Impact of Vaginal Prolapse Repair and Mid-Urethral Sling on Urgency Incontinence

Objectives: Limited evidence exists on the effect of combined native tissue vaginal repair with mid-urethral sling on urgency urinary incontinence (UUI) symptoms. The aim of this study was to evaluate the impact of native tissue vaginal repair with mid-urethral sling on UUI symptoms and determine associated factors for bothersome baseline and persistent UUI at 12 months post-operatively.

Methods: This retrospective cohort study is a secondary analysis of the ALTIS trial, a multicenter, non-inferiority, randomized trial of women with ≥ Stage II pelvic organ prolapse and symptomatic or occult stress urinary incontinence (SUI) who underwent native tissue vaginal repair or colpocleisis and were randomized to single incision (SI Altis™) versus retropubic (RP) sling. UUI symptoms were assessed at baseline and 12 months post-operatively using PFDI question #16 to determine the rates of persistent, resolved, and de novo UUI. Women were grouped according to severity of UUI symptoms into no or mild UUI bother (0,1) and significant bother (2, 3, or 4). A logistic regression was performed to determine associations between preoperative UUI and age, BMI, race, Charlson comorbidity index (CCI), menopausal status, symptomatic SUI, stage of POP and dominant prolapse compartment. The same analyses were repeated at 12 months post-operatively including the type of sling performed (SI vs. RP).

Results: Between 2018 and 2023, 280 subjects were enrolled across 7 sites and 255 were randomized. The mean age of the cohort was 67 ± 12 years and preoperative median stage of prolapse was III. Overall, 81% underwent reconstructive native tissue repair and 19% colpocleisis. At baseline, 58 (23%) of the subjects had no bothersome UUI symptoms (0,1) and 196 (77%) had greater than mild bother (2, 3, 4). Variables associated with baseline UUI bother included BMI (OR 1.58, 95% CI (1.12-2.21), p< 0.08), and symptomatic SUI (OR 4.76 95% CI (2.52-8.97), p < 0.001). At 12 months, 41% had persistent UUI, 59% reported UUI resolved, and 11% developed de novo UUI symptoms. At 12 months post-operatively, univariate analysis showed only age (OR 1.03, 95% CI (1.00-1.06), p = 0.014) and CCI (OR 1.20, 95% CI (0.99-1.45), p = 0.05) to be significantly associated with bothersome UUI. On multivariate analysis, only the association with age persisted (OR 1.06, 95% CI (1.01-1.12), p < 0.001). Colpocleisis was the only significant protective factor (OR 0.10, 95% CI (0.48-1.68), p = 0.004) and those who underwent colpocleisis were 3.44 (95% CI 1.74-6.80) times more likely to not experience UUI symptoms. Sling type (SI vs. RP) and prolapse compartment repair were not associated.

Conclusions: For women undergoing native tissue vaginal repair and concomitant sling, almost 60% saw resolution of baseline UUI symptoms, especially those undergoing colpocleisis.