A Model for Predicting the Risk of De Novo Stress Urinary Incontinence in Women Undergoing Pelvic Organ Prolapse Surgery

Jelovsek, J. Eric MD, MMEd; Chagin, Kevin MS; Brubaker, Linda MD, MS; Rogers, Rebecca G. MD; Richter, Holly E. PhD, MD; Arya, Lily MD; Barber, Matthew D. MD, MHS; Shepherd, Jonathan P. MD, MSc; Nolen, Tracy L. DrPh; Norton, Peggy MD; Sung, Vivian MD; Menefee, Shawn MD; Siddiqui, Nazema MD, MHS; Meikle, Susan F. MD, MSPH; Kattan, Michael W. PhD; on behalf of the Pelvic Floor Disorders Network

doi: 10.1097/AOG.0000000000000094
Contents: Original Research

OBJECTIVE: To construct and validate a prediction model for estimating the risk of de novo stress urinary incontinence (SUI) after vaginal pelvic organ prolapse (POP) surgery and compare it with predictions using preoperative urinary stress testing and expert surgeons' predictions.

MATERIALS AND METHODS: Using the data set (n=457) from the Outcomes Following Vaginal Prolapse Repair and Midurethral Sling trial, a model using 12 clinical preoperative predictors of de novo SUI was constructed. De novo SUI was determined by Pelvic Floor Distress Inventory responses through 12 months postoperatively. After fitting the multivariable logistic regression model using the best predictors, the model was internally validated with 1,000 bootstrap samples to obtain bias-corrected accuracy using a concordance index. The model's predictions were also externally validated by comparing findings against actual outcomes using Colpopexy and Urinary Reduction Efforts trial patients (n=316). The final model's performance was compared with experts using a test data set of 32 randomly chosen Outcomes Following Vaginal Prolapse Repair and Midurethral Sling trial patients through comparison of the model's area under the curve against: 1) 22 experts' predictions; and 2) preoperative prolapse reduction stress testing.

RESULTS: A model containing seven predictors discriminated between de novo SUI status (concordance index 0.73, 95% confidence interval [CI] 0.65–0.80) in Outcomes Following Vaginal Prolapse Repair and Midurethral Sling participants and outperformed expert clinicians (area under the curve 0.72 compared with 0.62, P<.001) and preoperative urinary stress testing (area under the curve 0.72 compared with 0.54, P<.001). The concordance index for Colpopexy and Urinary Reduction Efforts trial participants was 0.62 (95% CI 0.56–0.69).

CONCLUSION: This individualized prediction model for de novo SUI after vaginal POP surgery is valid and outperforms preoperative stress testing, prediction by experts, and preoperative reduction cough stress testing. An online calculator is provided for clinical use.

LEVEL OF EVIDENCE: III

A valid, individualized prediction model for de novo stress urinary incontinence after vaginal pelvic organ prolapse surgery outperforms preoperative stress testing and expert prediction.

Obstetrics, Gynecology & Women's Health Institute and Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio; the Department of Obstetrics & Gynecology and Urology, Stritch School of Medicine, Loyola University Chicago, Chicago, Illinois; the Departments of Obstetrics and Gynecology and Surgery, University of New Mexico Health Sciences Center, Albuquerque, New Mexico; the Departments of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama, University of Pennsylvania, Philadelphia, Pennsylvania, University of Utah, Salt Lake City, Utah, Women and Infants Hospital, Providence, Rhode Island, Kaiser Permanente, San Diego, California, and Duke University Medical Center, Durham, North Carolina; the Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; RTI International, Research Triangle Park, North Carolina; and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland.

Corresponding author: J. Eric Jelovsek MD, MMEd, Cleveland Clinic, 9500 Euclid Avenue A81, Cleveland, OH 44195; e-mail: jelovsj@ccf.org.

Supported by grants from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (2U01HD41249, 2U10 HD41250, 2U10 HD41261, 2U10 HD41267, 1U10 HD54136, 1U10 HD54214, 1U10 HD54215, 1U10 HD54241, U10 HD069013, U10 HD069025, U10 HD069010, U10 HD069010, and U01 HD069031) and the National Institutes of Health Office of Research on Women's Health.

Financial Disclosure Dr. Rogers has received royalties from UpToDate for writing a pelvic organ prolapse section and from the American College of Obstetricians and Gynecologists for a DVD video (Repair of a Fourth Degree Obstetrical Laceration [2002]). She has also been the Data Safety Monitoring Chair for the TRANSFORM trial, sponsored by American Medical Systems. Dr. Richter has received research grants from Astellas, Pelvalon, and the University of California San Francisco/Pfizer. She has served as a consultant for Pelvalon and Astellas. The other authors did not report any potential conflicts of interest.

© 2014 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.