate the change in the symptoms before and after surgery. According to an earlier report, the presence of OAB symptoms was indicated by a total OABSS of ≥3 [13]. The postvoid residual urine volume (PVR) of ≥100 mL was defined as the presence of voiding dysfunction according to earlier studies [14, 15]. We usually perform uroflowmetry in addition to PVR measurement preoperatively; however, PVR was used as an indicator of bladder outlet obstruction (BOO) because data on uroflowmetry were often insufficient and the data could not be obtained from all patients. Daily life-impairing UI was defined as UI that interferes with daily life because of urine leakage regardless of whether it is stress UI, urge UI, or mixed UI. Receiver operator characteristic analysis identified an International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) score of ≥6 as indicative of daily life-impairing UI 1 year postoperatively (area under curve=0.749). We did not implement behavioral therapy or pharmacotherapy in this study.

Statistical Analysis

Pearson chi-square test was employed to investigate the correlation between preoperative plus intraoperative factors and postoperative OAB symptoms or OAB improvement. Multiple logistic regression analysis was performed to determine the independent factors contributing to the presence of postoperative OAB symptoms or postoperative OAB improvement. Statistical analysis was performed using JMP PRO ver. 17 (SAS Institute Inc., USA). A P-value <0.05 was considered statistically significant. Cases with missing values were statistically treated as having missing values.

RESULTS

Patients’ background is presented in Table 1. Intraoperative bladder injury was observed in 4 patients and anterior vaginal wall injury in 8; however, no serious postoperative complications were noted. All of them were rated as Clavien–Dindo classification grade I [16].

The results of the correlation analysis between pre- and intraoperative factors and the presence of postoperative OAB symptoms revealed that the presence of preoperative OAB or UI was significantly associated with postoperative OAB (both P<0.05). Moreover, the presence of both symptoms was significantly associated with postoperative OAB (P=0.010) (Table 2).

The findings of another correlation analysis between pre- and intraoperative factors and improvement of postoperative OAB symptoms revealed that the presence of preoperative OAB and that of either symptom were significantly associated with postoperative OAB improvement (both P<0.05) (Table 3).

Multivariate logistic regression analysis was also performed to evaluate the independent factors for postoperative OAB symptoms. In the univariate and multivariate analyses, the presence of both OAB and UI and operative time were significant predictors among pre- and intraoperative factors (P=0.005, P=0.020, respectively) (Table 4). Further univariate and multivariate analyses of multiple logistic regression analysis revealed that the presence of either of the symptoms was an independent contributor to postoperative OAB improvement (P=0.015) (Table 5).

The OABSS improved significantly 3–12 months after surgery in the group with OAB ≥3; 3–12 months after surgery in the group with preoperative UI (+); 6 and 12 months after surgery in the group with preoperative UI (-); and 3–12 months after surgery in the group with both or either of the symptoms in box plots (all P<0.05) (Fig. 1A-C).

DISCUSSION

In the correlation analysis of this study, the presence of both OAB and UI was associated with the presence of postoperative OAB symptoms (Table 2). In another correlation analysis, the presence of preoperative OAB and either of the symptoms were significantly associated with postoperative OAB improvement (Table 3). Multiple logistic regression analysis showed that the presence of both symptoms was an independent factor for postoperative OAB symptoms (Table 4). Conversely, the presence of either of the symptoms could help improve postoperative OAB symptoms (Table 5). From Tables 3 and 5, the presence of preoperative OAB symptoms seemed to contribute more to postoperative OAB improvement. Box plots also showed a significant difference in postoperative OABSS in every group (Fig. 1). From these findings, LSC could improve both OAB and UI symptoms even in patients with both symptoms. In other words, LSC could alleviate OAB as well as UI.

