Introduction: Pelvic organ prolapse (POP) in female patients is associated with sexual dysfunction and various urination disorders which may severely compromise their quality of life. Physicians often take no notice of changes to the upper urinary tract despite a number of reports putting the rate of impaired urinary flow in the upper urinary tract within the range of 7-43%. Due to lack of symptoms, ureterohydronephrosis in such patients may often go unnoticed and result in chronic kidney disease (CKD).
Objective: to assess changes to the upper urinary tract in patients with pelvic organ prolapse.
Methods: The study included 245 females with stage III - IV anteroapical prolapse. Staging was based on the POP-Q system. Kidney ultrasound was used to detect ureterohydronephrosis. All patients with ureterohydronephrosis underwent IV contrast-enhanced multislice computed tomography of the abdomen or, in case of stage 3b CKD, CT without contrast agent. Functional tests included uroflowmetry. Prolapse was managed with six-strap light mesh implant. Pairs of straps were introduced through (1) the sacrospinous and sacrotuberous ligaments, (2) the obturator muscles at equal distance from the pubic tubercle and ischial spine and (3) through the obturator muscles at the level of the pubic notch of the obturator foramen. Uterine and bladder prolapse prompted posterior colporrhaphy at the end of surgery. Follow-up examinations were performed in 1 month, 6 months and then annually, if needed. In select cases (97 patients), follow-up lasted over 5 years.
Results: Ureterohydronephrosis was detected in 27 (11%) patients. Of them, 26 had bilateral involvement, and only one patient had unilateral ureterohydronephrosis (right side). All the patients with ureterohydronephrosis had stage IV point C prolapse according to the POP-Q system. The majority of patients (24/27, 88.8%) developed CKD: 7 patients - stage 2, 13 patients - stage 3a and 4 patients - stage 3b. Surgery resulted in successful recovery of urinary flow in the upper urinary tract in 26 (96%) patients. In one case, persisting bilateral ureterohydronephrosis prompted simultaneous bilateral laparoscopic ureterocystostomy. Blood creatinine was low in 24 (88.8%) patients, and it only returned to normal values in 7 (25.9%) cases. It is worth noting that in all patients with ureterohydronephrosis post-void residual urine volume ranged from 0 to 100 ml. Urinary flow blockage was associated with lengthening and narrowing of the lower segments of the ureters as a result of prolapse. Another important contributing factor was the blood vessels in the cardinal ligaments of the uterus compressing the ureters.
Conclusions: Progressing POP leads to anatomic and functional changes in the lower urinary tract with subsequent involvement of the upper urinary tract. In the majority of cases, recovery of normal topography of the pelvic floor enables normal urinary flow in the upper urinary tract.
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