Management of Complications in Laparoscopic Sacrocolpopexy: Focus on Urinary Incontinence

Abstract

Pelvic organ prolapse (POP) is a prevalent condition worldwide with detrimental effects on patients’ quality of life. Laparoscopic sacrocolpopexy (LSC) has emerged as the gold standard for managing complex and high-grade POP. While anatomical and subjective outcomes have been extensively documented, the management of its associated complications, particularly urinary incontinence, remains challenging. This study evaluates the strategies implemented to address complications arising from LSC, focusing on urinary incontinence. A retrospective multicenter study analyzed 325 patients who underwent LSC using lightweight macroporous Surelift Uplift mesh between 2011 and 2019. Data on perioperative and long-term complications, with emphasis on urinary incontinence management, were extracted from participating centers. Among them, the incidence of new-onset stress urinary incontinence (SUI) postoperatively was 12.9%. A total of 21 patients required further treatment for urinary symptoms, including mid-urethral sling (MUS) procedures in 5.5% and botulinum toxin injections for overactive bladder (OAB) in 0.9%. The findings underscore the importance of proactive and tailored management strategies for urinary incontinence following LSC. While the procedure demonstrates low complication rates and high anatomical success, urinary symptoms require vigilant monitoring and intervention in a two-step procedure for stress incontinence, if needed.

1. Introduction

Pelvic organ prolapse (POP) has a significant global prevalence of approximately 23%, reaching up to 50% in women over 80 years old [1,2]. This condition leads to distressing symptoms such as urinary and fecal incontinence, sexual dysfunction, and a consequent decline in patients’ quality of life [3,4]. Laparoscopic sacrocolpopexy (LSC) has become the preferred surgical technique for managing complex POP due to its robust anatomical outcomes [5]. Despite its benefits, LSC has significant risks associated with it [6], such as urinary incontinence, which can arise de novo or persist postoperatively [7].

To date, scientific evidence reflects controversial data on whether combined POP and anti-incontinence surgery should be performed either in a one- or a two-step approach in women with POP and symptomatic SUI [8,9]. Past studies have found that patients with prolapse and preoperative SUI who underwent prolapse surgery alone had slightly higher but non-significant rates of persistent SUI compared to those who also received concurrent continence surgery [10]. This evidence suggests that, in many women with preoperative symptomatic or occult SUI, symptoms resolve after prolapse repair alone, potentially exposing some to unnecessary additional procedures and associated risks.

On the other hand, a Cochrane Review described a benefit in performing continence surgery at the time of the prolapse surgery [11], eliminating bothersome symptoms of SUI while avoiding second-time surgery. One-step surgery has also been described as the most cost-effective approach compared to staged intervention [12].

The purpose of this study is to analyze the prevalence and management of urinary complications in a cohort of patients undergoing LSC with Surelift Uplift mesh, focusing on the outcomes of conservative and surgical interventions.

2. Materials and Methods

A national, retrospective, multicenter observational study was designed, including six expert centers. A total of 325 women aged >18 years with symptomatic ≥stage II POP (Pelvic Organ Prolapse Quantification system points Aa, Ba or C/D—1 cm or greater) [13] who underwent LSC using Surelift Uplift mesh between March 2011 and December 2019 were included, with or without concurrent hysterectomy. Patients were required to have at least one year of follow-up. Inclusion criteria were limited to cases meeting the POPQ ≥ stage II threshold, while no predefined exclusion criteria were applied. Ethical approval was obtained from local committees.

Preoperative and postoperative data were collected, including demographics, POP-Q staging, and urinary symptomatology. Intraoperative adverse events (iAEs) were collected and classified according to the ICARUS Global Surgical Collaboration Checklist [14]. Intraoperative adverse events are graded using the severity grading system proposed by the European Association of Urology [15].

Postoperative complications were classified using the Clavien–Dindo system. Specific data on urinary symptoms were extracted from ICIQ-SF standardized questionnaire. Clinical cough stress tests were performed in order to assess overt SUI. Patients were evaluated at 6 weeks, 3 months, and 6 months after surgery and yearly until 5 years.

