Is there a role for colposuspension?
Dr Luigi Bombieri, Derriford Hospital, Plymouth, PL6 8DH, UK.
Over the past decade surgery for urinary stress incontinence has undergone a process of scrutiny and refinement. Some traditional procedures (e.g. anterior colporrhaphy and needle suspensions) are no longer considered appropriate for the primary treatment of stress incontinence, while other well-established procedures (e.g. retropubic suspensions and slings) have been recognised as effective but are burdened with considerable morbidity. New developments and research have aimed to reduce complications while maintaining efficacy.
Colposuspension has become established as the ‘gold standard’ procedure for stress incontinence due to its high success rate (as compared with other procedures) and its proven record of durability.1 It is, however, a major abdominal procedure and postoperative complications are well documented. Some complications, such as voiding difficulty and de novo detrusor instability, have been associated with increasing bladder neck elevation.2 Refinement of surgical technique at colposuspension (with avoidance of excessive bladder neck elevation) might therefore reduce morbidity without compromising success.3
Slings have also evolved with the development of the tension-free vaginal tape (TVT). The TVT has been shown by its developers to be an effective minimal access procedure with reduced morbidity. The evidence so far has prompted the National Institute for Clinical Excellence (NICE) to approve the use of TVT in the UK.4
Despite a lack of long-term results and the evidence to deal with failures and complications, the TVT has proved hugely popular amongst surgeons and patients. A recent survey of practice amongst members of the International Urogynecology Association shows that the TVT has overtaken the colposuspension as the preferred incontinence procedure.5
The future role of colposuspension and TVT depends largely on the outcome of comparative and long-term follow-up studies and also on the effect of these procedures in complex cases (such as failed surgery and coexistent prolapse).
LONG-TERM EFFICACY OF INCONTINENCE SURGERY
The status as ‘gold standard’ procedure for stress incontinence enjoyed by the colposuspension operation has been built progressively and is based on comparative studies and long-term follow-up series. Colposuspension has been shown to be more effective than anterior repair, needle suspension and paravaginal defect repair. It has also been shown to be as effective as the Marshall–Marchetti–Krantz procedure (but it is easier to perform, corrects cystocoele and causes less osteitis pubis) and as effective as slings (but with less complications). Numerous reports quote high success rates of 70%–90% after 5–15 years.
The results from a UK-based multi-centre randomised study comparing TVT with colposuspension show equal success rates at 6 months and 2 years, and reduced morbidity for TVT.6,7 There are two long-term follow-up studies showing persisting efficacy for the TVT after 5 and 7 years.8,9 Although the reports are methodologically sound, they are not independent (they are produced by the same team that developed the TVT), and numbers are relatively small.
The only comparative study with long-term follow-up (where colposuspension was compared with needle suspension and anterior repair) has shown that only half of the failures occur within the first year; the other half of the failures occurred later, between 1 and 5 years follow-up.10
There is therefore a need for long-term results of randomised studies and independent case series. These studies, as well as information from national registries,11 should also clarify the incidence of possible long-term complications such as urethral erosion. Until then the colposuspension as well as the TVT should be offered to all women, with information that enables them to make an informed choice, as suggested by the NICE guidelines. The proven record of success in the long term of the colposuspension is particularly relevant for young women, who also have a naturally lower likelihood of developing complications.
THE MANAGEMENT OF FAILED SURGERY
The success of a procedure should be based not only on outcomes and complications but also on the possible difficulties that might be encountered when managing failures. The success of the colposuspension is also based on the successful outcome of repeat surgery. A second colposuspension can be technically difficult due to scarring in the retropubic space, but reports from tertiary referral centres have consistently shown high success rates of 80%.12–14 The TVT has also been shown to be effective after failed retropubic procedures.15 However, there is at present very little information on how to manage patients with failed TVT.
The presence of a foreign body with dense fibrosis in the retropubic space and around the urethra might make repeat surgery difficult. Repeat TVT appears to be successful, but so far there have been only two reported case series with a total of five patients.16,17 There is a need for more experience on the management of the failed TVT before it can be fully recommended as the first choice procedure.
