Need for prophylactic sling after pelvic organ prolapse repair under question. (Future Incontinence at Issue).

ST. Louis -- Whether to do a prophylactic incontinence procedure on a patient who is having a pelvic organ prolapse repair is a clinical conundrum that's begging to be researched, Dr. Robert Kovac said at the 11th International Pelvic Reconstructive and Vaginal Surgery Conference.

"It's a very problematic situation. You've got an elderly women with big-time prolapse. The prolapse itself is kinking the urethra and that's why she's continent. Then you go in and fix that prolapse, and if you don't do something prophylactically; it's your loss if that's the one that leaks on you," said Dr. Clifford Wheeless of Johns Hopkins University Medical Center, Baltimore.

At the same time, there is no reliable test to determine which patients undergoing prolapse repair are going to leak later and would therefore need a prophylactic sling. Since that's the case, "I would do a prophylactic [sling] on all of them," Dr. Wheeless asserted at the meeting, which was jointly sponsored by the Society of Pelvic Reconstructive Surgeons and the American College of Obstetricians and Gynecologists.

There may not be data to support that tactic, he said, but "I've just had too many [patients] where I've done a beautiful repair, and going home they're incontinent. They don't remember what a beautiful repair you did on their prolapse. They remember the fact that they're going home in diapers."

Dr. Fred Govier of Virginia Mason Medical Center, Seattle, agreed. "I see a large number of these people," he said, referring to patients who have incontinence following pelvic organ prolapse repair.

"If you've got a women with a third-degree cystocele in the office, it's tough to make that woman leak. Even if you study her with a pessary in place, the results can be misleading and many women will come back leaking," Dr. Govier told this newspaper.