VOIDING FUNCTION, BLADDER PHYSIOLOGY AND PHARMACOLOGY, AND FEMALE UROLOGY
Int Urogynecol J 2012; 23: 589e595.
Abstract available at http://jurology.com/ Editorial Comment: The huge difference in the results reported in these 2 series defies logical explanation. With a 2-year followup of 142 of 180 patients, the Kennelly et al article reports a cough stress test and 1-hour pad weight objective efficacy rate of 84.5% and 80.1%, respectively, with a subjective efficacy rate (determined by the answer to the question, “Do you experience, and if so, how much are you bothered by urine leakage related to physical activity, coughing or sneezing?”) of 92.9%. The Hogewoning et al article, reporting on 57 of 77 patients, details a continence rate of 44%, with 28% of the patients reporting “very much better” on the PGI-I (Patient Global Impression of Improvement) scale, and 40% of the patients reporting “much better.” The latter article cites success rates of 69% to 91% having been reported at 1 year with this technique. The authors of the latter article list a number of possible modifying factors that could account for the relatively poor results but it seems obvious that the final chapter regarding short and long-term results with this procedure has yet to be written. Alan J. Wein, MD, PhD (hon)
Re: Long-Term Outcomes Following Abdominal Sacrocolpopexy for Pelvic Organ Prolapse I. Nygaard, L. Brubaker, H. M. Zyczynski, G. Cundiff, H. Richter, M. Gantz, P. Fine, S. Menefee, B. Ridgeway, A. Visco, L. K. Warren, M. Zhang and S. Meikle University of Utah School of Medicine, Salt Lake City, Utah JAMA 2013; 309: 2016e2024.
Abstract available at http://jurology.com/ Editorial Comment: This article requires a few readings to grasp its full significance. In essence, it is a long-term followup from the CARE (Colpopexy and Urinary Reduction Efforts) trial (ie abdominal sacrocolpopexy for pelvic organ prolapse, with or without Burch suspension).1 In the original study after 2 years the incidence of stress urinary incontinence was 32% after suspension vs 45.2% in those who did not undergo suspension. The outcome definition for this extension of the study included anatomical failure of prolapse or symptomatic failure. Composite failure meant either anatomical or symptomatic failure. The estimated probability of failure from parametric survival models 7 years after the prolapse surgery was 0.29 for those undergoing vs 0.24 for those not undergoing concomitant suspension. Corresponding probabilities for anatomical failure were 0.27 and 0.22 and, for composite failure, 0.48 and 0.34. Interestingly probability of failure for stress urinary incontinence was 0.62 for those who underwent Burch suspension and 0.77 for those who did not. The conclusions and discussion points by the authors are interesting. 1) Abdominal sacrocolpopexy is less effective than desired; 2) there is no consensus on defining cure after pelvic organ prolapse surgery, and 2-year cure rates for abdominal sacrocolpopexy have ranged in the literature from 19% to 97%; 3) despite progressive loss of anatomical support, the surgery generally provides relief of prolapse symptoms, and the low operation rate (95% have not sought re-treatment) may imply that women find the treatment adequate; 4) attempts at surgical prevention of stress incontinence at the time of abdominal pelvic organ prolapse surgery involve no clinically significant tradeoff; and 5) complications related to synthetic mesh continued to occur over time. Erosion (defined as exposed mesh material in the vagina or viscera) had a probability estimate at the time of the last known treatment failure (6.18 years) of 10.5%, emphasizing that consideration of the use of mesh requires “balancing the need for greater effectiveness with the probability of more complications.” Alan J. Wein, MD, PhD (hon) 1. Brubaker L, Nygaard I, Richter HE et al: Two-year outcomes after sacrocolpopexy with and without Burch to prevent stress urinary incontinence. Obstet Gynecol 2008; 112: 49.
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Int Urogynecol J 2012; 23: 589e595.
Abstract available at http://jurology.com/ Editorial Comment: The huge difference in the results reported in these 2 series defies logical explanation. With a 2-year followup of 142 of 180 patients, the Kennelly et al article reports a cough stress test and 1-hour pad weight objective efficacy rate of 84.5% and 80.1%, respectively, with a subjective efficacy rate (determined by the answer to the question, “Do you experience, and if so, how much are you bothered by urine leakage related to physical activity, coughing or sneezing?”) of 92.9%. The Hogewoning et al article, reporting on 57 of 77 patients, details a continence rate of 44%, with 28% of the patients reporting “very much better” on the PGI-I (Patient Global Impression of Improvement) scale, and 40% of the patients reporting “much better.” The latter article cites success rates of 69% to 91% having been reported at 1 year with this technique. The authors of the latter article list a number of possible modifying factors that could account for the relatively poor results but it seems obvious that the final chapter regarding short and long-term results with this procedure has yet to be written. Alan J. Wein, MD, PhD (hon)
Re: Long-Term Outcomes Following Abdominal Sacrocolpopexy for Pelvic Organ Prolapse I. Nygaard, L. Brubaker, H. M. Zyczynski, G. Cundiff, H. Richter, M. Gantz, P. Fine, S. Menefee, B. Ridgeway, A. Visco, L. K. Warren, M. Zhang and S. Meikle University of Utah School of Medicine, Salt Lake City, Utah JAMA 2013; 309: 2016e2024.
Abstract available at http://jurology.com/ Editorial Comment: This article requires a few readings to grasp its full significance. In essence, it is a long-term followup from the CARE (Colpopexy and Urinary Reduction Efforts) trial (ie abdominal sacrocolpopexy for pelvic organ prolapse, with or without Burch suspension).1 In the original study after 2 years the incidence of stress urinary incontinence was 32% after suspension vs 45.2% in those who did not undergo suspension. The outcome definition for this extension of the study included anatomical failure of prolapse or symptomatic failure. Composite failure meant either anatomical or symptomatic failure. The estimated probability of failure from parametric survival models 7 years after the prolapse surgery was 0.29 for those undergoing vs 0.24 for those not undergoing concomitant suspension. Corresponding probabilities for anatomical failure were 0.27 and 0.22 and, for composite failure, 0.48 and 0.34. Interestingly probability of failure for stress urinary incontinence was 0.62 for those who underwent Burch suspension and 0.77 for those who did not. The conclusions and discussion points by the authors are interesting. 1) Abdominal sacrocolpopexy is less effective than desired; 2) there is no consensus on defining cure after pelvic organ prolapse surgery, and 2-year cure rates for abdominal sacrocolpopexy have ranged in the literature from 19% to 97%; 3) despite progressive loss of anatomical support, the surgery generally provides relief of prolapse symptoms, and the low operation rate (95% have not sought re-treatment) may imply that women find the treatment adequate; 4) attempts at surgical prevention of stress incontinence at the time of abdominal pelvic organ prolapse surgery involve no clinically significant tradeoff; and 5) complications related to synthetic mesh continued to occur over time. Erosion (defined as exposed mesh material in the vagina or viscera) had a probability estimate at the time of the last known treatment failure (6.18 years) of 10.5%, emphasizing that consideration of the use of mesh requires “balancing the need for greater effectiveness with the probability of more complications.” Alan J. Wein, MD, PhD (hon) 1. Brubaker L, Nygaard I, Richter HE et al: Two-year outcomes after sacrocolpopexy with and without Burch to prevent stress urinary incontinence. Obstet Gynecol 2008; 112: 49.
419