THE MANAGEMENT OF COEXISTENT INCONTINENCE AND CYSTOCOELE
Stress incontinence commonly presents in association with pelvic organ prolapse. The colposuspension is traditionally performed for the treatment of both stress incontinence and cystocoele, as it corrects ‘paravaginal’ defects. However, colposuspension has been shown to have a failure rate of up to 34% for the correction of anterior vaginal prolapse.18 This might be due to failure to correct ‘central’ defects. These type of defects have been shown using magnetic resonance imaging (MRI) in 28% of women with cystocoele.19
More recently, women have been offered TVT in combination with anterior vaginal repair. The success rate of the TVT when performed in combination with prolapse repair does not appear to be affected.20 However, anterior vaginal repair of cystocoele has been shown to have a high recurrence rate and satisfactory results have been reported to be as low as 30%–46%.21 This might be due to failure to correct ‘lateral’ defects.
It is thus clear that both anterior vaginal repair and colposuspension fail to correct the anatomical defect in a significant proportion of patients and that no one operation will be suitable for all patients. In order to select the appropriate procedure and improve cure rates, the type of defect might need to be diagnosed preoperatively. At present, the clinical assessment of site-specific defects has no strong scientific foundations. It has been suggested that the absence of vaginal rugae over the prolapse indicates a ‘central’ defect. It has also been suggested that successful correction of the cystocoele during examination by elevating the lateral vaginal fornices with open forceps is suggestive of a ‘paravaginal’ defect. Future research is needed to validate the clinical assessment of site-specific defects and to investigate whether each type of defect requires a different operation (e.g. colposuspension for ‘paravaginal’ defects and anterior vaginal repair for ‘central’ defects). Until more information becomes available, the management of combined stress incontinence and cystocoele will probably be determined by the surgeon's personal preference as to the best incontinence procedure.
THE MANAGEMENT OF ‘POTENTIAL’ INCONTINENCE AND SEVERE PROLAPSE
‘Potential’ or ‘latent’ stress incontinence is commonly demonstrated in women with severe uterine or vaginal vault prolapse. Stress incontinence is seen during clinical examination when pushing the prolapse up or is reported by women following insertion of a pessary.
It is generally acknowledged that the incidence of ‘potential’ stress incontinence far exceeds the actual development of stress incontinence after surgical correction of the prolapse.22 As a consequence surgeons are unsure as to how this potential problem should be managed. Some take the view that a prophylactic incontinence procedure is warranted in order to avoid further surgery. Others argue that incontinence surgery has potential morbidity and should be performed only as a second stage procedure if necessary. Although there is at present very little data to support either policy, those in favour of prophylactic surgery are likely to perform a TVT if the prolapse is corrected using the vaginal route (e.g. at vaginal hysterectomy or sacrospinous ligament fixation) and a colposuspension if an abdominal route is chosen (e.g. at sacrocolpopexy).
Gordon et al.23 have reduced the incidence of postoperative stress incontinence using prophylactic TVT (no cases seen), after observing postoperative stress incontinence in 50% and 23% of women, respectively, when using prophylactic anterior repair and needle suspension. Similarly, Meschia et al.24 have reduced the incidence of postoperative stress incontinence from 44% after prophylactic anterior repair to 8% with TVT.
Colposuspension is commonly performed during sacro-colpo-pexy for vaginal vault prolapse, not only to prevent postoperative stress, but also to correct a coexistent cystocoele. The value of this practice is currently being evaluated in a randomised study.
The future role of colposuspension depends in large part on the long-term outcome of ongoing studies concerning the TVT. It is likely that colposuspension will loose the status of ‘most frequently performed anti-incontinence procedure’. However, until conclusive evidence on long-term success and complications becomes available, colposuspension should continue to be offered as well as TVT, so that women can make an informed choice. This is particularly important in young women.
No one operation is suitable for all patients and it is likely that colposuspension will continue to be performed opportunistically by most surgeons when patients have additional pathology requiring abdominal surgery (e.g. hysterectomy). This will provide invaluable experience to trainees, as there is a real danger that performing only TVT will lead to loss of familiarity with the retropubic space, which might make it difficult to deal with complications such as haemorrhage.
Colposuspension will probably retain a place in the management of prolapse with coexistent stress incontinence (or ‘potential’ stress incontinence). Future studies on patients with mixed pathology (incontinence and prolapse) need to focus on the outcome of prolapse surgery as well as the outcome of incontinence surgery.