Int Urogynecol J DOI 10.1007/s00192-016-3144-z

ORIGINAL ARTICLE

Predictors of voiding dysfunction following extensive vaginal pelvic reconstructive surgery Tsia-Shu Lo 1,2,3 & Nagashu Shailaja 2,4 & Wu-Chiao Hsieh 2 & Ma. Clarissa Uy-Patrimonio 2,5 & Faridah Mohd Yusoff 2,6 & Rami Ibrahim 2,7

Received: 4 May 2016 / Accepted: 28 August 2016 # The International Urogynecological Association 2016

Abstract Introduction and Hypothesis The objective of this study was to identify the predictors of postoperative voiding dysfunction in women following extensive vaginal pelvic reconstructive surgery. Methods We enrolled 1,425 women who had pelvic organ prolapse of POP-Q stage III or IV and had undergone vaginal pelvic reconstructive surgery with or without transvaginal mesh insertion from January 2006 to December 2014. All subjects were required to complete a 72-h voiding diary, and the IIQ-7, UDI-6, POPDI-6 and PISQ-12 questionnaires. Urodynamic study was performed preoperatively and postoperatively.

* Tsia-Shu Lo [email protected]

1

Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Keelung, Medical Center, 222, Maijin Road, Keelung, Taiwan 204, Republic of China

2

Division of Urogynecology, Department of Obstetrics and Gynecology, Linkou, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan, Taiwan, Republic of China

3

School of Medicine, Chang Gung University, Taoyuan, Taiwan, Republic of China

4

Department of Obstetrics and Gynaecology, Peoples Education Society Medical College and Research Centre, Kuppam, Andhra Pradesh, India

5

Department of Obstetrics and Gynecology, Dr. Pablo O. Torre Memorial Hospital, Bacolod City, Philippines

6

Department of Obstetrics and Gynaecology, Hospital Sultanah Nur Zahirah, Kuala, Terengganu, Malaysia

7

Department of Obstetrics and Gynecology, Albashir Hospital, Amman, Jordan

Results Of the 1,425 women, 54 were excluded due to incomplete data, and 1,017 of the remaining 1,371 (74.2 %) had transvaginal mesh surgery and 247 (18 %) had concurrent midurethral sling insertion. Of 380 women (27.7 %) with preoperative voiding dysfunction, 37 (9.7 %) continued to have voiding dysfunction postoperatively. Of the remaining 991 women (72.3 %) with normal preoperative voiding function, 11 (1.1 %) developed de novo voiding dysfunction postoperatively. The overall incidence of postoperative voiding dysfunction was 3.5 % (48/1,371). Those with concurrent midurethral sling insertion were at higher risk of developing voiding dysfunction postoperatively (OR 3.12, 95 % CI 1.79 – 5.46, p < 0.001). Diabetes mellitus, preoperative detrusor pressure at maximal flow (Dmax) <10 cm H2O and postvoid residual volume ≥200 ml were significant risk factors for the development of postoperative voiding dysfunction (OR 3.07, 1.84 and 2.15, respectively; 95 % CI 1.69 – 5.60, 1.39 – 2.91 and 1.10 – 3.21, respectively). Conclusions Diabetes mellitus, concurrent midurethral sling insertion, preoperative Dmax <10 cm H2O and postvoid residual volume ≥200 ml in patients with advanced pelvic organ prolapse were risk factors for the development of postoperative voiding dysfunction after vaginal pelvic reconstructive surgery. Therefore, counseling is worthwhile before considering vaginal pelvic reconstructive surgery. Keywords Voiding dysfunction . Dmax . Post void residue (PVR)

Introduction Voiding dysfunction following pelvic organ prolapse (POP) surgery is a longstanding concern and is distressing for the surgeon as well as the patient. Voiding dysfunction, a

