The Outcomes of Prophylactic Midurethral Sling at the Time of Pelvic Organ Prolapse Repair: A Comparative Study

INTRODUCTION: Patients who undergo surgery for advanced pelvic organ prolapse (POP) are at an increased risk for developing de novo or worsening stress urinary incontinence (SUI). There is not much argument against placing a midurethral sling (MUS) in women who have had SUI demonstrated objectively before surgery. However, the debate is still ongoing regarding the management of women with advanced POP who do not have preoperative SUI, even though de novo SUI is a real risk in this group. OBJECTIVE: The objective of this retrospective cohort study is to evaluate whether the outcomes of MUS are different between women who had subjective SUI preoperatively and who did not. METHODS: In this retrospective cohort study, electronic medical records of patients who underwent MUS placement concomitantly with POP repair between the years of 2017 and 2023 were reviewed at a single institution. We extracted information on the patients’ demographic characteristics, medical history, prolapse stage at the time of the procedure, type of sling, and postoperative complications. The cases who had preoperative SUI were labeled as “non-prophylactic sling,” and those who did not were named the “prophylactic sling” group. Propensity score matching was applied to the non-prophylactic and prophylactic sling groups to allow for equal comparisons in terms of different covariates. The primary outcome was the development of recurrent SUI in the non-prophylactic group or de novo SUI in the prophylactic group in the postoperative period. Secondary outcomes included voiding difficulties, mesh complications, overactive bladder (OAB), or pelvic pain in the postoperative period. For all analyses, results were considered significant when p<0.05. RESULTS: We identified a total of 1,132 patients who underwent POP repair with non-prophylactic or prophylactic MUS placement. After propensity match scoring, each group had 409 patients. Follow-up time for the study was 15.4 months for non-prophylactic slings and 15.3 months for prophylactic slings. The average age in the non-prophylactic group was 66.64 years, while that in the prophylactic group was 67.03 years. In both, non-prophylactic and prophylactic groups, respectively, the patients were predominantly postmenopausal (93% and 94%), White (91.6% and 89.7%), had stage 3 prolapse (64% and 70%), and underwent TVT (79% and 75%). Primary outcome, the rate of postoperative SUI, was significantly increased in the non-prophylactic sling group (5.1%) compared to the prophylactic sling group (1.7%) (p=0.011). Interestingly, recurrent urinary tract infection (UTI) rate was also significantly increased in non-prophylactic group. (4.6 versus 1.5%, p=0.013). There was no significant difference in voiding difficulty, reoperation for voiding difficulty, vaginal mesh exposure, reoperation for sling related to mesh exposure, new onset or worsening overactive bladder, or pelvic pain attributable to sling placement between the groups. CONCLUSIONS: In this comparison of women who had MUS together with POP repair, postoperative SUI risk was significantly lower in women who had MUS prophylactically. The risk of recurrent UTI was significantly increased in women who had preoperative SUI. Groups were similar regarding the presence of mesh complications, new onset or worsening overactive bladder, and pelvic pain (Tables 1 and 2).