None of the patients in our sample were submitted for a concurrent anti-incontinence procedure at the time of the LSC. Based on postoperative results, those with significant urinary incontinence and who were willing to undergo another procedure were operated on using a specific anti-incontinence technique: the mid-urethral sling (MUS) procedure or botulinum toxin intravesical injection. Patients with minor symptoms or who were unwilling to undergo surgery were managed with dietary and/or pharmacological treatments.

The statistical analysis was performed using IBM SPSS Statistics for Windows, version 22.0 (IBM Corp, Armonk, NY, USA). Descriptive analysis was performed. Continuous variables are presented as the mean and standard deviation (SD) (normal distribution) or as median and interquartile range (IQR) (non-normal). Categorical variables are presented as frequencies and percentages.

3. Results

A total of 325 laparoscopic SCP patients were analyzed with a median patient age of 66 (IQR 61–73) and body mass index (BMI) of 26.9 (4.05 SD).

The median number of pregnancies was three (IQR: 2–4), and the median number of vaginal deliveries was two (IQR: 2–3). The majority of the patients did not report previous instrumental deliveries (median: 0, IQR: 0–0) or abortions (median: 0, IQR: 0–1).

Regarding the previous urological surgery, 8.3% of the patients (27/325) had a history of at least one urological intervention, distributed as follows:

• Litiasis-related surgeries (44.0%): Including ureteroscopy and percutaneous nephrolithotomy.
• Oncological surgeries (16.0%): Radical or partial nephrectomy and transurethral resection of bladder tumors.
• Functional surgeries (28.0%): Primarily mid-urethral sling procedures (TVT/TOT), Burch colposuspension, and botulinum toxin injections.

A total of 24 surgical iAEs were identified among 325 patients (7.4%). Of these, 1 (0.3%) was related to bleeding, 15 (4.6%) to bladder injury, 4 (1.2%) to intestinal injury, 2 (0.6%) to ureteral injury, and 2 (0.6%) to vaginal injury. All iAEs were categorized as surgical based on the ICARUS classification. According to the assumed severity grading, 20 were Grade II and 4 were Grade III; no Grade IV or V events were reported. No additional anesthesiologic or nursing complications occurred. These data are summarized in

Table 1. Intraoperative complications during LCS.

Surgical Complications (ICARUS)	Severity by Grade (EAUiaiC)	n	%
Total		24	7.4
Bleeding	II	1	0.3
Bladder Injury	II	15	4.6
Intestinal Injury	III	4	1.2
Ureteral Injury	II	2	0.6
Vaginal Injury	II	2	0.6

.

As reflected in

Table 2. Postoperative complications following LCS [16].

Early Postoperative Complications	n	%
I-II	27	8.3
III	4	1.2
IV	2	0.6
Other Postoperative Complications
Vaginal mesh exposure	4	1.2
Constipation	36	11
Bowel occlusion	3	0.9
Bowel occlusion requiring surgery	1	0.3

[16], most of the early postoperative complications were transient and treated successfully with non-invasive treatments. However, 1.8% of the patients suffered a Clavien–Dindo grade III-IV complication requiring reintervention:

• One patient suffered a complicated bowel obstruction.
• One patient has a laparoscopic port eventration.
• There were two cases of urinary fistula secondary to unnoticed intraoperative ureteral lesion.
• One patient had minimal vaginal mesh exposure (<1 cm).
• One patient suffered anaphylactic shock.

Focusing on urinary incontinence, 129 patients experienced preoperative stress incontinence (39.7%); 64 patients (19.7%) referred pure SUI while 65 patients (20%) suffered mixed urinary incontinence (MUI). Pure urgency urinary incontinence (UUI) was described in 59 patients (10.2%).

In the postoperative period, 75 patients (24.3%) reported SUI, 15 patients (4.9%) UUI, and 7 patients (2.3%) MUI, assuming a total of 82 patients with stress incontinence (25.23%). Of the 325 patients, 42 (12.9%) developed de novo SUI postoperatively. A subset of patients reported urgency urinary incontinence (4.9%) or mixed urinary incontinence (2.3%). These data are extracted from

Table 3. Prevalence of preoperative and postoperative urinary incontinence in patients with LCS.

