Title: Surgical Treatment of Stress Urinary Incontinence
1Surgical Treatment of Stress Urinary Incontinence
- Hann-Chorng Kuo
- Department of Urology
- Buddhist Tzu Chi General Hospital
2Surgical Goals for Stress Urinary Incontinence
- To restore urinary continence
- To preserve normal micturition
- Free of bladder outlet obstruction
- Not to create newly developed urge incontinence
or exacerbate existing urge incontinence - Not to jeopardize renal function
3Historical surgical procedures for stress urinary
incontinence
- Kelly plication procedure
- Marshall-Marchetti-Kratz procedure
- Pereyra procedure
- Stamey bladder neck suspension
- Raz bladder neck suspension
- Gittes bladder neck suspension
4Marshall Marchetti Krantz Procedure
5Repair of Paravaginal defect
6Current popular surgical procedures for SUI
- Burch colposuspension procedure
- Fascial pubovaginal sling procedure
- Vaginal sling procedure
- Collagen, Teflon, fat injection
- Synthetic pubovaginal sling procedure
- Tension free vaginal tape
- Laparoscopic bladder neck suspension
7Burch colposuspension
8Periurethral injection for SUI
9Laparoscopic Bladder neck suspension
10Laparoscopic Colposuspension
11Long term (5-year) results of Anti-incontinence
surgery
12Surgical results by Types of stress incontinence
13Success rates of SUI in Different surgical
procedures
14Goals for Surgical correction of Stress
incontinence
- Adequate vaginal support of the urethra and
bladder neck for urethral hypermobility - Restoration of hammock effect during stress for
damages in attachments to fascia pelvis - Increase urethral coaptation if intrinsic
sphincteric deficiency exists - Correct prolapse concomitantly
- Do not create bladder outlet obstruction
15Elevated bladder neck after Incontinence surgery
16Defects in vaginal attachment and vaginal wall
weakness
17Anterior colporrhaphy with pubovaginal sling
procedure
18Pubovaginal Sling procedures
- Fascial sling rectus fascia, fascia lata
- Sling on a string
- Artificial sling - mersilene silastic dacron
marlex - Cadaveric or porcine collagen sling
- Bone anchor sling
- TVT / SPARC polypropylene mesh
19Techniques of Pubovaginal sling procedure
20Fascial and Silastic slings
- Silastic and fascial slings are not elastic
- Both form rigid support at bladder neck
- Move very little 1 to 2 mm only
- Produce proximal compression
- More likely to be obstructive
- Mersilene more likely to erode
21TVT tension-free vaginal tape
- First published 1996 by Ulmsten
- gt200,000 performed worldwide to date
- Innovative in
- Midurethral positioning
- Stretchable woven Prolene mesh
- Rough edge for fixation to tissues
- Local or regional anaesthesia / day surgery
22MECHANICAL PROPERTIES OF IMPLANT MATERIALS
23Obstruction of TVT Sling
24Operative success rate in SUI
25Prolene mesh Pubovaginal sling procedure
- 64 patients, aged 37 82 years
- Mean follow-up 24 months
- 52 were dry, 2 were dry after a second sling, 10
had improvement but mild SUI - Satisfactory rate 86
- Persistent DI in 3, resolution of DI in 3,
- De novo DI in 4
26Polypropylene mesh sling
27Techniques in performing prolene mesh pubovaginal
sling
28Urodynamic results after pubovaginal sling
procedure
29Videourodynamic results after Pubovaginal sling
procedure
30Detailed surgical techniques for Prolene
pubovaginal sling
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52Bladder neck after Pubovaginal sling procedure
53Transrectal sonography after PVS
54Histology of prolene mesh sling
55Injection Therapy for ISD
- Facilitate coaptation of urethral mucosa
- Create some degree of outlet obstruction
- De novo urge in 12.6 28
- 3 of patients had allergic reaction
- A second injection is needed in 11-25
- A higher failure rate in fat injection
- The depth of injection relates to success rate
56Surgical Therapy for SUI
- Sling and retropubic procedures had 82-84
success rate beyond 48 months - Needle suspension 65-70 success
- Sling appears to be the most efficacious over
time for all types of SUI - Success rate should be determined at least 24
months after procedure
57Complications of Sling procedure
- Bladder perforation
- De novo urge incontinence
- Urinary retention after operation
- Sling erosion and infection
- Granuloma formation in vaginal wall
- Abdominal wall herniation
- Persistent wound pain and lump sensation
58How to prevent surgical failure
- Accurate diagnosis of types of SUI before
operation - Concomitant correction of cystocele and vesiceral
prolapse - Minimal dissection of suburethral endopelvic
fascia - Properly identify the bladder neck
- Hemostasis and sterile surgical procedures
- Adjust the suspension tension to avoid obstruction
59Low contractility in patient with SUI with
cystocele
60Recurrence of Incontinence
- Identify the cause of recurrent incontinence
- Investigate anatomical defects in urethra
- Use of prolene mesh for definite correction
- Treating denovo urge with anticholinergics
- Release of sling if presence of obstruction
- Apply a second sling for persistent ISD after the
first anti-incontinence surgery
61A second sling to cure persistent stress
incontinence due to ISD
Synphysis pubis
Synphysis pubis
Urethra
Urethra
Bladder
Bladder
Sling2
Sling1
Sling2
Sling1
62When urine retention develops
- Pressure flow study to determine the cause
- Most of patients can void within 2 weeks
- On CISC or trocar cystostomy for training
- Give alpha-blocker and baclofen
- Give NSAID to eradicate inflammation and relieve
wound pain - Have more patience than the patients do
63Postoperative Outlet Obstruction
- An elevated and semi-open bladder neck without
difficulty in cystoscopy will prevent - Patients present with dysuria, urge, and large
residual urine - High detrusor pressure and low flow rate
- Transrectal sonography to detect angulation
- Lysis of sling tension can be performed within 7
postoperative days
64Adequate thickness of endopelvic fascia prevent
sling compression
Urethral Striated muscle
Urethral Striated muscle
Incompetent urethra
Competent urethra
Sling
Sling
A
B
65Videourodynamics in Post-incontinence surgery BOO
66Transvaginal urethrolysis
- A tolerable way to relieve sling tension
- Midline vaginal incision under local anesthesia
- Find the sling and cut it at midline
- Suture the sling edges to prevent complete
slippage of the sling - A high continence rate remains
67Management of areflexic bladder following
incontinence surgery
- Pressure flow to determine cause of SUI
- Avoid incontinence surgery in low compliant
bladder - Use of fascial sling instead of EBNS
- Select a procedure easy for urethrolysis
- Apply the sling loosely at proximal urethra
- Teach patient to use CISC for evacuation