Surgical Replacement of the Uterosacral- and Pubourethral-Ligaments as Treatment for Urgency Urinary Incontinence

Research Article

Austin J Womens Health. 2016; 3(1): 1019.

Surgical Replacement of the Uterosacral- and Pubourethral-Ligaments as Treatment for Urgency Urinary Incontinence

Ludwig S*, Stumm M, Mallmann P and Jager W*;

Department of Obstetrics and Gynecology, University of Cologne, Germany

*Corresponding author: Jager W and Ludwig S, Abteilung Gynakologie und Geburtshilfe, Department of Obstetrics and Gynecology, Universitat zu Köln, Kerpener Strasse 34, 50931 Köln, Germany

Received: December 16, 2015; Accepted: March 25,2016; Published: March 29, 2016


Aim: The bilateral replacement of the uterosacral ligaments was developed for the treatment of female pelvic organ prolapse. The aim of the present study was to evaluate the effect of this treatment on Mixed Urinary Incontinence (MUI) and Urgency Urinary Incontinence (UUI) in patients with minor prolapse.

Materials and Methods: This was a retrospective study of 71 women suffering from MUI and UUI. Previous conservative treatments had failed. They were operated by Cervico-Sacropexy (CESA) or Vagino-Sacropexy (VASA).

All patients had apical vaginal prolapse (POP-Q stage I - II). Urinary incontinence was classified according to validated urinary incontinence questionnaires. The outcome was evaluated 4 months after surgery. Patients who were still urinary incontinent received an additional Transobturator Tape (TOT). The final outcome was assessed 4 months thereafter.

Results: 71 patients suffering from MUI and UUI with POP-Q stage I - II were surgically treated by CESA (n=26) and VASA (n=45). After CESA and VASA, the apical vaginal prolapse was repaired in all patients. 16 patients (62%) of the CESA group and 15 patients (33%) of the VASA group were cured of their urinary incontinence. The uncured patients agreed to an additional TOT and 53% of them were cured after this procedure. An overall cure rate for MUI and UUI of 77% was obtained by CESA and 71% by VASA.

Conclusion: Besides the repair of genital prolapse, the bilateral replacement of the uterosacral ligaments by CESA or VASA cured 33% to 62% of patients who suffered from MUI and UUI. After a TOT an overall cure rate ranging from 71% to 77% was observed

Keywords: Urgency urinary incontinence; Mixed urinary incontinence; Uterosacral ligaments; Cervico-Sacropexy; Vagino-Sacropexy


BBUSQ-22: Birmingham Bowel and Urinary Symptoms Questionnaire; CESA: Cervico-Sacropexy; ICIQ-UI-SF: International Consultation on Incontinence Modular Questionnaire; MUI: Mixed Urinary Incontinence; OAB-SS: Overactive Bladder Symptom Score; POP: Pelvic Organ Prolapse; POP-Q: Pelvic Organ Prolapse Quantification System; PUL: Pubourethral Ligament; PVDF: Polyvinylidene Fluoride; SUI: Stress Urinary Incontinence; TOT: Transobturator Tape; UI: Urinary Incontinence; USL: Uterosacral Ligament; UUI: Urgency Urinary Incontinence; VASA: Vagino- Sacropexy


In 2000, Barber et al. reported a new surgical procedure for the treatment of pelvic organ prolapse [1]. Basically, they sutured the apex of the vagina to the left and right Uterosacral Ligament (USL). Besides the “excellent anatomical correction of the prolapse“, they observed a “significant improvement of voiding function“ [1].

In 2003, Amundsen combined this bilateral uterosacral ligament fixation with a pubovaginal sling in patients who additionally suffered from Stress Urinary Incontinence (SUI) [2]. In all of their 33 patients, SUI was successfully treated after this combined procedure. However, the most remarkable observation in this study was that also 14 out of 17 (82%) patients suffering from Urgency Urinary Incontinence (UUI) were cured after these operations.