		Postoperative UI n (%)
		Asymptomatic	SUI	UUI	MUI	Missing	Total
Preoperative UI n (%)	Asymptomatic	100 (74.1%)	30 (22.2%)	0 (0.0%)	1 (0.7%)	4 (3%)	135 (100%)
	SUI	39 (60.9%)	17 (26.6%)	3 (4.7%)	2 (3.1%)	3 (4.7%)	64 (100%)
	UUI	34 (57.6%)	9 (15.3%)	6 (10.2%)	3 (5.1%)	7 (11.9%)	59 (100%)
	MUI	37 (56.9%)	19 (29.2%)	6 (9.2%)	1 (1.5%)	2 (3.1%)	65 (100%)
	Missing	2 (100%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	0 (0.0%)	2 (100%)
	Total	212 (65.2%)	75 (23.1%)	15 (4.6%)	7 (2.2%)	16 (4.9%)	325 (100%)

.

There were no statistically significant differences between the patients with and without postoperative urinary incontinence in terms of age (p = 0.631), hypertension (p = 0.368), diabetes (p = 0.672), dyslipidemia (p = 0.361), vaginal deliveries (p = 0.970), or previous prolapse surgery (p = 0.124). However, the body mass index (BMI) was significantly higher in the incontinence group (27.33 ± 4.05 vs. 26.38 ± 4.15, p = 0.011), as detailed in

Table 4. Clinical characteristics of patients with and without postoperative urinary incontinence.

Variable	Postoperative Continent (Mean ± SD or %)	Postoperative Incontinent (Mean ± SD or %)	p-Value
Age (years)	66.32 ± 9.56	66.93 ± 10.35	0.631
Hypertension (%)	105 (47.9%)	51 (54.3%)	0.368
Diabetes (%)	41 (18.7%)	15 (16.0%)	0.672
Dyslipidemia (%)	81 (37.0%)	29 (30.9%)	0.361
Vaginal Deliveries (≥1) (%)	215 (98.2%)	93 (98.9%)	0.970
Previous Prolapse Surgery (%)	44 (20.1%)	12 (12.8%)	0.124
BMI (kg/m2)	26.38 ± 4.15	27.33 ± 4.05	0.011

.

Pelvic floor muscle training was initiated in 70% of the symptomatic patients. Pharmacological treatment consisted of anticholinergics to manage overactive bladder (OAB), offered to patients with urgency incontinence.

Mid-urethral sling (MUS) procedures were performed in 18 patients, accounting for 5.5% of the cases. Botulinum toxin injections were utilized in three patients (0.9%) to provide relief for refractory urgency symptoms. These findings are presented in

Table 5. Prevalence of postoperative stress urinary incontinence in patients with LCS and use of MUS in second surgery.

		Postoperative UI n (%)
		Stress Incontinence	Use of MUS
Preoperative UI n (%)	Asymptomatic	31 (29.7%)	3 (9.7%)
	SUI	19 (29.7%)	7 (36.8%)
	UUI	12 (16.8%)	5 (41.6%)
	MUI	20 (30.7%)	3 (15%)
	Missing	2	-

.

4. Discussion

Previous studies have shown optimal results in women after minimally invasive POP surgery (sacrocolpopexy), especially in complex or high-grade (>II) prolapse [17]. Though conventional laparoscopy has been considered an adequate approach to SCP [18], in recent years, robot-assisted laparoscopic surgery has been described as a comparable option [19] with less overall operating time [20].

To date, there has been no clear evidence on how to manage urinary incontinence in patients undergoing LSC. POP has been associated with both stress and urgency urinary incontinence. Due to its shared multifactorial nature (age, parity and collagen integrity), most patients with pelvic prolapse present with SUI based on urethral hypermobility [21,22]. On the other hand, multiple studies have described a correlation between POP and OAB [23,24,25] causing UUI secondary to obstruction.

Petros [26] developed the theory of the integral system, based on laxity in the four main suspensory ligaments and perineal body as the main cause of POP and its associated urinary symptoms. Therefore, restoration of ligament/fascial length and tension is required to restore anatomy and function. This theory supports initially approaching patients with POP and urinary incontinence (IU) without specific anti-incontinence procedure but only minimally invasive POP surgery.

The literature reports preoperative stress urinary incontinence (SUI) in 50% of patients with stage II POP and 33% of those with stage III POP [27]. In our study, the prevalence of preoperative SUI was comparable, with 39.7% of the patients presenting with either pure or mixed SUI.

