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Outcomes of a Staged Midurethral Sling Strategy for Stress Incontinence and Pelvic Organ Prolapse

Giugale, Lauren E. MD; Carter-Brooks, Charelle M. MD, MSc; Ross, James H. MD; Shepherd, Jonathan P. MD, MSc; Zyczynski, Halina M. MD

doi: 10.1097/AOG.0000000000003448
Contents: Urogynecology: Original Research

OBJECTIVE: To evaluate the proportion of women who experienced resolution of stress urinary incontinence (SUI) symptoms after surgery for pelvic organ prolapse (POP) without a concomitant incontinence procedure.

METHODS: We conducted a retrospective observational study of women with preoperative subjective and objective SUI who underwent minimally invasive sacrocolpopexy or uterosacral ligament suspension from 2009 to 2015. We excluded cases with incontinence procedures. The primary outcome was the proportion of women with subjective resolution of SUI postoperatively, defined as the absence of patient reported SUI symptoms during follow-up. Secondary outcomes included the proportion of women who underwent a subsequent staged midurethral sling (MUS) procedure and factors associated with resolution of SUI and staged MUS placement.

RESULTS: Of 93 women, most were white (n=90, 98%) with stage III POP (n=55, 59%). Mean age was 59.5±8.9 years and body mass index 28.7±4.7. Seventy-three patients (78%) underwent minimally invasive sacrocolpopexy, and 20 (22%) underwent uterosacral ligament suspension. Median follow-up was 8.3 months (interquartile range 3.4–26.7). Postoperatively, 28 (30%) patients reported resolution of SUI, and 65 (70%) reported persistent SUI. Of the 93 patients, 47 (51%) were treated for persistent SUI and 34 (37%) underwent a staged MUS procedure. Among the staged MUS procedures, 27 (79%) were placed within 12 months. Median time to staged MUS procedure was 5.5 months (interquartile range 4.2–9.9). After controlling for degree of preoperative SUI bother, obese women were less likely to experience resolution of SUI after prolapse repair (odds ratio 0.28, 95% CI 0.08–0.95). We did not identify any factors that were significantly associated with undergoing a staged MUS procedure on univariate analyses (P>.05).

CONCLUSION: Preoperative SUI resolved in nearly a third of women after prolapse surgery without a concomitant incontinence procedure. In a population typically offered a concomitant MUS procedure at the time of prolapse repair, a staged approach may result in nearly two-thirds fewer patients undergoing MUS procedures. This information may be helpful during preoperative shared decision making.

Stress urinary incontinence resolved after 30% of prolapse repairs, and, compared with concomitant midurethral slings, a staged strategy may result in substantially fewer sling procedures.

UPMC Magee-Womens Hospital, and the Department of Obstetrics, Gynecology and Reproductive Sciences, Division of Urogynecology and Pelvic Reconstructive Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania; and the Department of Obstetrics and Gynecology, Trinity Health Of New England, Hartford, Connecticut.

Corresponding author: Lauren E. Giugale, MD, Department of Obstetrics, Gynecology and Reproductive Sciences, UPMC Magee-Womens Hospital, Pittsburgh, PA; email:

Statistical analyses for this project was supported, in part, by the National Institutes of Health through grant number UL1-TR-001857.

Financial Disclosure Halina Zyczynski receives grant funding from the National Institutes of Health through the Pelvic Floor Disorders Network. The other authors did not report any potential conflicts of interest.

Presented as a poster at the International Continence Society Annual Meeting, August 28–31, 2018, Philadelphia, Pennsylvania; and as an oral presentation at the American Urogynecologic Society Pelvic Floor Disorders Week, October 9–13, 2018, Chicago, Illinois.

The authors thank Nalyn Siripong and Li Wang of the University of Pittsburgh Clinical and Translational Science Institute for their statistical contribution to this project.

Each author has confirmed compliance with the journal's requirements for authorship.

Peer reviews and author correspondence are available at

© 2019 by the American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.