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A multicenter retrospective cohort study comparing urethral diverticulectomy with and without pubovaginal sling.
Am J Obstet Gynecol. 2020 08; 223(2):273.e1-273.e9.AJ

Abstract

BACKGROUND

Urethral diverticulum is a rare entity and requires a high suspicion for diagnosis based on symptoms and physical exam with confirmation by imaging. A common presenting symptom is stress urinary incontinence (SUI). The recommended treatment is surgical excision with urethral diverticulectomy. Postoperatively, approximately 37% of patients may have persistent and 16% may have de novo SUI. An autologous fascial pubovaginal sling (PVS) placed at the time of urethral diverticulectomy (UD) has the potential to prevent and treat postoperative SUI. However, little has been published about the safety and efficacy of a concomitant pubovaginal sling.

OBJECTIVE

The objective of this study was to compare the clinical presentation, outcomes, complications, and diverticulum recurrence rates in women who underwent a urethral diverticulectomy with vs without a concurrent pubovaginal sling.

STUDY DESIGN

This multicenter, retrospective cohort study included women who underwent a urethral diverticulectomy between January 1, 2000, and December 31, 2016. Study participants were identified by Current Procedure Terminology codes, and their records were reviewed for demographics, medical or surgical history, symptoms, preoperative testing, concomitant surgeries, and postoperative outcomes. Symptoms, recurrence rates, and complications were compared between women with and without a concomitant pubovaginal sling. The primary outcome was the presence of postoperative stress urinary incontinence symptoms. Based on a stress urinary incontinence rate of 50% with no pubovaginal sling and 10% with a pubovaginal sling, we needed a sample size of 141 participants who underwent diverticulectomy without a pubovaginal sling and 8 participants with a pubovaginal sling to achieve 83% power with P<.05.

RESULTS

We identified 485 diverticulectomy cases from 11 institutions who met the inclusion criteria; of these, 96 (19.7%) cases had a concomitant pubovaginal sling. Women with a pubovaginal sling were older than those without a pubovaginal sling (53 years vs 46 years; P<.001), and a greater number of women with pubovaginal sling had undergone diverticulectomy previously (31% vs 8%; P<.001). Postoperative follow-up period (14.6±26.9 months) was similar between the groups. The pubovaginal sling group had greater preoperative stress urinary incontinence (71% vs 33%; P<.0001), dysuria (47% vs 30%; P=.002), and recurrent urinary tract infection (49% vs 33%; P=.004). The addition of a pubovaginal sling at the time of diverticulectomy significantly improved the odds of stress urinary incontinence resolution after adjusting for prior diverticulectomy, prior incontinence surgery, age, race, and parity (adjusted odds ratio, 2.27; 95% confidence interval, 1.02-5.03; P=.043). It was not significantly protective against de novo stress urinary incontinence (adjusted odds ratio, 0.86; 95% confidence interval, 0.25-2.92; P=.807). Concomitant pubovaginal sling increased the odds of postoperative short-term (<6 weeks) urinary retention (adjusted odds ratio, 2.5; 95% confidence interval, 1.04-6.22; P=.039) and long-term urinary retention (>6 weeks) (adjusted odds ratio, 6.98; 95% confidence interval, 2.20-22.11; P=.001), as well as recurrent urinary tract infections (adjusted odds ratio, 3.27; 95% confidence interval, 1.26-7.76; P=.013). There was no significant risk to develop a de novo overactive bladder (adjusted odds ratio, 1.48; 95% confidence interval, 0.56-3.91; P=.423) or urgency urinary incontinence (adjusted odds ratio, 1.47; 95% confidence interval, 0.71-3.06; P=.30). A concomitant pubovaginal sling was not protective against a recurrent diverticulum (adjusted odds ratio, 1.38; 95% confidence interval, 0.67-2.82; P=.374). Overall, the diverticulum recurrence rate was 10.1% and did not differ between the groups.

CONCLUSION

This large retrospective cohort study demonstrated a greater resolution of stress urinary incontinence with the addition of a pubovaginal sling at the time of a urethral diverticulectomy. There was a considerable risk of postoperative urinary retention and recurrent urinary tract infections in the pubovaginal sling group.

