Should patients undergoing vaginal prolapse surgery have a concomitant midurethral sling (MUS)? Some strongly advocate that all such patients should, others support a staged approach, while some suggest a selected approach. Which is correct?

Patients presenting for pelvic organ prolapse (POP) repair will have one of 5 scenarios with respect to stress urinary incontinence (SUI) (see table). It is clear that some individuals undergoing surgical repair of POP will develop de novo SUI postoperatively. However, there are others with preoperative SUI who will have resolution of SUI following POP repair alone without concomitant anti-incontinence surgery.¹ Nevertheless, concomitant SUI surgery is often performed at the time of POP repair in order to reduce or prevent de novo or “occult” SUI occurrence. Those with bothersome de novo SUI following POP repair will potentially be subjected to another surgery for repair of SUI which could have been treated contemporaneously at the time of POP repair. Due to this potential burden, several multicenter trials have examined the efficacy and safety of a concomitant surgical approach including some funded by the National Institutes of Health.^2,3 However, the potential benefits of doing such “prophylactic” surgery in all patients undergoing POP repair must be balanced against the additional expense and operative time as well as the potential for adverse outcomes from these surgeries (failure, bleeding, pain, bladder outlet obstruction etc) especially if MUS is being considered as the SUI treatment. Importantly, many patients will not develop SUI after POP surgery, thus doing an anti-incontinence procedure on all patients with POP will subject many patients who were not destined to develop SUI to an unneeded, superfluous and potentially dangerous procedure at the time of POP repair.

Additionally, considerable ongoing controversy exists surrounding the use of transvaginal mesh in the form of MUS for the treatment of SUI. The risk of complications from the use of MUS in all settings remains a consideration.⁴ In fact, one recent study suggests a trend towards fewer slings at the time of POP repair since the U.S. Food and Drug Administration notification on mesh in 2011.⁵

Ideally, if we could predict preoperatively who will develop SUI following POP surgery, many individuals could be spared an unnecessary sling. Simple prolapse reduction with a pessary combined with a period of observation for the development of symptomatic SUI⁶ or POP reduction at the time of urodynamics (UDS) have been suggested as methods of identifying and selecting some patients for SUI surgery at the time of POP repair.⁷ However, this may over- or underestimate the actual incidence and/or introduce unnecessary costs such that some authors argue for doing slings in all such patients.⁸ Predictive models have also been developed for selecting patients for concomitant SUI surgery.⁹ Nevertheless, such preoperative predictors are not universally reliable, and thus some authors support a staged approach advocating for a SUI surgery only in those with de novo SUI following POP repair.^1,10

At present, the choice of placing a MUS at time of POP repair in patients without SUI is complicated, without an overwhelmingly “correct” answer, especially in the era of the ongoing mesh controversy. Many variables can be considered in this shared decision making process between patient and surgeon and these will be strongly debated during the Crossfire session at the AUA Annual Meeting on Monday, September 13 (7:30 a.m.–8:00 a.m.).