PREDICTORS FOR DETRUSOR OVERACTIVITYFOLLOWING EXTENSIVE VAGINAL PELVIC RECONSTRUCTIVE SURGERY
T. LO1, K. CHUAN CHI2, R. K. IBRAHIM 3, W. HSIEH 4;
1Chang Gung Mem. Hosp., Keelung, Taiwan, 2ChangKung Mem. Hosp., Keelung, Taiwan, 3Albashir Hosp., Amman,Jordan, 4Chang Gung Mem. Hosp. Linkou Med. Ctr., Taoyuan,Taiwan.
Introduction: Detrusoroveractivity (DO) following pelvic organ prolapse (POP) surgery withand without mid-urethra sling (MUS) is a long-standing distressingconcern for surgeons and patients alike. The mechanisms by whichpostoperative DO can develop are not fully understood.
Objective:The objective of this study is to identify the predictors for DO inwomen following extensive vaginal pelvic reconstructive surgery (PRS)with and without mid- MUS for advanced POP.
Methods: Womenwho had Pelvic Organ Prolapse Quantification (POP-Q) system stagingstage III or greater between January 2006 to December 2015 wereincluded. Women with incomplete post-operative data wereexcluded.Preoperative evaluation comprising of detailed medicalhistory, physical examination, cough stress test, 72 hr bladderdiary, urinary analysis, and cultures were done. We included womenwith DM after optimizing diabetic control and those with stroke andParkinsonian disease. Urodynamic evaluations were performed for allwomen both pre and postoperatively using the appropriately sizedpessary for prolapse reduction. The diagnosis of Detrusoroveractivity (DO) was made on the basis of demonstrable involuntarydetrusor contractions during the filling phase that may bespontaneous or provoked. The choice of transvaginal mesh procedure(TVM) depended upon the type of TVM available at the institutionswhere surgery was being performed, with the women’s consent.Surgical procedures carried out were vaginal hysterectomy, anteriorand posterior colporrhaphy with or without TVM and sacrospinousfixation (SSF) with or without MUS. Follow-up evaluations werescheduled at one week, one month, three months, six months, andannually. Evaluations comprised detailed history, quality of life(QoL) questionnaires, vaginal examinations, 72hr bladder diary andultra-sonographic urethral cystography. The follow-up period afterpelvic reconstructive procedure for POP ranged from 12 to 87 months(median 59.6 months). Postoperative urodynamics were performed at sixmonths to one year postoperatively. The outcome of postoperative DOwas documented based on these urodynamics.
Results: 1,503women with severe POP stages III and IV who had undergone vaginal PRSwith or without MUS during this study period were reviewed: 56 womenwere excluded due to the incomplete post-operative data; 1447 womenwere finally included in this study. Women who had TVM insertion were1083 of 1447 (74.84%) and concomitant MUS were 353 (24.39%). Agedistributions between patient groups showed that postoperative DO wassignificantly more in the age group ≧66yryears. Even presence of neurological disorders (CVA, Parkinsoniandisease) and pre-op urodynamic parameters like MUCP ≧60 cmH2O, MFR <15 ml/s, Dmax ≧20 cmH2O and PVR ≧ 200 mlwere significantly associated with post-operative DO either de novoor persistent. However, parity, menopausal status, obesity, uterinepreservation, presence of diabetes mellitus and type of vaginal meshwith and without MUS used did not have significant impact on thedevelopment of DO. Women aged ≧66yr were 2.71 times (95 % CI 1.14-6.43, p = 0.019), women withstroke were 18.72 times (95 % CI 7.40-47.37, p < 0.001),Parkinsonian disease were 15.56 times (95 % CI 3.10-78.24, p =0.004), MUCP ≧ 60 cmH2Owere 1.87 times (95% CI 1.12-3.15, p = 0.016), MFR <15 ml/s were1.04 times (95% CI 1.01-1.35, p = 0.003), Dmax ≧20cmH2O were 1.9 times (95% CI 1.21-2.98, p 0.005) and PVR ≧200ml were 2.15 times (95 % CI 1.36-3.38, p < 0.001) at greaterrisk than women aged <66yr, women without stroke and Parkinsoniandisease, MUCP < 60 cmH2O, Dmax < 20 cmH20, MFR <15 ml/s andPVR < 200ml for developing postoperative DO either de novo orpersistent after vaginal PRS with and without MUSprocedure.
Conclusions: Age ≧66 yr, neurological factors like CVA and Parkinsonian disease,pre-operative BOO (MUCP ≧60 cmH2O, MFR < 15 ml/s, Dmax ≥ 20 cmH2O) and PVR ≥ 200ml areindependent risk factors for developing postoperative DO followingvaginal PRS with and without MUS for advanced POP.