Authors+Show Affiliations

Female Pelvic Medicine and Reconstructive Surgery, MedStar Washington Hospital Center/Georgetown University, Washington, DC. Electronic address: sarahbradleymd@gmail.com.Female Pelvic Medicine and Reconstructive Surgery, Mayo Clinic, Rochester, MN.Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN.Department of Obstetrics and Gynecology, University of Pittsburgh Medical Center, Pittsburgh, PA.Department of Obstetrics and Gynecology, New York University School of Medicine, New York, NY.Department of Obstetrics and Gynecology, Emory, Atlanta, GA.Department of Obstetrics and Gynecology, University of South Florida, Tampa, FL.Female Pelvic Medicine and Reconstructive Surgery, Massachusetts General Hospital, Boston, MA.Female Pelvic Medicine and Reconstructive Surgery, UTSW, Dallas, TX.Female Pelvic Medicine and Reconstructive Surgery, The Ohio State University, Columbus, OH.Female Pelvic Medicine and Reconstructive Surgery, Cooper University Hospital, Camden, NJ.Department of Biostatistics and Biomedical Informatics, MedStar Health Research Institute, Washington, DC.Department of Obstetrics and Gynecology, University of South Florida, Tampa, FL.Female Pelvic Medicine and Reconstructive Surgery, MedStar Washington Hospital Center/Georgetown University, Washington, DC.

Pub Type(s)