Int Urogynecol J

diagnosis based on symptoms and urodynamic investigations, is defined as abnormally slow and/or incomplete micturition [1]. Because of the absence of clear definitions, attempting to classify and clarify voiding dysfunction is difficult. The standardization of terminology of lower urinary tract dysfunction, published by the International Continence Society (ICS), does not provide clear distinction [2]. In females, voiding dysfunction may occur if the detrusor muscle cannot maintain effective contraction, if the urethra fails to relax to lower the urethral resistance or if there is failure in synchronizing these actions, all of which lead to detrusor sphincter dyssynergia [3]. In POP, kinking of the urethra in patients with cystocele or direct compression of the urethra by the prolapsed organ causes bladder outlet obstruction (BOO) [4]. A potential complication of iatrogenic postsurgical obstruction leading to voiding dysfunction can be anticipated. Excessive elevation of the bladder neck during colposuspension or undue tension applied to a sling are the most likely causes of postoperative voiding difficulty [5]. Damage to motor parasympathetic nerves during surgery can possibly lead to impaired detrusor contraction, resulting in detrusor overactivity or detrusor underactivity (DUA) [6, 7]. The true incidence of voiding dysfunction following pelvic reconstructive surgery (PRS) is difficult to ascertain because there is a lack of standardization for its assessment. However, the incidence of voiding difficulty after anti-incontinence surgery ranges from 2.4 % to 24 % [8]. In addition to iatrogenic causes of voiding dysfunction following gynecological surgery, pharmacological, inflammatory, endocrine (diabetic cystopathy), bladder over-distension and psychogenic causes are nonsurgical factors contributing to voiding dysfunction [9]. The mechanisms by which postoperative voiding dysfunction can develop are not fully understood. Questions arise as to how to preoperatively predict the possibility of voiding dysfunction development so that the surgeon can counsel the patient objectively as to the best surgical option. The aim of this study was to explore the impact of vaginal PRS on voiding function in patients with POP.

Materials and methods This study was conducted in Chang Gung Memorial Hospitals from January 2006 to December 2014. Women who had severe POP, Pelvic Organ Prolapse Quantification (POP-Q) stage III or IV and who presented for urogynecological consultation in three different Chang Gung Memorial Hospital branches (Linkou, Taipei, and Xiamen) were considered for enrollment in this study. Women with incomplete postoperative data were excluded (54 patients; Fig. 1). This was a retrospective study. Data were collected from electronic medical records.

Fig. 1 Study flow chart (SS sacrospinous suspension, SSF sacrospinous„ fixation, MUS midurethral sling, USI urodynamic stress urinary incontinence). Prolift (Gynecare PROLIFT Anterior and Posterior Pelvic Floor Repair Systems; Ethicon, Inc., Somerville, NJ, USA). Perigee™ system (American Medical Systems, Minnetonka, MN, USA). Avaulta Plus BioSynthetic Support System (C.R. Bard, Inc., Murray Hill, NJ, USA). Elevate™ Anterior and Apical Prolapse Repair System (American Medical Systems, Minnetonka, MN, USA) >

As part of the institutional protocol, preoperative evaluation systematically included a detailed medical history, physical examination, cough stress test, urinalysis, and cultures to rule out urinary infection, and a multichannel urodynamic study (UDS) was performed using appropriately sized pessaries for prolapse reduction. The cough stress test was performed with the patient in a semilithotomy position with the bladder filled comfortably with at least 200 ml of urine. The patient was asked to perform a forceful cough while the examiner observed for leakage from the urethral meatus during a clinical examination. Women with diabetes mellitus (DM) were included after optimizing diabetic control. UDS were performed in all women undergoing PRS both before and after surgery by a trained UDS nurse using the Dantec Menuet system (Dantec Medical A/S, Skovlunde, Denmark) and the Solar Gold system (Medical Measurement Systems, Dover, NH, USA). Multichannel UDS comprised uroflowmetry, filling and voiding cystometry, and urethral pressure profilometry. Urodynamic SUI (USI) was diagnosed on the basis of demonstrable involuntary leakage of urine during increased abdominal pressure in the absence of a detrusor contraction observed on filling cystometry. All patients practiced inserting a ring pessary for prolapse reduction when UDS were performed. Patients who had urinary leakage only when the prolapse was repositioned were considered to have occult USI. Multichannel UDS was done according to the standard International Urogynecological Association/ICS (IUGA/ICS) protocol. Prolapse was assessed with the patient in a semilithotomy position and staged according to the IUGA/ICS POP-Q system [2]. All women were properly counseled by the operating surgeons regarding treatment options, possible clinical outcomes and possible complications. The choice of transvaginal mesh (TVM) procedure depended upon the type of TVM available at the institutions where surgery was being performed with the women’s consent. All conditions were defined according to ICS standards. Chang Gung Memorial Hospital institutional review board approval was obtained for evaluation of this study (IRB:102-2976B). Surgical procedures were carried out under regional or general anesthesia. Those performed in sequence were vaginal hysterectomy, anterior and posterior colporrhaphy with or without TVM and sacrospinous fixation (SSF) with or without midurethral sling (MUS) insertion. The types of TVM used were Prolift Anterior and Posterior (Prolift T), the Perigee