Lower urinary tract symptoms such as BOO and OAB often occur in patients with POP. In these patients, BOO is a common cause of OAB symptoms and UUI and is considered a significant contributing factor to these symptoms [17]. According to several earlier studies, OAB symptoms subsided following effective treatment for POP [17-20]. In a previous study, 53% (22 of 40) of the patients who underwent non-mesh procedures for prolapse repair experienced resolution of OAB symptoms, and better postoperative OAB scores were significantly associated with the maximal flow rate [20]. In another study, preoperative detrusor obstruction was the only significant predictor of symptom alleviation in patients with POP, and OAB symptoms were resolved after TVM [21]. In patients with severe POP, 63% (24 of 38) of UUI cases resolved following prolapse correction surgery or that urgency and frequent symptoms significantly decreased 6 months and 1 year following vaginal reconstructive and obliterating procedures [22, 23]. The authors proposed that mesh repair-induced postoperative OAB improvement was associated with urethral obstruction release. In the present study, 78 out of 97 (80.4%) patients had an OAB total score of ≥3 before surgery, and 47 out of 78 patients (60.3%) still had an OAB total score of ≥3; however, only 12 out of 78 patients (15.4%) had a worse OAB total score 12 months after LSC. Therefore, it is likely that LSC also reduced BOO and enhanced pelvic floor support in this study as seen in earlier studies.

LSC offers numerous advantages, such as less intraoperative blood loss and a shorter hospital stay; thus, it has been a preferred procedure in recent years [24, 25]. Compared with traditional surgical methods, its postoperative recurrence rate is lower; however, it requires extended operating hours and a higher degree of expert skills [25]. When LSC or TVM is recommended to patients with POP, some patients choose LSC, which appears to have a lower recurrence rate and fewer complications. Native tissue repair is not as commonly selected because of concerns regarding increased recurrence rates. In a previous report, UI was significantly lower in patients who underwent LSC as well as TVM, and the ICIQ-SF scores were also significantly lower in patients who underwent either of the surgical methods [26]. Therefore, this study was conducted based on the prediction that OABSS would improve postoperatively in patients who underwent LSC along with ICIQ-SF and that OAB symptoms would be more significantly alleviated in patients with preoperative OAB symptoms and/or UI.

This study has several limitations. First, it is a clinical study at a single institution. Second, the study population is relatively small. Third, the median follow-up period of 12.3 months was relatively short. Thus, to increase the generalizability of the data and reach a consensus on these limitations, a more comprehensive multi-center study in the future would provide more conclusive evidence based on these findings. A direct comparison with TVM studies would also further increase the statistical power and robustness of the findings of this study. Moreover, longer observation periods would further support the validity and long-term reliability of the study results.

In conclusion, LSC may have the potential to treat OAB symptoms with or without UI. The presented findings indicate that LSC would improve OAB symptoms in patients with preoperative OAB and/or UI compared with those without such symptoms.

NOTES

Grant/Fund Support

This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Research Ethics

Every procedure performed in this study complied with the ethical guidelines of the National Defense Medical College and the principles of the 2013 edition of the Declaration of Helsinki. The National Defense Medical College Ethics Committee approved this study protocol on August 21, 2020 (Saitama, Japan; ID, 4219). Each patient provided written informed consent.

Conflict of Interest

No potential conflict of interest relevant to this article was reported.

AUTHOR CONTRIBUTION STATEMENT

· Conceptualization: KKuroda, KH, KKawamura, AM, HK, KI

· Data curation: KKuroda, KH, KKawamura, AM, HK, KI

· Formal analysis: KKuroda, KH, KKawamura, AM, HK, KI

· Methodology: KKuroda, KH, KKawamura, AM, HK, KI

· Project administration: KKuroda, KH, KKawamura, AM, HK, KI

· Visualization: KKuroda, KH, KKawamura, AM, HK, KI

· Writing - original draft: KKuroda, KH, KKawamura, AM, HK

· Writing - review & editing: KKuroda, KI

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Fig. 1.

Box plots reveal significant decreases in overactive bladder symptom score 3–12 months after surgery (3–12 POM) in the group with preoperative OAB of ≥3 (A), group with preoperative urinary incontinence (UI) (+) and UI (−) (B), group with both OAB and UI, and group with either OAB or UI (C). *Significantly different from the preoperative status (BS) (P<0.001), **Significantly different from the preoperative status (BS) (P<0.05). BS, before surgery; POM, postoperative months; OAB, overactive bladder; UI, urinary incontinence; NS, not significant.

Table 1.