Our study demonstrates a significant improvement in stress urinary incontinence (SUI) rates, both pure and mixed, during follow-up after laparoscopic SCP. Among the patients with preoperative SUI, 37% (47/129) no longer reported symptoms postoperatively. Only a small proportion of the symptomatic patients required additional anti-incontinence procedures.

Borstad et al. [8] compared SUI outcomes with combined prolapse (SLC) and sling (MUS) surgery versus a two-step sequential approach in patients with persistent SUI three months after POP surgery. One-step surgery reduced the risk of postoperative SUI (5% vs. 23% at one-year post-surgery); in contrast, 44% of patients who underwent prolapse surgery alone never required SUI treatment. By 12 months, up to one-third of the women experienced SUI resolution or a significant improvement with prolapse surgery alone. These results are consistent with the findings in our study, decreasing the need for a more invasive procedure.

Van der Ploeg [9] designed another prospective study analyzing the differences in patients undergoing prolapse repair surgery with and without the placement of MUS. Women who underwent combined surgery showed lower rates of SUI: 39% vs. 78% (RR: 1.97; 95% CI: 1.44–2.71). Only 10% of women in the combined surgery group required further treatment for SUI, compared to 37% in the isolated prolapse repair group. Nevertheless, severe complications were more frequent in the MUS group than in the control group (16% versus 6%).

A recent meta-analysis conducted by the same group [28] reported that, in POP repair surgery, the number of patients required to treat (NNT) to prevent one case of significant de novo SUI varied based on preoperative status: nine for those with preoperative continence, seven for patients with occult SUI, and two for individuals with clinical SUI prior to surgery. Despite these results, the percentage of patients in our study who required MUS surgery (5.5%) is significantly lower compared to the number of women with preoperative SUI (39.7%). According to our results, the performance of anti-incontinence procedures associated with POP repair surgery should be considered on an individualized basis, particularly in patients with concomitant SUI.

Around 10% of asymptomatic patients develop postoperative SUI (de novo SUI) [29].

In the OPUS trial [30], 72% of patients developed de novo SUI within the first 3 months compared to 30% of those who received an MUS concurrently with POP surgery. Previously, Visco et al. [31] demonstrated a higher incidence of postoperative SUI in patients with occult SUI regardless of whether combined treatment was performed (CS without Burch: 58% vs. 38% [p = 0.04]; CS with Burch: 32% vs. 21% [p = 0.19]). In our cohort, 194 patients did not present with stress incontinence before POP surgery, and only 43 of them developed postoperative SUI, 8 of them requiring MUS (3 previously asymptomatic, 5 with UUI).

The relatively low utilization of MUS procedures in our cohort may warrant further investigation to determine the optimal patient selection criteria for concomitant anti-incontinence procedures during LSC.

Referring to UUI, an evaluation of the effect of POP repair on OAB symptoms reported resolution rates of up to 50–70% for UI [32,33,34]. In our cohort, 34/59 patients with preoperative UUI were asymptomatic after LCS and only 9 patients persisted with pure or mixed UUI. Finally, in the postoperative follow-up, three patients persisted with refractory urinary urgency, requiring botulinum toxin injections. These outcomes align with previously published data and highlight the corrective potential of LSC in addressing urgency symptoms in patients with POP.

In our study, postoperative urinary incontinence was recorded as a cumulative outcome, without stratification based on the time of onset. Consequently, we were unable to determine whether incontinence developed in the early postoperative period or emerged later during follow-up. This represents a limitation of our study, as the temporal evolution of urinary symptoms could provide additional insights into their etiology and management. Future studies should aim to incorporate a time-stratified assessment of urinary incontinence to better understand its progression after laparoscopic sacrocolpopexy.

5. Conclusions

Laparoscopic sacrocolpopexy using Surelift Uplift mesh demonstrates low complication rates and positive anatomical outcomes in the treatment of pelvic organ prolapse. Our findings indicate that most patients with preoperative urinary incontinence improve without the need for an additional anti-incontinence procedure, while a subset develops de novo stress urinary incontinence. These results highlight the importance of individualized patient management and structured follow-up to optimize long-term continence outcomes.