Int Urogynecol J 1425 POPQ III and IV 373- SSF 656- Perigee +SS 168- Avaulta A +SS 124- Proli T 104- Elevate A 54 paents excluded due to no post-operave urodynamic data 19-SSF 24- Perigee +SS 4-Avaulta A +SS 4-Proli T 3-Elevate A 1371

POPQ III and IV

Pre-OP- Normal voiding funcon (991, 72.3%) 252-SSF (with MUS-80) 461-Perigee +SS (with MUS-98) 123-Avaulta A +SS (with MUS-20) 81-Proli T (with MUS-14) 74-Elevate A (with MUS- 4)

Pre-OP- Voiding dysfuncon (380, 27.7%) (with MUS-12) 102- SSF 171- Perigee +SS (with MUS-15) 41-Avaulta A +SS (with MUS- 8) 39-Proli T (with MUS- 5) 27-Elevate A (with MUS-1)

Post-OPVoiding dysfuncon (37, 9.7%) 10-SSF (with MUS-4) 16-Perigee +SS (with MUS-7) 3-Avaulta A+SS (with MUS-1) 3-Proli T (with MUS-3) 5-Elevate A (with MUS-0)

Post-OPVoiding dysfuncon (11, 1.1%) 3-SSF (with MUS-1) 6- Perigee +SS (with MUS-2) 1-Avaulta A+SS (with MUS-1) 1- Proli T (with MUS-1) 0- Elevate A (with MUS-0)

Post-OPNormal voiding funcon (343, 90.3%) 92-SSF (with MUS- 8) 155-Perigee +SS (with MUS- 8) 38-Avaulta A+SS (with MUS- 7) 36-Proli T (with MUS- 2) 22-Elevate A (with MUS- 1)

48, 3.5%

Post-OPNormal voiding funcon (980, 99.9%) 249-SSF (with MUS- 79) 455-Perigee +SS (with MUS- 96) 122-Avaulta A+SS (with MUS-19) 80-Proli T (with MUS- 13) 74-Elevate A (with MUS- 4)

1323, 96.5%

Pre-OP no USI, n=306

Pre-OP USI, n=74

Pre-OP no USI, n=664

Pre-OP USI, n=327

(80.5% 306/380)

(19.5% 74/380)

(67.0% 664/991)

(33.0% 327/991)

De novo USI: 45 (14.7%)

MUS, n=41

No USI 261 (85.3%)

No MUS, n=33

Persistent USI 7 (17.1%) No USI 34 (82.9%)

Persistent USI 20 (60.6%) No USI 13 (39.3%)

MUS, n=216

De novo USI: 63 (9.5%)

No MUS, n=111

No USI 601 (90.5%) Persistent USI 22 (10.2%)

Persistent USI 67 (60.3%)

No USI 194 (89.8%)

108, 11.1% (De novo USI)

29, 11.3% (Persistent USI aer MUS)

No USI 44 (39.6%)

87, 60.4% (Persistent USI)

POPQ, pelvic organ prolapse quanficaon system; SSF, sacrospinous ligament fixaon; MUS, mid-urethra sling