Barber and Amundsen focused their treatment on patients with advanced pelvic organ prolapse (POP-Q stages II– IV). However, the high cure rate of their combined treatment modality led us to hypothesize that a defect of the USL and Pubourethral Ligament (PUL) plays a critical role in the development of Mixed Urinary Incontinence (MUI) and UUI [3]. We therefore decided to offer women suffering from MUI and UUI even with less advanced pelvic organ prolapse (e.g. POP-Q stage I) a surgical replacement of the USL.

In contrast to Barber and Amundsen, we chose an abdominal approach because we decided to replace the defective USL. We sutured alloplastic (polyvinylidene fluoride, PVDF) USL tapes at the sacral bones and at the cervix (CESA) or vagina (VASA).

Besides the repair of prolapse, we analyzed the clinical outcome of 71 patients with UUI and MUI treated by CESA or VASA operation.

Materials and Methods


This study was initiated for patients suffering from Mixed Urinary Incontinence (MUI) and Urgency Urinary Incontinence (UUI) with otherwise asymptomatic pelvic organ prolapse. All patients had failed previous conservative treatments. They all had pelvic organ prolapse either of the uterus or vaginal vault, however, not reaching to the hymen (POP-Q stage I– II). All patients were operated by Cervico-Sacropexy (CESA) or Vagino-Sacropexy (VASA). If they still remained incontinent thereafter, they received a Transobturator Tape (TOT) in a second operation.

Exclusion criteria were Stress Urinary Incontinence (SUI) only, previous sacrospinous fixation, sacrocolpopexy, colposuspension and vaginal or abdominal pelvic mesh implantation.

All examinations and surgeries were performed at the Department of Obstetrics and Gynecology at University Hospital of Cologne, Germany.

All women underwent detailed internal genitalia urogynecological examination, preoperative cytology of the cervix and ultrasound screening. Details about previous operations (e.g. anterior colporrhaphy) were taken from the records.

Clinical examinations were performed before CESA or VASA and 4 months after the surgeries. The continence status was evaluated at that time by validated urinary incontinence questionnaires and personal interviews. A TOT was indicated when patients were not cured from their urinary incontinence after CESA or VASA. In these patients the follow-up was exactly the same as after CESA and VASA.

For the purpose of this report, patients who did not appear at follow-up examinations were excluded (“drop-outs“).

Evaluation of urinary incontinence

Urinary Incontinence (UI) was assessed and classified according to the recommendation of the ICS [4]. UI symptoms were based on micturition protocols and assessed by means of validated incontinence questionnaires (the Birmingham Bowel and Urinary Symptoms Questionnaire, BBUSQ-22, the International Consultation on Incontinence Modular Questionnaire, ICIQ-UI-SF and the Overactive bladder symptom score, OABSS) [5-7]. Whenever needed, a study nurse explained the questions to the patients.

For the purpose of this manuscript we deliberately decided to focus the analysis on the following three Questions:

Question 1: “How many times do you typically urinate from waking in the morning until sleeping at night?“

Question 2: “How often do you leak urine because you cannot defer the sudden desire to urinate?“

Question 3: “Does urine leak when you are active, exert yourself, cough or sneeze?“.

UUI was defined as =8 voids per day and / or involuntary urinary leakage =1 times a day. SUI was defined as urinary leakage during exercise, coughing or sneezing. MUI was defined as symptoms of both groups (UUI and SUI).

Evaluation of pelvic organ prolapse

Pelvic organ prolapse measurements were carried out according to the POP-Q system described by Bump et al. [8]. Patients were classified according to the apical descent, which is represented by POP-Q point C. The POP-Q measurements were done in lithotomyposition with Valsalva and cough maneuvers.


Cervico-sacropexy (CESA) and vagino-sacropexy (VASA): Cervico-sacropexy (CESA) or vagino-sacropexy (VASA) was performed; these are open abdominal surgical treatments described by Jager et al. [9]. In brief, specially designed Polyvinylidene Fluoride (PVDF) tapes (Dynamesh CESA, Dynamesh VASA, FEG Textiltechnik mbH, Aachen, Germany) were used to replace the Uterosacral Ligaments (USL) (Figure 1) [10,11].