A midurethral sling during prolapse repair? Women must decide
Women can become incontinent after surgery to repair a vaginal prolapse, and the risk is high enough for surgeons to consider placing a prophylactic midurethral sling at the time of the repair. This approach helps prevent incontinence but causes extra surgical complications, according to a randomised trial.
Women who had the prophylactic sling were half as likely to develop new incontinence in the year after surgery than controls who had small sham incisions to mimic placement of a sling (27.3% (45/165) v 43.0% (74/172); adjusted odds ratio 0.48, 95% CI 0.30 to 0.77). They were also significantly more likely to have a bladder perforation (6.7% (11/164) v 0% (0/172)), a major bleed or vascular complication (3.1% (5/164) v 0% (0/172)), a urinary tract infection (31.0% (49/158) v 18.3% (30/164)), or incomplete bladder emptying at discharge (42.6% (69/162) v 30.0% (51/170)).
Continent women scheduled for repair of a vaginal prolapse face a difficult choice, says a linked editorial (p 2422): a sling now, or potentially a sling later? Only they can make this choice, in conversation with an experienced surgeon. Most of the women in this trial had an anterior prolapse staged two or three out of a possible four—the vaginal wall bulging close to or just beyond the entrance to the vagina. They had a variety of operations, most commonly a combined anterior repair and apical suspension, at seven different hospitals in the US.
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