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System, the Elevate Anterior/Apical system (Elevate A), and the Avaulta Anterior (Avaulta A) system. Details of the TVM procedures have been described previously [10–13]. SSF was performed by the right unilateral posterior approach, as described by Miyazaki [14]. Cystoscopy to evaluate the integrity of the lower urinary tract was performed in all patients who had a TVM inserted. Patients were encouraged to pass urine once the Foley catheter was removed and were discharged only if they could urinate comfortably with acceptable residual urine levels. Follow-up evaluations were scheduled at 1 week, 1 – 3 months, 6 months, and annually. Evaluations included a detailed history, quality of life questionnaires, vaginal examinations, 3-day bladder diary and ultrasonographic urethral cystography. All procedures were done by senior, experienced gynecologists. For the purposes of audit, postoperative UDS were performed at 6 months to 1 year postoperatively. The outcome of postoperative voiding dysfunction was documented based on these UDS. Although the surgeons were a heterogeneous group, homogeneous outcomes and follow-up were achieved because of the uniform institutional protocol. We defined voiding dysfunction as a postvoid residual volume (PVR) of >50 ml or 20 % of postvoid because it is the resultant effect of all types of voiding dysfunction. We measured PVR by sterile catheterization of the urinary bladder. Descriptive statistics were used for demographics and perioperative data. The voiding dysfunction rates among groups of patients categorized according to age, parity and body mass index (BMI) were compared using analysis of variance. Patients were classified into three age groups: 28 – 46 years (reproductive age), 47 – 65 years (nonreproductive age), and 66 years or older (mature). Patients were classified into three parity groups: 0 – 2 (low), 3 – 5 (normal), and 6 or more (high). Nulliparous women were included in the low parity group, since the number of nulliparous women was too small to be analyzed separately. Patients were classified into three BMI groups: 17 – 23 kg/m2 (normal), 23.1 – 29 kg/m2 (overweight), and 29.1 kg/m2 or greater (obese). When the assumption of the chi-squared test was violated (i.e., when more than one cell had an expected count of <1 or >20 % of the cells had an expected count of <5), Fisher’s exact test was used. A logistic regression model and odds ratios (OR), with 95 % confidence intervals (CI), was used to assess the independent prognostic values of the variables associated with postoperative stress urinary incontinence (SUI). All statistical tests were two sided. A p value <0.05 was considered statistically significant.

Results The medical records of 1,425 women with severe POP stages III or IV who had undergone vaginal PRS with or without

MUS insertion during the study period were screened. Of these 1,425 women, 54 were excluded due to incomplete postoperative data, and 1,371 were finally included in the study. Women who were continent preoperatively underwent surgery as scheduled, without anti-incontinence procedures. Vaginal PRS with MUS insertion was performed in 257 (64 %) of 401 women who had associated USI preoperatively. Persistent USI occurred more frequently amongst women who did not undergo concomitant MUS insertion than in those who did (60.4 % vs. 11.3 %). The incidence of persistent USI was similar preoperatively in those with and without associated voiding dysfunction. The length of follow-up after PRS varied from 12 to 87 months with a median of 59.6 months. Preoperative voiding dysfunction was shown by UDS in 380 patients (27.7 %), and in 37 of these patients (9.7 %) UDS showed persistent voiding dysfunction postoperatively. The remaining 991 patients (72.3 %) had normal voiding function based on normal PVR preoperatively. Of these 991 patients, 11 (1.1 %) developed urodynamic de novo voiding dysfunction postoperatively. The remaining 980 patients (99.9 %) had normal voiding function on follow-up between 6 months and 1 year postoperatively. The overall incidence of voiding dysfunction in patients undergoing extensive vaginal PRS with or without MUS insertion was 3.5 % (48 patients), and 96.5 % (1,323 patients) had normal voiding function postoperatively (Fig. 1). Preoperative USI was observed in 401 patients (29.24 %) while the remaining 970 patients were continent. USI was associated with voiding dysfunction in only 74 patients, and the remaining 327 patients who had USI preoperatively did not have associated voiding dysfunction. Of these 970 continent patients, 108 (11.1 %) developed de novo USI. Of patients who did not undergo concomitant MUS insertion, 60.4 % showed persistent USI and of those who did undergo concomitant MUS insertion, 11.3 % showed persistent USI. Demographic data are shown in Table 1. Of patients who had postoperative voiding dysfunction, 50 % were in the age group 47 – 65 years (not statistically significant). Similarly, parity, menopausal status, obesity, uterine preservation and type of vaginal mesh used were not significantly associated with the development of voiding dysfunction. Significant differences were observed in women with DM and MUS insertion (p <0.001). Urodynamic parameter evaluations showed significant differences in Dmax (<10 cm H2O) and PVR (≥200 ml) among women who developed postoperative voiding dysfunction (both p < 0.001). Maximal urethral closure pressure, functional urethral length and maximal flow rate were not significantly associated with the development of postoperative voiding dysfunction. Univariate logistic regression (Table 2) was performed to identify independent predictors of postoperative voiding dysfunction. DM,