Comparative Study
Journal Article
Multicenter Study

Language

eng

PubMed ID

32504566

Citation

Bradley, Sarah E., et al. "A Multicenter Retrospective Cohort Study Comparing Urethral Diverticulectomy With and Without Pubovaginal Sling." American Journal of Obstetrics and Gynecology, vol. 223, no. 2, 2020, pp. 273.e1-273.e9.
Bradley SE, Leach DA, Panza J, et al. A multicenter retrospective cohort study comparing urethral diverticulectomy with and without pubovaginal sling. Am J Obstet Gynecol. 2020;223(2):273.e1-273.e9.
Bradley, S. E., Leach, D. A., Panza, J., Sassani, J., Escobar, C., Ogorek, J., Jackson, E., Hudson, P., Hamner, J. J., Smith, P. E., Schroeder, M., Zeymo, A., Wyman, A. M., & Gutman, R. E. (2020). A multicenter retrospective cohort study comparing urethral diverticulectomy with and without pubovaginal sling. American Journal of Obstetrics and Gynecology, 223(2), e1-e9. https://doi.org/10.1016/j.ajog.2020.06.002
Bradley SE, et al. A Multicenter Retrospective Cohort Study Comparing Urethral Diverticulectomy With and Without Pubovaginal Sling. Am J Obstet Gynecol. 2020;223(2):273.e1-273.e9. PubMed PMID: 32504566.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - A multicenter retrospective cohort study comparing urethral diverticulectomy with and without pubovaginal sling. AU - Bradley,Sarah E, AU - Leach,Douglas A, AU - Panza,Joseph, AU - Sassani,Jessica, AU - Escobar,Christina, AU - Ogorek,John, AU - Jackson,Elisha, AU - Hudson,Patricia, AU - Hamner,Jennifer J, AU - Smith,Pamela E, AU - Schroeder,Michelle, AU - Zeymo,Alexander, AU - Wyman,Allison M, AU - Gutman,Robert E, Y1 - 2020/06/03/ PY - 2020/01/24/received PY - 2020/06/01/revised PY - 2020/06/01/accepted PY - 2020/6/7/pubmed PY - 2020/9/1/medline PY - 2020/6/7/entrez KW - fascial sling KW - pubovaginal sling KW - stress urinary incontinence KW - urethral diverticulectomy KW - urethral diverticulum SP - 273.e1 EP - 273.e9 JF - American journal of obstetrics and gynecology JO - Am J Obstet Gynecol VL - 223 IS - 2 N2 - BACKGROUND: Urethral diverticulum is a rare entity and requires a high suspicion for diagnosis based on symptoms and physical exam with confirmation by imaging. A common presenting symptom is stress urinary incontinence (SUI). The recommended treatment is surgical excision with urethral diverticulectomy. Postoperatively, approximately 37% of patients may have persistent and 16% may have de novo SUI. An autologous fascial pubovaginal sling (PVS) placed at the time of urethral diverticulectomy (UD) has the potential to prevent and treat postoperative SUI. However, little has been published about the safety and efficacy of a concomitant pubovaginal sling. OBJECTIVE: The objective of this study was to compare the clinical presentation, outcomes, complications, and diverticulum recurrence rates in women who underwent a urethral diverticulectomy with vs without a concurrent pubovaginal sling. STUDY DESIGN: This multicenter, retrospective cohort study included women who underwent a urethral diverticulectomy between January 1, 2000, and December 31, 2016. Study participants were identified by Current Procedure Terminology codes, and their records were reviewed for demographics, medical or surgical history, symptoms, preoperative testing, concomitant surgeries, and postoperative outcomes. Symptoms, recurrence rates, and complications were compared between women with and without a concomitant pubovaginal sling. The primary outcome was the presence of postoperative stress urinary incontinence symptoms. Based on a stress urinary incontinence rate of 50% with no pubovaginal sling and 10% with a pubovaginal sling, we needed a sample size of 141 participants who underwent diverticulectomy without a pubovaginal sling and 8 participants with a pubovaginal sling to achieve 83% power with P<.05. RESULTS: We identified 485 diverticulectomy cases from 11 institutions who met the inclusion criteria; of these, 96 (19.7%) cases had a concomitant pubovaginal sling. Women with a pubovaginal sling were older than those without a pubovaginal sling (53 years vs 46 years; P<.001), and a greater number of women with pubovaginal sling had undergone diverticulectomy previously (31% vs 8%; P<.001). Postoperative follow-up period (14.6±26.9 months) was similar between the groups. The pubovaginal sling group had greater preoperative stress urinary incontinence (71% vs 33%; P<.0001), dysuria (47% vs 30%; P=.002), and recurrent urinary tract infection (49% vs 33%; P=.004). The addition of a pubovaginal sling at the time of diverticulectomy significantly improved the odds of stress urinary incontinence resolution after adjusting for prior diverticulectomy, prior incontinence surgery, age, race, and parity (adjusted odds ratio, 2.27; 95% confidence interval, 1.02-5.03; P=.043). It was not significantly protective against de novo stress urinary incontinence (adjusted odds ratio, 0.86; 95% confidence interval, 0.25-2.92; P=.807). Concomitant pubovaginal sling increased the odds of postoperative short-term (<6 weeks) urinary retention (adjusted odds ratio, 2.5; 95% confidence interval, 1.04-6.22; P=.039) and long-term urinary retention (>6 weeks) (adjusted odds ratio, 6.98; 95% confidence interval, 2.20-22.11; P=.001), as well as recurrent urinary tract infections (adjusted odds ratio, 3.27; 95% confidence interval, 1.26-7.76; P=.013). There was no significant risk to develop a de novo overactive bladder (adjusted odds ratio, 1.48; 95% confidence interval, 0.56-3.91; P=.423) or urgency urinary incontinence (adjusted odds ratio, 1.47; 95% confidence interval, 0.71-3.06; P=.30). A concomitant pubovaginal sling was not protective against a recurrent diverticulum (adjusted odds ratio, 1.38; 95% confidence interval, 0.67-2.82; P=.374). Overall, the diverticulum recurrence rate was 10.1% and did not differ between the groups. CONCLUSION: This large retrospective cohort study demonstrated a greater resolution of stress urinary incontinence with the addition of a pubovaginal sling at the time of a urethral diverticulectomy. There was a considerable risk of postoperative urinary retention and recurrent urinary tract infections in the pubovaginal sling group. SN - 1097-6868 UR - https://www.unboundmedicine.com/medline/citation/32504566/A_multicenter_retrospective_cohort_study_comparing_urethral_diverticulectomy_with_and_without_pubovaginal_sling_ L2 - https://linkinghub.elsevier.com/retrieve/pii/S0002-9378(20)30617-7 DB - PRIME DP - Unbound Medicine ER -