Clinical characteristics of the LSC patients (N=97)

Characteristic	Value
Age (yr)	74 (69.5–78)
BMI (kg/m²)	22.7 ± 2.4
Diabetes mellitus
Present	12 (12.4)
Absent	85 (87.6)
POP-Q stage
Stage 2	6 (6.2)
Stage 3	71 (73.2)
Stage 4	20 (20.6)
Previous hysterectomy
Present	9 (9.3)
Absent	88 (90.7)
Blood loss (mL)	2 (0–8.5)
Operative time (hr)	3.0 (2.55–4.16)
Mesh used
Polyform	30 (30.9)
ORIHIME	67 (69.1)
Preoperative voiding dysfunction (PVR ≥ 100 mL)
Present	35 (36.1)
Absent	62 (63.9)
Preoperative OAB
≥3	78 (80.4)
≤2	19 (19.6)
Preoperative life-impairing UI
Present	57 (58.8)
Absent	40 (41.2)
Intraoperative complications
Bladder injury	4 (4.1)
AVW injury	8 (8.2)

Values are presented as median (interquartile range), mean±standard deviation, number (%).

LSC, laparoscopic sacrocolpopexy; BMI, body mass index; POP-Q, pelvic organ prolapse quantification; PVR, postvoid residual urine volume; OAB, overactive bladder; UI, urinary incontinence; AVW, anterior vaginal wall.

Table 2.

Association between the presence of postoperative OAB symptoms and pre- and intraoperative variables

Variable	Postoperative OAB score		P-value
Variable	≥3	≤2	P-value
Age (yr)			0.698
≥ 74	28 (51.9)	26 (48.1)
< 74	24 (55.8)	19 (44.2)
BMI (kg/m²)			0.129
≥ 22.7	30 (61.2)	19 (38.8)
< 22.7	22 (45.8)	26 (54.2)
Diabetes mellitus			0.726
Present	7 (58.3)	5 (41.7)
Absent	45 (52.9)	40 (47.1)
POP-Q			0.717
Stage 4	10 (50.0)	10 (50.0)
Stage ≤ 3	42 (54.6)	35 (45.4)
Previous hysterectomy			0.127
Present	7 (77.8)	2 (22.2)
Absent	45 (51.1)	43 (48.9)
Operative time (hr)			0.065
≥ 3.1	27 (64.3)	15 (35.7)
< 3.1	25 (45.4)	30 (54.5)
Mesh used			0.971
Polyform	16 (53.3)	14 (46.7)
ORIHIME	36 (53.7)	31 (46.3)
Preoperative PVR (mL)			0.072
≥ 100	23 (65.7)	12 (34.3)
< 100	29 (46.8)	33 (53.2)
Preoperative OAB			0.008
≥3	47 (60.3)	31 (39.7)
≤2	5 (26.3)	14 (73.7)
Preoperative UI			0.024
Present	36 (63.2)	21 (36.8)
Absent	16 (40.0)	24 (60.0)
Preoperative OAB or UI or both			0.010
Both	35 (66.0)	18 (34.0)
Either	12 (48.0)	13 (52.0)
Neither	5 (26.3)	14 (73.7)

Values are presented as number (%).

OAB, overactive bladder; BMI, body mass index; POP-Q, pelvic organ prolapse quantification; PVR, postvoid residual urine volume; UI, urinary incontinence.

Table 3.

Association between postoperative OAB improvement and pre- and intraoperative variables

Variable	Worse	Better/no change	P-value
Age (yr)			0.567
≥ 74	10 (18.5)	44 (81.5)
< 74	10 (23.3)	33 (76.7)
BMI (kg/m²)			0.146
≥ 22.7	13 (26.5)	36 (73.5)
< 22.7	7 (14.6)	41 (85.4)
Diabetes mellitus			0.689
Present	3 (25.0)	9 (75.0)
Absent	17 (20.0)	68 (80.0)
POP-Q			0.939
Stage 4	4 (20.0)	16 (80.0)
Stage ≤ 3	16 (20.8)	61 (79.2)
Previous hysterectomy			0.901
Present	2 (22.2)	7 (77.8)
Absent	18 (20.5)	70 (79.5)
Operative time (hr)			0.091
≥ 3.1	12 (28.6)	30 (71.4)
< 3.1	8 (14.5)	47 (85.5)
Mesh used			0.920
Polyform	6 (20.0)	24 (80.0)
ORIHIME	14 (20.9)	53 (79.1)
Preoperative PVR (mL)			0.247
≥ 100	5 (14.3)	30 (85.7)
< 100	15 (24.2)	47 (75.8)
Preoperative OAB			0.010
≥3	12 (15.4)	66 (84.6)
≤2	8 (42.1)	11 (57.9)
Preoperative UI			0.701
Present	11 (19.3)	46 (80.7)
Absent	9 (22.5)	31 (77.5)
Preoperative OAB or UI or both			0.019
Both	10 (18.9)	43 (81.1)
Either	2 (8.00)	23 (92.0)
Neither	8 (20.6)	11 (79.4)