Int Urogynecol J Table 1 Clinical characteristics of 1,371 women with severe pelvic organ prolapse undergoing transvaginal pelvic reconstructive surgery

Variable

No. of patients

Postoperative voiding function

p valuea

Abnormal (%), n = 48

Normal (%), n = 1,323

162 706 503

6 24 18

156 682 485

0.975

Parity 0–2 3–5 ≥6

270 941 160

10 32 6

260 909 154

0.856

Body mass index (kg/m2) 17 – 23 23.1 – 29 ≥29.1

346 905 120

13 31 4

333 874 116

0.765

959 412

33 15

926 397

0.854

With Without Transvaginal mesh type No mesh (SS) Perigee + SS

91 1,280

3 45

88 1,235

0.913

354 632

13 22

341 610

0.483

Avaulta A + SS Prolift T Elevate A MUS insertion With Without

164 120 101

4 4 5

160 116 96

257 1,114

20 28

237 1,086

<0.001

Diabetes mellitus With Without

162 1,209

14 34

148 1,175

<0.001

32 16

889 434

0.939

30 18

902 421

0.407

19 29

461 862

0.499

21 20 7

24 964 335

<0.001 <0.001 0.897

9 39

1,082 241

<0.001

Age (years) 28 – 46 47 – 65 ≥66

Menopause With Without Uterus preservation

Maximal urethral closure pressure (cm H2O) ≥60 921 <60 450 Functional urethral length (cm) ≥2 932 <2 439 Maximal flow rate (ml/s) <15 480 ≥15 891 Detrusor pressure at maximal flow (cm H2O) <10 45 10 – 20 984 ≥20 342 Postvoid residual volume (ml) <200 1,091 ≥200 280 SS sacrospinous suspension

p values in bold are statistically significant (<0.05) a

Fisher’s exact test

Int Urogynecol J Table 2 Univariate logistic regression analysis of factors associated with postoperative voiding dysfunction in patients with severe pelvic organ prolapse Covariate

Odds ratio

95 % CI

28 – 46

1

Reference

47 – 65 ≥66

1.09 1.04

0.45 – 2.62 0.42 – 2.56

p value

Ages (years)

Parity 0–2

0.848 0.941

1

Reference

3–5

1.09

0.54 – 2.19

0.818

≥6

0.91

0.37 – 2.67

0.781

17 – 23

1

Reference

23.1 – 29 ≥29.1

0.76 1.21

0.52 – 1.97 0.60 – 2.24

0.562 0.670

0.95 0.94

0.52 – 1.72 0.30 – 2.96

0.854 0.913

1 1.06

Reference 0.54 – 2.07

0.876

Avaulta A + SS Prolift T Elevate A

1.51 1.10 0.74

0.50 – 3.31 0.40 – 4.12 0.27 – 2.04

0.464 0.863 0.561

MUS insertion Diabetes mellitus

3.12 3.07

1.79 – 5.46 1.69 – 5.60

<0.001 <0.001

2

Body mass index (kg/m )

