Female Pelvic Medicine and Reconstructive Surgery, MedStar Washington Hospital Center/Georgetown University, Washington, DC.
Female Pelvic Medicine and Reconstructive Surgery, Mayo Clinic, Rochester, MN.
Am J Obstet Gynecol. 2020 Aug;223(2):273.e1-273.e9. doi: 10.1016/j.ajog.2020.06.002. Epub 2020 Jun 3.
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.
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.
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.
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.
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.
尿道憩室是一种罕见的疾病，需要根据症状和体格检查高度怀疑，并通过影像学检查来确诊。常见的表现症状为压力性尿失禁（SUI）。推荐的治疗方法是手术切除和尿道憩室切除术。术后，约 37%的患者可能会持续出现压力性尿失禁，16%的患者可能会新发压力性尿失禁。在进行尿道憩室切除术时同时放置自体筋膜耻骨阴道吊带（PVS），可能有助于预防和治疗术后压力性尿失禁。然而，关于同期耻骨阴道吊带的安全性和有效性的研究甚少。
本研究的目的是比较行尿道憩室切除术时是否同时行耻骨阴道吊带术的患者的临床表现、结局、并发症和憩室复发率。
这是一项多中心回顾性队列研究，纳入了 2000 年 1 月 1 日至 2016 年 12 月 31 日期间行尿道憩室切除术的女性患者。通过当前操作术语代码识别研究参与者，并对其记录进行了回顾，以了解患者的人口统计学、医疗或手术史、症状、术前检查、同时进行的手术以及术后结局。比较了有和没有同期耻骨阴道吊带的患者的症状、复发率和并发症。主要结局是术后出现压力性尿失禁症状。基于没有耻骨阴道吊带的压力性尿失禁发生率为 50%，有耻骨阴道吊带的压力性尿失禁发生率为 10%，我们需要 141 例未行耻骨阴道吊带的憩室切除术患者和 8 例行耻骨阴道吊带的患者，以实现 83%的效能，P<.05。
我们从 11 家机构中确定了 485 例符合纳入标准的憩室切除术病例；其中 96 例（19.7%）患者同时行耻骨阴道吊带术。有耻骨阴道吊带的患者比没有耻骨阴道吊带的患者年龄更大（53 岁 vs 46 岁；P<.001），且有更多的患者之前行过憩室切除术（31% vs 8%；P<.001）。两组的术后随访时间（14.6±26.9 个月）相似。耻骨阴道吊带组术前的压力性尿失禁（71% vs 33%；P<.0001）、排尿困难（47% vs 30%；P=.002）和复发性尿路感染（49% vs 33%；P=.004）更为严重。在调整了既往憩室切除术、既往尿失禁手术、年龄、种族和产次后，行尿道憩室切除术时同时行耻骨阴道吊带术显著提高了压力性尿失禁缓解的可能性（调整后的优势比，2.27；95%置信区间，1.02-5.03；P=.043）。但它对新发压力性尿失禁没有明显的保护作用（调整后的优势比，0.86；95%置信区间，0.25-2.92；P=.807）。同期耻骨阴道吊带增加了术后短期（<6 周）尿潴留（调整后的优势比，2.5；95%置信区间，1.04-6.22；P=.039）和长期（>6 周）尿潴留（调整后的优势比，6.98；95%置信区间，2.20-22.11；P=.001）以及复发性尿路感染（调整后的优势比，3.27；95%置信区间，1.26-7.76；P=.013）的风险。新发膀胱过度活动症（调整后的优势比，1.48；95%置信区间，0.56-3.91；P=.423）和急迫性尿失禁（调整后的优势比，1.47；95%置信区间，0.71-3.06；P=.30）的风险没有显著增加。同期耻骨阴道吊带并不能预防憩室复发（调整后的优势比，1.38；95%置信区间，0.67-2.82；P=.374）。总的来说，憩室复发率为 10.1%，两组之间无差异。
这项大型回顾性队列研究表明，在进行尿道憩室切除术时同时行耻骨阴道吊带术可显著提高压力性尿失禁的缓解率。同期耻骨阴道吊带术会增加术后短期和长期尿潴留以及复发性尿路感染的风险。
