NEUROUROLOGY & FEMALE UROLOGY

Development of de novo urge incontinence in women post sling: The role of preoperative urodynamics in assessing the risk
Alperin M, Abrahams-Gessel S, Wakamatsu MM
Division of Urogynecology, Department of Obstetrics and Gynecology and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh, Pennsylvania
Neurourol Urodyn. 2008; 27: 407-11

• Aims: The study was undertaken to investigate if there are specific identifiable risk factors on the preoperative history or urodynamics testing associated with an increased risk for the development of symptoms of de novo urge urinary incontinence after a minimally invasive sling procedure.
• Methods: Two hundred eighty-one women who had undergone minimally invasive sling surgery for stress urinary incontinence between January 2000 and December 2003 were identified. The records of 92 patients were included in this review.
• Results: Twenty-five patients (27%) reported urge urinary incontinence on postoperative questioning. Clinical and urodynamic parameters were correlated with the development of de novo urge urinary incontinence. Preoperative history parameters were not predictive of the increased risk of de novo urge urinary incontinence, with the exception of increased preoperative daytime frequency (OR 3.3 (1.2, 9.1)). Of 16 women whose detrusor pressure during the filling phase of cystometry exceeded 15 cm H2O, de novo urge urinary incontinence developed in 9 (56%) vs. 16 (21%) of 76 women, whose detrusor pressure was </= 15 cm H2O (OR 4.6 (1.4, 15.0)).
• Conclusions: Directed patient history is only minimally helpful in the identification of women at increased risk for the development of de novo urge urinary incontinence, with the exception of the complaint of increased daytime frequency. Women with elevated detrusor pressure during the filling phase of cystometry were more likely to develop urge urinary incontinence postoperatively. Therefore, we suggest that preoperative urodynamic evaluation, and specifically detrusor pressure > 15 cm H2O may help identify patients at increased risk of developing de novo urge urinary incontinence following the minimally invasive sling procedure. Neurourol. Urodynam. 27:407-411, 2008. (c) 2007 Wiley-Liss, Inc.
  
  
• Editorial Comment
  The authors reviewed a population of women who had undergone a midurethral sling. Out of this population, 92 women were identified as having had no complaints and/or urodynamic evidence of urge urinary incontinence or detrusor overactivity before their operation. Of those 92 women, 25 (27%) developed de novo postoperative urge urinary incontinence after their surgery. The authors found that of all the preoperative variables examined, only a history of daytime urinary frequency or a bladder filling pressure of > 15 cm of water predicted an increased risk for the development of de novo urge urinary incontinence. All the patients underwent a midurethral retropubic operation with none receiving a transobturator sling.
  This manuscript points out the definite morbidity of new onset urinary urge incontinence after an anti-incontinence operation for stress urinary incontinence. A 27% incidence rate seems high but is very realistic. Great interest would be if the authors would expand their study in the future to look at patients who underwent a transobturator technique to see if the rates of new onset urinary urge incontinence would be the same given the potential for less obstruction with this newer technique. In addition, in view of the large number of patients available for review, it would be very beneficial for the data base to be re-mined to note if the remaining 189 patients who were excluded for history of reported urinary urge incontinence preoperatively or evidence of detrusor overactivity on preoperative evaluation had resolution of their complaint(s) on a historical basis. This is a topic that has been examined for greater than two decades. Readers should revisit the article written by Dr. E. McGuire, almost exactly 20 years ago in the same journal on this very topic (1).

Reference
McGuire E: Bladder instability and stress incontinence. Neurourol Urodyn. 1988; 7: 563-7.

Steven P. Petrou, M.D
Associate Professor of Urology
Chief of Surgery, St. Luke’s Hospital
Associate Dean, Mayo School of Graduate Medical Education
Jacksonville, Florida, USA
E-mail: petrou.steven@mayo.edu