Surgical%20Treatment%20of%20Stress%20Urinary%20Incontinence

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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
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Definition of Urinary Incontinence

• Urinary incontinence is the complaint of any
• involuntary leakage of urine.
• Abram P et al. Neuro Urodyn 02

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Terminology - Symptoms

• Stress urinary incontinence (SUI)
• - Involuntary leakage on effort or exertion, or
  on sneezing or coughing

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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)

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Impact on Quality of Life

• Embarrassment
• Reduced Self esteem
• Impaired emotional psychological well-being
• Poorer sexual relationships
• Impaired social activities and relationships

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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

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Stress incontinence Weakness of the pelvic
floor muscles
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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

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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

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Surgical Treatment

• Paravaginal repair
• Bladder neck suspensions
• Bladder Neck Slings / Midurethral slings
• Periurethral injections
• Artificial sphincter

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Surgical Treatment
benefit
risk
minimal complication
Best long term result
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Bladder Neck Suspensions

• To use the anterior vagina as a hammock to
  elevate the bladder neck
• Needle suspensions
• Retropubic suspensions
• - abdominal
• - laparoscopic

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Retropubic Suspensions

• Burchs
• MMK

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Burchs Colposuspension

• Suspension of anterior vagina to the
  iliopectineal ligament(Coopers ligament)
• Abdominal
• ? Laparoscopic

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Burch Colposuspension
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Burch Colposuspension
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Subjective Cure Rate for Burchs Operation
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Objective Cure Rate for Burchs Operation
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Burchs

• 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

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Burchs Colposuspension

• Complications
• Detrusor overactivity 5 10
• Voiding difficulty 10 15
• Apical / posterior 5 17
• compartment prolapse

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Slings

• Sling under the bladder neck or mid-urethra
• Correct hypermobility
• Increase sphincter closure pressure

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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

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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

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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
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Tension-free Vaginal Tape (TVT)

• Ulmsten et al in 1996
• Treats stress incontinence by positioning a
  polypropylene mesh tape underneath the urethra
• Monofilament, macroporous, gt75 microns
• Free passage of marophages
• In growth of fibroblast
• Minimize erosion / infection

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Tension-free vaginal Tape
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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

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Transobturator Tape (outside in)
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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)

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Transobturator Tape (inside out)
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Imaging
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TVT / TOT / TVT-O Complications

• 3
• Voiding difficulty, hemorrhage, hematoma, bladder
  perforation, infection
• No report of rejection, erosion or fistula

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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
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Comparison of Mid-urethral Sling vs
Colposuspension (QEH)
Colposuspension Mid-urethral Sling
No. of patients 222 402
Age 50.74 60.36 (plt0.001)
Bladder injury () 0.9 4 (p0.03)
Days of bladder training (mean) 3.96 3.41
1 year subjective success () 82.7 89 (p0.03)
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) (p0.007)
3 years objective success () 77.1 85.6 (p0.04)
5 years subjective success () 75.8 (95) 89.2 (74) (p0.03)
5 years objective success () 77.9 91.9 (p0.01)
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• 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

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Peri-urethral Injection

• