Charles W. Nager

Pelvic organ prolapse, a condition in which the pelvic organs drop into the vagina causing pressure and discomfort, is a highly prevalent condition that confers

(1) Background: There is wide variation in the reported prevalence rates for pelvic organ prolapse (POP). There is also wide variation in the rate at which surgical interventions for pelvic organ prolapse are performed, as well as the type of interventions undertaken. As part of the International Consultation on Incontinence (ICI), our committee was tasked to produce evidence-based pathways for the surgical management of POP, any associated stress urinary incontinence (SUI), and bowel dysfunction. (2) Methods: To enable us to generate such evidence, we undertook a thorough search for the POP surgery-related, English-language scientific literature published up to April 2021. (3) Results: The committee evaluated the literature and made recommendations based on the Oxford grading system. (4) Conclusions: This review serves to provide a summary of the 2021 ICI surgical management of an evidence-based prolapse pathway and outline the evidence used to inform this guidance.

To the Editor My coauthors and I report some database updates and resulting changes in our Original Investigation titled “Effect of Vaginal Mesh Hysteropexy vs Vaginal Hysterectomy With Uterosacral Ligament Suspension on Treatment Failure in Women With Uterovaginal Prolapse: A Randomized Clinical Trial,” published in the September 17, 2019, issue of JAMA.¹ During the final database cleaning for the final 5-year study database lock, a biannual study-wide audit review of the Pelvic Organ Prolapse Quantification (POPQ) examination data identified some updates that influenced the value of the primary outcome (treatment failure). There were 3 failure events for which a POPQ data correction either increased the time to initial failure (1 patient randomized to undergo hysteropexy) or changed the value of the event from a failure to a nonfailure (1 patient randomized to undergo hysteropexy and 1 randomized to undergo hysterectomy). In addition, there were a few minor database updates that did not affect the primary outcome but altered some of the at-visit failure and failure-type rates. The adjusted hazard ratio of failure for hysteropexy vs hysterectomy changed from 0.62 to 0.61.

(Abstracted from JAMA 2019;322:1054–1065) Two surgical options for patients with uterovaginal prolapse are vaginal hysterectomy with suture apical suspension or transvaginal mesh hysteropexy, a uterine preservation procedure. An analysis of a US database from 2007 to 2011 estimated that 13% of women underwent pelvic organ prolapse surgery by the age of 80 years.

Surgery for uterovaginal prolapse is common. In an analysis of a US database from 2007 to 2011, an estimated 13% of women underwent pelvic organ prolapse surgery by the age of 80 years.¹ In a 2016 British Society of Urogynecology survey with a 42% response rate, 75% of 212 urogynecology surgeons considered vaginal hysterectomy the procedure of choice for women with uterovaginal prolapse.² Uterine-sparing suspension techniques, known as hysteropexy, are increasing in usage, but in a US inpatient hospital database from 2002 to 2012, hysteropexy accounted for 5% of uterovaginal prolapse procedures and hysterectomies were performed 8 times more often.³ In a survey of 244 US women with an 89% response rate, 36% preferred uterine preservation, 20% preferred hysterectomy, and 44% were ambivalent assuming comparable outcomes at the time of uterovaginal prolapse repair.⁴ The broad range of age, goals, and expectations of women who seek prolapse surgical correction and the elective nature of treatment are ideally weighed in a shared decision-making process grounded in sound scientific evidence.

Urinary incontinence is a prevalent condition worldwide and causes a tremendous impact on a woman's quality of life. While conservative and non‐surgical therapies are options for treatment, surgery for stress urinary incontinence (SUI) is common. Options include colposuspension, slings (pubovaginal and midurethral), and periurethral bulking. While evidence supports each of these options in the treatment of SUI, each is associated with various rates of success and unique adverse event profiles. Urgency urinary incontinence (UUI) is initially treated with behavioral modification and pharmacologic means, with surgery reserved for those with refractory symptoms or significant complications from medication use. At present, intravesical onabotulinumtoxinA injections, percutaneous tibial nerve stimulation, and sacral neurostimulation are all viable options for refractory UUI/overactive bladder. As with surgical interventions for SUI, each of these is, likewise, associated with unique outcomes and adverse event profiles. Herein, we summarize the findings and conclusions from the 6th International Consultation on Incontinence (ICI) regarding surgical treatment of urinary incontinence in women.

Aims: Traditional technology to characterize urethral pressure changes during dynamic conditions is limited by slow response times or artifact‐inducing withdrawal maneuvers. The 8F high‐resolution manometry (HRM) catheter (ManoScan™ ESO, Covidien) has advantages of fast response times and the ability to measure urethral pressures along the urethral length without withdrawal. Our objective was to determine static and dynamic maximum urethral closure pressures (MUCPs) and resting functional urethral length (FUL) in women using HRM before and after transurethral bulking and compare results to other women who underwent midurethral sling (MUS).Methods: We recorded rest, cough, and strain MUCPs and FUL in 24 women before and after transurethral bulking with polydimethylsiloxane (Macroplastique®) using the HRM catheter and compared these changes to HRM values from 26 women who had the same measures before and after MUS.Results: At rest, MUCPs increased minimally after both urethral bulking and MUS (3 vs 0.4 cm H₂O respectively, P = 0.4). Under dynamic conditions there were statistically insignificant small increases in MUCP and these increases were markedly less than after MUS (cough: 1.5 vs 63.8 cm H₂O, P < 0.001 and strain: 11.5 vs 57.7 cm H₂O, P < 0.001). FUL increased by 0.5 cm after transurethral bulking (P = 0.003), and decreased by 0.25 cm after MUS placement (P = 0.012).Conclusions: The mechanism of continence after urethral bulking differs from MUS. While MUS increases dynamic MUCP, bulking may rely on increasing the length of the continence zone.