Values are presented as number (%).

OAB, overactive bladder; BMI, body mass index; POP-Q, pelvic organ prolapse quantification; PVR, postvoid residual urine volume; UI, urinary incontinence.

Table 4.

Factors contributing to the presence of postoperative OAB symptoms in multiple logistic regression analysis

Variable	Univariate			Multivariate
Variable	OR	95% CI	P-value	OR	95% CI	P-value
Age (yr) (≥ 74 or < 74)	1.17	0.52–2.62	0.698	-	-	-
BMI (kg/m²) (≥ 22.7 or < 2.7)	1.87	0.83–4.19	0.130	-	-	-
Diabetes mellitus (present or absent)	1.24	0.37–4.23	0.726	-	-	-
POP-Q stage (4 or ≤ 3)	1.20	0.45–3.21	0.717	-	-	-
Previous hysterectomy (present or absent)	3.34	0.66–17	0.146	-	-	-
Operative time (hr) (≥ 3.1 or < 3.1)	2.16	0.95–4.93	0.067	2.89	1.18–7.53	0.020
Mesh used (Polyform or ORIHIME)	1.02	0.43–2.41	0.971	-	-	-
Preoperative PVR (mL) (≥ 100 or < 100)	2.18	0.92–5.14	0.075	2.11	0.84–5.54	0.115
Preoperative (OAB or UI or both)	5.44	1.69–17.52	0.005	5.47	1.66–20.76	0.005

OAB, overactive bladder; OR, odds ratio; CI, confidence interval; BMI, body mass index; POP-Q, pelvic organ prolapse quantification; PVR, postvoid residual urine volume; UI, urinary incontinence.

Table 5.

Factors contributing to postoperative OAB improvement in multiple logistic regression analysis

Variable	Univariate			Multivariate
Variable	OR	95% CI	P-value	OR	95% CI	P-value
Age (yr) (≥ 74 or < 74)	1.33	0.5–3.57	0.567	-	-	-
BMI (kg/m²) (≥ 22.7 or < 2.7)	2.12	0.76–5.88	0.151	-	-	-
Diabetes mellitus (present or absent)	1.33	0.33–5.46	0.689	-	-	-
POP-Q stage (4 or ≤ 3)	1.05	0.31–3.58	0.939	-	-	-
Previous hysterectomy (present or absent)	1.11	0.21–5.81	0.901	-	-	-
Operative time (hr) (≥ 3.1 or < 3.1)	2.35	0.86–6.42	0.096	2.43	0.85–6.95	0.098
Mesh used (Polyform or ORIHIME)	1.06	0.36–3.08	0.920	-	-	-
Preoperative PVR (mL) (≥ 100 or < 100)	1.91	0.63–5.82	0.252	-	-	-
Preoperative (OAB or UI or both)	8.36	1.52–46.15	0.015	8.68	1.53–49.09	0.015

OAB, overactive bladder; OR, odds ratio; CI, confidence interval; BMI, body mass index; POP-Q, pelvic organ prolapse quantification; PVR, postvoid residual urine volume; UI, urinary incontinence.

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Official Journal of Korean Society of Functional and Reconstructive Urology & ESSIC (International Society for the Study of BPS) & Korean Society of Urological Research & The Korean Children’s Continence and Enuresis Society & The Korean Association of Urogenital Tract Infection and Inflammation & Korean Society of Geriatric Urological Care
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