Surgical Treatment of Stress Urinary Incontinence

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Surgical Treatment of Stress Urinary Incontinence

• Hann-Chorng Kuo
• Department of Urology
• Buddhist Tzu Chi General Hospital

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Surgical 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

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Historical 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

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Marshall Marchetti Krantz Procedure
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Repair of Paravaginal defect
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Current 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

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Burch colposuspension
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Periurethral injection for SUI
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Laparoscopic Bladder neck suspension
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Laparoscopic Colposuspension
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Long term (5-year) results of Anti-incontinence
surgery
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Surgical results by Types of stress incontinence
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Success rates of SUI in Different surgical
procedures
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Goals 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

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Elevated bladder neck after Incontinence surgery
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Defects in vaginal attachment and vaginal wall
weakness
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Anterior colporrhaphy with pubovaginal sling
procedure
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Pubovaginal 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

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Techniques of Pubovaginal sling procedure
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Fascial 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

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TVT 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

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MECHANICAL PROPERTIES OF IMPLANT MATERIALS
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Obstruction of TVT Sling
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Operative success rate in SUI
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Prolene 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

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Polypropylene mesh sling
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Techniques in performing prolene mesh pubovaginal
sling
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Urodynamic results after pubovaginal sling
procedure
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Videourodynamic results after Pubovaginal sling
procedure
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Detailed surgical techniques for Prolene
pubovaginal sling
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Bladder neck after Pubovaginal sling procedure
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Transrectal sonography after PVS
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Histology of prolene mesh sling
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Injection 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

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Surgical 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

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Complications 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

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How 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

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Low contractility in patient with SUI with
cystocele
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Recurrence 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

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A second sling to cure persistent stress
incontinence due to ISD
Synphysis pubis
Synphysis pubis
Urethra
Urethra
Bladder
Bladder
Sling2
Sling1
Sling2
Sling1
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When 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

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Postoperative 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

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Adequate thickness of endopelvic fascia prevent
sling compression
Urethral Striated muscle
Urethral Striated muscle
Incompetent urethra
Competent urethra
Sling
Sling
A
B
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Videourodynamics in Post-incontinence surgery BOO
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Transvaginal 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

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Management 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