Combined pelvic reconstructive surgery and transobturator tape (monarc) in women with advanced prolapse and urodynamic stress incontinence: a case control series

STUDY OBJECTIVE: The aim was to evaluate the safety and efficacy of transobturator tape (TOT) using Monarc with extensive vaginal reconstructive surgery in patients with urodynamic stress incontinence (USI) and advanced genital prolapse (stage > or = III pelvic organ prolapse quantification system staging).

DESIGN: Case control study. Canadian Task Force classification II-2.

SETTING: Medical school-affiliated hospital.

PATIENTS: A total of 57 women were surgically treated (28 stage III and 29 stage IV prolapse). Urodynamic stress incontinence was defined as demonstrable involuntary urine leakage with negative pressure transmission observed at stress urethral pressure profile. Severe USI was defined as leak on 1-hour pad test of more than 10 g.

INTERVENTIONS: The indicated extensive pelvic reconstructive procedures including anterior colporrhaphies, posterior colporrhaphies, vaginal total hysterectomies, sacrospinous ligament fixations, and LeFort procedures were completed before the TOT procedure. The TOT procedure using Monarc device was performed through a separate small vaginal incision sparing vaginal reconstructive procedures.

MEASUREMENTS AND MAIN RESULTS: The mean follow-up period was 18.2 months. Objective data were available for 51 patients. In all, 44 (86.3%) were completely dry at 1 year postoperatively. Among the 7 failures, 5 had severe preoperative USI. No major surgical complications, including bladder injury, occurred. The mean blood loss was 154 mL; the mean operating time for complete procedure and TOT alone was 86 minutes and 18 minutes, respectively; and the mean postoperative hospital stay was 4.1 days. Six (10.5%) patients maintained intermittent catheterization for more than 72 hours. All were classified as having severe bladder outlet obstruction preoperatively. Two patients developed recurrent prolapse onto stage II (pelvic organ prolapse quantification system staging). Urodynamic parameters related to voiding dysfunction showed an improvement after the surgery. De nova detrusor instability was observed in 2 patients.

CONCLUSION: Using separate incisions and sequencing the TOT as the last procedure, the combination surgery is safe and effective for USI and advanced pelvic prolapse. The bladder outlet obstructions caused by severe prolapse and preoperative severity of urinary incontinence seem to be a risk factor for prolonged postoperative catheterization and failure of antiincontinent procedure, respectively. Additional information on treatment of recurrent prolapse required a longer period of follow-up.