Combining Pectoplexy with TVT for Vaginal Prolapse and Stress Urinary Incontinence
Concurrent TVT placement with prolapse repair (including pectoplexy) is supported for women with both stress urinary incontinence and vaginal prolapse, with synthetic midurethral slings demonstrating superior efficacy and lower retention rates compared to other anti-incontinence procedures when performed alongside prolapse surgery.
Efficacy of Combined Procedures
Synthetic midurethral slings (including TVT) combined with prolapse repair achieve an 85-87% cure rate at 12-47 months, which is comparable to TVT performed in isolation 1. The American Urological Association meta-analysis demonstrates that when any patient receives concurrent prolapse treatment, synthetic slings at the midurethra maintain excellent outcomes with cure/dry rates of 85% (95% CI 80-89%) at 12-23 months and 87% (95% CI 81-91%) at 24-47 months 1.
- Multiple studies confirm that TVT can be effectively combined with various prolapse repairs, including anterior/posterior colporrhaphy and apical suspension procedures 2, 3.
- In women with symptomatic stress incontinence undergoing prolapse repair, adding TVT reduces postoperative incontinence from 35.7% to 6.7% compared to prolapse repair alone 3.
Urinary Retention Risk
The retention rate for synthetic midurethral slings with concurrent prolapse treatment is only 3% (2-5%), significantly lower than bladder neck slings at 10% or autologous fascial slings at 5% 1. This difference was considered clinically important by the AUA guideline panel 1.
- Retention lasting more than 1 month or requiring intervention occurs in approximately 3% of patients receiving synthetic midurethral slings with prolapse repair 1.
- When TVT is combined with sacrospinous colpopexy specifically, short-term retention (up to 1 week) increases to 33.3%, though long-term retention rates remain comparable to TVT alone 4.
De Novo Urgency Considerations
De novo urge incontinence occurs in 11% of patients receiving synthetic midurethral slings with concurrent prolapse treatment, which is comparable to rates without prolapse repair 1. This represents a quality of life consideration that should be discussed preoperatively.
- For patients with preexisting urge incontinence, postoperative urgency persists in approximately 52% when synthetic midurethral slings are combined with prolapse repair 1.
- These urgency rates are lower than those seen with retropubic suspensions (14% de novo) or autologous fascial slings (10% de novo) when combined with prolapse repair 1.
Management of Occult Stress Incontinence
For women without symptomatic stress incontinence but with severe prolapse, pessary testing identifies those at high risk for postoperative incontinence 5. Among women with positive pessary tests who underwent hysterectomy without TVT, 64.7% developed symptomatic stress incontinence postoperatively 5.
- Prophylactic TVT in women with positive pessary tests achieves a 90.6% cure rate for preventing postoperative stress incontinence 5.
- However, in women with occult stress incontinence, prolapse repair alone may be as efficient as adding TVT, with decreased voiding dysfunction risk (0% vs 27.3%) 3.
Perioperative Management
Cystoscopy should be performed as a standard component during TVT placement with prolapse repair to detect bladder perforations, which occur in approximately 6% of cases 1.
- Urinary catheter removal after a short postoperative period is associated with lower rates of recatheterization, bladder infection, and length of stay 1.
- Early catheter removal (postoperative day 1 vs day 5) shows no benefit for prolonged catheterization in women undergoing combined procedures 1.
Common Complications
Bladder injury occurs in 6% of synthetic midurethral sling cases, urinary tract infection in 11%, and vaginal mesh extrusion in 7% when performed with prolapse repair 1. These rates are acceptable compared to alternative procedures.
- Fever occurs in approximately 8-11% of cases when combining procedures 1.
- Wound complications occur in 8% of combined procedures 1.
Key Clinical Pitfall
Avoid placing synthetic slings at the bladder neck rather than midurethra when combining with prolapse repair, as bladder neck placement increases retention rates from 3% to 10% and urethral/bladder erosion rates to 5% 1.