From Our 2012 Archives
'Sling' Implant May Cut Risk of Incontinence After Prolapse Surgery
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WEDNESDAY, June 20 (HealthDay News) -- Women who have surgery to treat pelvic organ prolapse can reduce their risk of incontinence afterward by having a second procedure done simultaneously where surgeons implant a "sling" to support the urethra, new research finds.
However, experts caution that women who got the sling were at a higher risk for complications such as difficulty emptying the bladder, urinary tract infection, bladder perforation and bleeding.
Though the researchers characterize the complications as relatively minor, other experts say the risks should be taken seriously. And some of the women might not have needed the sling procedure in the first place, since only 25 percent of women getting the prolapse surgery actually experience incontinence, according to background information in the study.
Pelvic organ prolapse occurs when muscles and tissues in the pelvic cavity weaken. The tissues hold organs such as the bladder, uterus and colon in place. When weakened, the organs droop into the pelvic cavity, pressing into the vagina. In severe cases, vaginal tissue protrudes out of the body.
Prolapse surgery relieves the pressure on the lower pelvic cavity and puts the organs back in place, explained study author Dr. John Wei, a professor of urology at University of Michigan Ann Arbor.
But the surgery can have unintended consequences, including incontinence. It's believed that the fallen organs block the urethra (the duct that carries urine), Wei explained. When the organs are lifted back up by surgery, the blockage clears and, as a result, women may experience stress incontinence, or leaking urine during activities ranging from coughing to exercise.
In the study, researchers split 337 women who underwent pelvic organ prolapse surgery and who did not have any incontinence prior to surgery into two groups. One group got the sling procedure at the same time; the other received a "sham," or fake sling surgery. The women could not tell if they had the real or the fake surgery.
At three months, nearly half (49 percent) of women in the sham group reported incontinence, compared with 24 percent of those who got the sling surgery.
At 12 months, 43 percent in the sham group and 27 percent in the sling group had urinary incontinence.
"Because we saw superiority of putting in the sling at the time of the surgery, it would make sense to offer women the option of putting in a [preventive] sling at the time of the prolapse repair," Wei said.
The study is published in the June 21 issue of the New England Journal of Medicine.
Not all experts were so enthusiastic.
The study, a randomized, controlled clinical trial, was well done and provides valuable statistics to share with women trying to make a decision about whether to get one or both procedures, said Dr. Gunhilde Buchsbaum, a urogynecologist and professor at University of Rochester Medical Center, in New York. She offers women the option of doing the prolapse repair and the preventive incontinence surgery at the same time, or doing the prolapse repair and waiting to see if the patient is bothered by incontinence afterward.
"I think that the finding of these studies should be mainly used in counseling women and obtaining truly informed consent on whether or not one should place a sling in women at the time of prolapse surgery in women who otherwise have not complained of incontinence," Buchsbaum said.
But the risk of complications reported in the study should give women pause.
Nearly 7 percent of women had a bladder perforation and 3 percent experienced major bleeding in those who got the sling, while none in the prolapse-repair only group did. About 31 percent in the sling group developed a urinary tract infection, compared with 18 percent in the prolapse-repair only group. Another complication more common among the sling group was incomplete bladder emptying.
"We have to be rather careful about submitting our patients to real risks of real surgeries for problems they may or may not have," Buchsbaum said.
In her practice, about eight or nine of 10 women undergoing the prolapse surgery opt to wait and see before getting the sling surgery; one or two say, "'Let's get it over with,'" Buchsbaum said.
After these findings, Buchsbaum said she would be no more apt to encourage women to get the sling surgery at the same time. "This is a study that should help us counsel our patient, not to change practice," she said. "We should not underplay the risk of surgery. The risks are low, but risks are real and for the person who has the complication, it's quite real."
About one in five women will have surgery to repair pelvic organ prolapse in her lifetime, according to the study authors. Some 200,000 women undergo the surgery each year.
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SOURCE: John Wei, M.D., professor, urology, University of Michigan, Ann Arbor, Mich.; Gunhilde Buchsbaum, M.D., urogynecologist and professor, University of Rochester Medical Center, Rochester, N.Y.; June 20, 2012, New England Journal of Medicine