Menopause Uterus preservation Transvaginal mesh type No mesh (SS) Perigee + SS

Maximal urethral closure pressure (cm H2O) ≥60 1 Reference <60 0.98 0.54 – 1.176 Functional urethral length (cm) ≥2 1

0.939

Reference

<2 0.79 0.44 – 1.39 Maximal flow rate (ml/s) <15 1 Reference ≥15 1.22 0.69 – 2.15 Detrusor pressure at maximal flow (cm H2O) <10 (n = 45) 1.84 1.39 – 2.91 10 – 20 (n = 984) 1. Reference ≥20 (n = 342) 0.99 0.42 – 2.33 PVR (ml) <200 1 Reference ≥200 2.15 1.10 – 3.21

0.407 0.499

<0.001 0.897

<0.001

SS sacrospinous suspension Values in bold are statistically significant (p < 0.05)

concomitant MUS insertion, Dmax <10 cm H2O and PVR ≥200 ml were significant risk factors for the development of postoperative voiding dysfunction (all p < 0.001; OR 3.07, 3.12, 1.84 and 2.15, respectively; 95 % CI 1.69 – 5.60, 1.79 – 5.46, 1.39 – 2.91 and 1.10 – 3.21, respectively).

Discussion Predicting the development of postoperative voiding dysfunction has become essential for patients planning to undergo vaginal PRS with or without MUS insertion. The development of de novo voiding dysfunction after correction of POP in women who were continent preoperatively is distressing for the attending physician as well as for the patient. In this study, 1.1 % of patients developed de novo voiding dysfunction postoperatively. Statistically significant contributing factors were DM status, concomitant MUS insertion, Dmax <10 cm H2O and PVR ≥200 ml. There is a wide range of reported incidence of SUI following surgical repair of POP in continent women. This can be attributed to the various methods used in the studies investigating this issue. Al-Mandeel et al. found a high incidence of postoperative SUI (up to 42 %, by symptoms only) among 100 previously continent women 1 – 3 years after reconstructive vaginal surgery for POP [15]. Kasturi et al. found an incidence of de novo SUI of 25 % following TVM surgery [16]. In our previous study, the Elevate A system was associated with a high incidence of de novo SUI (26.3 %) in contrast to the Perigee system (8.3 %) [17]. The overall de novo USI rate in this study was 11.1 % regardless of whether the patient had voiding dysfunction preoperatively. Urodynamic parameters showing a significant correlation with the incidence of postoperative voiding dysfunction in this study were Dmax and PVR. There is no consensus as to the normal values for Dmax and PVR. However, Dmax values <10 cm H2O are considered to be hypotonic and correlate with a high incidence of DUA. DUA is associated with voiding and postmicturition urinary symptoms, and may be a predisposing factor for urinary infection and acute urinary retention. The etiology of DUA is multifactorial, and includes age, BOO, neurological disease and autonomic denervation. The true prevalence of this condition remains unknown, as most data come from referral populations. As such it is often difficult to distinguish DUA and BOO without invasive pressure flow studies [18]. In this study, patients with Dmax <10 cm H2O were 1.84 times (95 % CI 1.39 – 2.91, p < 0.001) at greater risk of developing postoperative voiding dysfunction than patients with Dmax ≥10 cm H2O. Current treatments for DUA have poor efficacy and tolerability, and often fail to improve quality of life. Muscarinic receptor agonists, in particular, have limited efficacy and frequent adverse effects. Bladder emptying might be achieved through Valsalva straining, and intermittent or indwelling catheterization, although sacral nerve stimulation can reduce dependency on catheterization [19]. We treated DUA with alpha adrenergic blockers, intermittent catheterization and nerve stimulation. Measurement of PVR is a noninvasive screening test for evaluating voiding dysfunction. Threshold values delineating

