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Need for prophylactic sling after pelvic organ prolapse repair under question. (Future Incontinence at Issue).

ST. Louis -- Whether to do a prophylactic incontinence procedure on a patient who is having a pelvic organ prolapse repair is a clinical conundrum that's begging to be researched, Dr. Robert Kovac said at the 11th International Pelvic Reconstructive and Vaginal Surgery Conference.

"It's a very problematic situation. You've got an elderly women with big-time prolapse. The prolapse itself is kinking the urethra and that's why she's continent. Then you go in and fix that prolapse, and if you don't do something prophylactically; it's your loss if that's the one that leaks on you," said Dr. Clifford Wheeless of Johns Hopkins University Medical Center, Baltimore.

At the same time, there is no reliable test to determine which patients undergoing prolapse repair are going to leak later and would therefore need a prophylactic sling. Since that's the case, "I would do a prophylactic [sling] on all of them," Dr. Wheeless asserted at the meeting, which was jointly sponsored by the Society of Pelvic Reconstructive Surgeons and the American College of Obstetricians and Gynecologists.

There may not be data to support that tactic, he said, but "I've just had too many [patients] where I've done a beautiful repair, and going home they're incontinent. They don't remember what a beautiful repair you did on their prolapse. They remember the fact that they're going home in diapers."

Dr. Fred Govier of Virginia Mason Medical Center, Seattle, agreed. "I see a large number of these people," he said, referring to patients who have incontinence following pelvic organ prolapse repair.

"If you've got a women with a third-degree cystocele in the office, it's tough to make that woman leak. Even if you study her with a pessary in place, the results can be misleading and many women will come back leaking," Dr. Govier told this newspaper.

When performing a prophylactic incontinence procedure, keep in mind that a lot of women with pelvic organ prolapse will have elevated residual urines and will void with abdominal straining rather than a detrusor contraction. "If you put a sling" in an elderly women who has elevated residual urine volume and zero detrusor pressure, "you're going to obstruct her," Dr. Govier explained.

A key factor to consider after the pelvic organ prolapse repair is whether the urethra is hypermobile.

But even if the urethra isn't hypermobile, Dr. Govier said he still places a sling. "If you look at these transvaginal slings, I won't say that our obstruction rate is zero, but it's very near zero. And you can't tell me your leakage rate is zero with these women who have third-degree cystoceles." The key is to make sure that "they have some detrusor pressure before you go in.

Others take issue with what they view as an encroachment of opinion-based decision making on what should be evidence-based medicine.

Studies have shown that a prophylactic procedure for urinary incontinence is not indicated if the patient cannot be made to leak before pelvic organ prolapse repair.

Given the potential risks of erosions and graft resections associated with sling materials, "I have a hard time accepting doing a prophylactic procedure for a lady that you can't make leak in the office," one member of the audience said during the discussion period. At the very worst, placing a sling in such a woman may lead to obstruction. 'At best, that's just anecdotal medicine, and that's what we're trying to get away from," he said.

Most patients will leak in the office. But if they don't leak, and they do end up with some incontinence after the pelvic organ prolapse repair, then fixing their incontinence is an easy procedure to do later, he added.
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Author:DeMott, Kathryn
Publication:OB GYN News
Date:Feb 1, 2002
Words:608
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