Colpocleisis is a highly effective obliterative procedure offered to women with significant prolapse and no desire for vaginal function. However, much remains to be learned regarding concomitant treatment of stress urinary incontinence (SUI) and postoperative voiding function after colpocleisis. It is unclear whether concomitant placement of a midurethral sling (MUS) during colpocleisis significantly affects voiding trial failure rates. The primary aim of this study was to compare failure rates of first voiding trial (VT) within 7 days after colpocleisis with and without MUS placement. The secondary aim was to compare failure rates of VT on postoperative day (POD) 1 after colpocleisis with and without MUS placement. Our hypothesis is that there will be no difference in VT failure rates after colpocleisis in women undergoing concomitant MUS compared to colpocleisis alone.

After Institutional Review Board approval, data were collected via electronic chart review of women who underwent colpocleisis at a single academic institution between January 2012 and October 2019 as identified by Current Procedural Terminology (CPT) billing codes. Individuals with a history of a neurological disorder that could affect voiding function or history of urinary diversion were excluded. All patients underwent a standardized VT within 7 days postoperatively; 300mL (or maximum tolerated volume if less than 300mL) of sterile water was instilled by Foley catheter into the bladder by gravity. VT failure was defined as inability to void ≥2/3 of an instilled volume after catheter removal. The timing of VT, inpatient (performed prior to hospital discharge on POD1) versus (vs) outpatient first VT, was made based on surgeon preference.
Clinical and demographic characteristics between those who did and did not have a MUS placed at the time of colpocleisis were compared. Student’s t test or Mann-Whitney U test for continuous variables and chi-squared test or Fisher’s exact test for categorical variables were used as appropriate. Logistic regression was used to examine the relationship between MUS placement and subsequent VT failure controlling for potential confounders (p<0.2). In the regression model for the risk of VT failure in the first 7 postoperative days, age, American Society of Anesthesiologists (ASA) class, prolapse stage, preoperative PVR, postoperative day of first VT, preoperative subjective urgency urinary incontinence (UUI), estimated blood loss (EBL), vaginal estrogen use at the time of surgery, and prior prolapse surgery were included. Similarly, the risk of POD1 VT failure was assessed controlling for ASA class, preoperative PVR, subjective UUI, and EBL. Level of statistical significance was set at 0.05.

119 women met inclusion criteria. All patients had a VT performed within 7 days postoperatively. The majority were Caucasian (82%) with a mean age of 77.3±7.1 years. There was no significant association between VT failure within 7 days and patient characteristics. 54/119 women (45.4%) had a concomitant MUS at the time of colpocleisis. First VT was performed a mean±SD of 3.1±2.2 days in the MUS group vs 1.8±1.8 days in no MUS group (p<0.001). Baseline clinical and demographic characteristics were similar between those with and without concomitant MUS except those who underwent concomitant MUS placement had more subjective and objective stress urinary incontinence (SUI) preoperatively (p<0.001), higher rates of reported urgency UI (UUI) preoperatively (81.5% vs 51.6%, p<0.001) and lower estimated blood loss (95.1 vs 126.9mL, p=0.02). Bivariate analysis revealed that VT failure rate within 7 days did not differ between those who did and did not undergo concomitant MUS placement (22.2% [77.8% success] vs 32.8% [67.2% success], p=0.20, respectively). Logistic regression demonstrated that the risk of VT failure in the first 7 postoperative days did not differ between women undergoing colpocleisis alone vs colpocleisis with MUS (aOR 0.56, 95% confidence interval [CI] 0.16,1.93). Of 119 women, 81 (68%) underwent a VT on POD1. Significant association was noted between overall VT failure on POD1 and diabetes (OR 3.21, 95%CI 1.13, 9.1). Concomitant MUS procedures were performed in 27/81 (33%). Clinical and demographic characteristics were similar between MUS vs. no MUS groups, except those undergoing MUS placement had higher subjective and objective preoperative SUI (p<0.001) and subjective preoperative UUI (85.2% vs. 43.4%, p<0.001). ASA class also differed between groups (p=0.049). Bivariate analysis revealed that VT failure rate on POD1 did not differ between those who did and did not undergo concomitant MUS placement (33.3% [66.7% success] vs 39.6% [60.4% success], p=0.58, respectively). Logistic regression demonstrated that risk of POD1 VT failure (aOR 0.8, 95% CI 0.22, 2.91) did not differ significantly between MUS vs. no MUS groups. Of note, 5/119 (4.2%) women continued to fail VT on POD7 (MUS group: 3(5.6%) vs No MUS group 2(3.1%), p=0.66).

Relatively high success rates of VT, both within 7 days and on POD1, were observed in a large cohort of women undergoing colpocleisis regardless of undergoing a concomitant MUS or not. At 1 week post-surgery, less than 5% of subjects continued to have incomplete bladder emptying, which did not differ between groups.

In conclusion, concomitant surgical management of SUI with a midurethral sling at the time of colpocleisis for advanced pelvic organ prolapse did not affect voiding trial failure rates in the first week after surgery. Therefore, the placement of concomitant MUS should not influence the timing of VT in women undergoing colpocleisis. This information may be used in preoperative counseling and help inform to patients’ expectations post surgery.