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Surgical Treatment of Stress Urinary Incontinence
Dr Cecilia Cheon
Consultant, Department of Obs. & Gyn.Queen Elizabeth Hospital, Hong Kong, China
President, HK Urgynaecology Association
Definition of Urinary Incontinence
Urinary incontinence is the complaint of any
involuntary leakage of urine.
Abram P et al. Neuro Urodyn 02
Terminology - Symptoms
• Stress urinary incontinence (SUI)
- Involuntary leakage on effort or
exertion, or on sneezing or coughing
Urodynamic Terminology
• Urodynamic stress incontinence (USI)
- Involuntary leakage of urine during
increased abdominal pressure, in the
absence of a detrusor contraction
- Old term: Genuine stress
incontinence (GSI)
Impact on Quality of Life
• Embarrassment
• Reduced Self esteem
• Impaired emotional & psychological well-
being
• Poorer sexual relationships
• Impaired social activities and relationships
Economic Issues
• USA – estimated to be $8.1 billion (Hu,
1984)
• Active evaluation and treatment of nursing
home residents resulted in considerable
cost savings
• Indirect benefit : improve QOL of sufferers,
difficult to quantify
Stress incontinence : Weakness of the pelvic floor muscles
Treatment Strategy in women with USI / SUI
Conservative treatment is the first line of treatment for women with SI
International Consultation on Incontinence 01, Paris
Treatment for SUI
1. General measures
2. Pelvic floor exercises, PFEs
3. Biofeedback
- perineometer, vaginal cones
4. Electrical stimulation treatment
5. Mechanical devices
6. Pharmacological treatment
7. Surgery
Surgical Treatment
• Paravaginal repair
• Bladder neck suspensions
• Bladder Neck Slings / Midurethral slings
• Periurethral injections
• Artificial sphincter
Surgical Treatment
benefit risk
Best longterm result
minimalcomplication
Bladder Neck Suspensions
To use the anterior vagina as a hammock to
elevate the bladder neck
• Needle suspensions
• Retropubic suspensions
- abdominal
- laparoscopic
Retropubic Suspensions
• Burch’s
• MMK
Burch’s Colposuspension
Suspension of anterior vagina to the
iliopectineal ligament ( Cooper’s ligamen
t)
Abdominal
Laparoscopic
Burch Colposuspension
Burch Colposuspension
Subjective Cure Rate for Burch’s Operation
Objective Cure Rate for Burch’s Operation
Burch’s
Success rate
• 39 trials, 3,301 women
• 1st year 85 – 90%
• 5 year 70%
• No significant difference between open and laparoscopic approach
Lapitan et al, Cochrane Database Systematic Reviews 2008
Burch’s Colposuspension
Complications
• Detrusor overactivity 5 – 10%
• Voiding difficulty 10 – 15%
• Apical / posterior 5 – 17%
compartment prolapse
Slings
Sling under the bladder neck or mid-urethra
• Correct hypermobility
• Increase sphincter closure pressure
Midurethral-slings
• To date, three major slings available
- Tension-free vaginal tape (retropubic
approach) – TVT
- Tension-free vaginal tape
(transobturator approach) – TOT / TVT-O
- Minisling
The Integral Theory of Continence
• Pelvic organ prolapse mainly caused by
connective tissue laxity in the vagina or its
supporting ligaments
• Stress urinary incontinence is essentially
due to pelvic floor muscle weakness
The pictorial diagnostic algorithm summarizes the relationships between structural damage in the three zones and urinary and fecal symptoms. Arrows represent directional muscle forces.Anterior zone: external urethral meatus to bladder neck; middle zone: bladder neck to cervix; posterior zone: vaginal apex, posterior vaginal wall, and perineal body.
PRM = m.puborectalis; PCM = pubococcygeus; PUL = pubourethral ligament; ATFP = arcus tendineus fascia pelvis; N = bladder base stretch receptors
Tension-free Vaginal Tape (TVT)
• Ulmsten et al in 1996 • Treats stress incontinence by
positioning a polypropylene mesh tape underneath the urethra
• Monofilament, macroporous, >75 microns
• Free passage of marophages• In growth of fibroblast• Minimize erosion / infection
Tension-free vaginal Tape
Transobturator Tape (TOT)
• Delorme1 in 2001 described the
transobturator (outside-in : TOT)
procedure
• Insert mesh tape under the urethra
through small incisions in the groin area
• eliminates retropubic needle passage
Transobturator Tape (outside in)
Transobturator Tape (TOT-O)
• A variation of the technique has been
described in 2003 by de Leval termed the
TOT vaginal tape ‘‘inside-out’’ technique
(TVT-O)
Transobturator Tape (inside out)
Imaging
TVT / TOT / TVT-O Complications
• 3%
• Voiding difficulty, hemorrhage,
hematoma, bladder perforation,
infection
• No report of rejection, erosion or fistula
Comparison of Mid-urethral sling (TVT) to various procedure
Tension-Free Midurethral Slings in the Treatment of Female Stress Urinary Incontinence: A Systematic Review and Meta-analysis of Randomized Controlled Trials of Effectiveness Giacomo Novara et al. (Italy) 2007
Comparison of Mid-urethral Sling vs Colposuspension (QEH)
Colposuspension Mid-urethral Sling
No. of patients 222 402
Age 50.74 60.36* (p<0.001)
Bladder injury (%) 0.9 4* (p=0.03)
Days of bladder training (mean) 3.96 3.41
1 year subjective success (%) 82.7 89* (p=0.03)
1 year objective success (%) 89.1 83.4
1 year DO (%) 27.7 30.2
3 years subjective success (%) 76.3 (169) 87.7 (173)* (p=0.007)
3 years objective success (%) 77.1 85.6* (p=0.04)
5 years subjective success (%) 75.8 (95) 89.2 (74)* (p=0.03)
5 years objective success (%) 77.9 91.9* (p=0.01)
• Today, mid-urethral slings not only have replaced the Burch colposuspension as the gold standard in the treatment of SUI but also are even more often performed than colposuspension
• Easy to perform, superior in terms of operation time, postoperative pain, and hospital stays
• but similar cure rates
Peri-urethral Injection
Use of injectable bulk forming agents to
increase the urethral closure pressure
Peri-urethral Injection
Material
• Fat
• Collagen
• Silicone
Peri-urethral Injection
Advantages
• Safe
Disadvantages
• Low success rate 25 – 60%
• Expensive
• Need to be repeated every 1-2 year
Artificial Sphincter
• Last resort
• Use when all the other operation have
failed
Artificial Sphincter
Conclusions
• 1 in 2 women in HK has urinary symptoms
1 in 3 women has SUI
• Much advances made in the care of
female urinary incontinence
• Effective treatment available which can
significantly improve women’s QoL
Conclusion
• The concept of the midurethral sling has revolutionized surgical treatment of SUI. Its minimally invasive approach and success rates have led to an increasing acceptance of the technique
• TVT and TOT are both comparable in cure rate• The TOT approach is a potentially safer method
owing to the avoidance of the retropubic space: bladder, vessels, bowel injury
• Pregnancy is not contraindicated and cesarean is not abolute
• Long-term studies and RCTs are needed
to identify the proper indications for the
various types of slings and to assess
efficacy and complication rates over time.