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what constitutes an abnormal PVR are poorly defined. However, most urologists agree that the lower threshold for defining abnormal residual urine volume is in the range 50 – 100 ml. High PVR can be caused by BOO, bladder hypocontractility or acontractility or, in rare cases, a large bladder diverticulum [20]. PVR higher than 30 ml is significantly associated with increasing age, higher grades of POP, and an increased prevalence of recurrent urinary tract infection [21]. In this study we defined a PVR of >50 ml or 20 % of postvoid as abnormal. We measured PVR by sterile catheterization rather than bladder scan because sterile catheterization was part of our UDS. Women with BOO most commonly present with urinary frequency, urgency, and urge incontinence, as well as recurrent urinary tract infection. Irritative lower urinary tract symptoms can result from detrusor instability associated with the BOO. Classic obstructive symptoms are uncommon. The diagnosis of BOO in women relies on clinical suspicion based on history, physical examination, and radiographic and endoscopic findings. The strict diagnosis of obstruction on the basis of pressure/flow cutoff values is not possible at the present time. Chassagne et al. showed that a cutoff value for peak flow rate (Qmax) of 15 ml/s or less and a detrusor pressure at maximal flow (PdetQmax) of 20 cm H2O or more in conjunction with a high clinical suspicion of obstruction provide reasonable predictive value [22]. Blaivas and Groutz also created a normogram to diagnose women with BOO, with a Qmax of less than 12 ml/s and PdetQmax of more than 30 cm H2O [23]. Women with BOO are more likely to develop urinary retention following MUS insertion. In the majority of patients postoperative voiding dysfunction can be managed conservatively, as we did in our study. The treatment options included were clean intermittent selfcatheterization, α-adrenergic blocker, β-cholinergic agonist, MUS take-down and urethral dilatation. Sling release was done in two patients, and one patient required mesh release to relieve BOO resulting from placement of a sling and TVM at too high a tension. Three of our patients developed BOO as a result of recurrent POP; they underwent reoperation. Recent studies have revealed that DM predisposes patients to a wide range of lower urinary tract dysfunction, from classic diabetic cystopathy of incomplete emptying to urgency incontinence [24]. Over 50 % of men and women with DM have bladder dysfunction [25, 26]. Bladder dysfunction is currently understood as a progressive condition encompassing a broad spectrum of lower urinary tract symptoms including urinary urgency, frequency, nocturia, and incontinence. Previously, the dysfunction was classically described as diminished bladder sensation, poor contractility, and increased PVR, termed bladder cystopathy [27]. However, bladder cystopathy most likely represents end-stage bladder failure with symptoms of infrequent voiding, difficulty initiating voiding and postvoid fullness. Bladder cystopathy is relatively uncommon. In a

number of clinical studies in men and women with DM, bladder instability or hypersensitivity was the most frequent finding, being found in 39 – 61 % of subjects [27]. We found that women with DM were at 3.07 times (95 % CI 1.69 – 5.60, p < 0.001) greater risk of postoperative voiding dysfunction than women without DM. As shown in our previous study, the tension-free vaginal tape procedure performed with concurrent vaginal pelvic relaxation surgery is a safe and effective treatment for USI and POP. Concomitant procedures also appear to relieve BOO caused by severe POP [28]. Performing prophylactic antiincontinence procedures at the time of POP repair is controversial in a patient who was continent preoperatively. It is of ethical concern when the prophylactic procedure may induce greater morbidity than the potential problem it was meant to correct. Prophylactic anti-incontinence procedures have been shown to reduce the incidence of postoperative SUI in patients with occult incontinence [29]. However, as anti-incontinence procedures come with a cost and potential risks, managing occult incontinence remains controversial. The strengths of our study were the large number of women who underwent standardized preoperative evaluation using standard ICS recommendations and standard high-quality operative procedures, and continuous long-term follow-up. The limitations were its retrospective nature, the number of different procedures performed, and the exclusion of patients who failed to undergo UDS, which could have significantly altered the overall OR.

Conclusions In our study population, DM, concomitant MUS insertion, Dmax <10 cm H2O and PVR ≥200 ml were found to be independent factors predicting the development of postoperative voiding dysfunction in patients with advanced POP after vaginal PRS. Therefore, counseling these women is worthwhile before considering vaginal PRS. Compliance with ethical standards Conflicts of interest None.

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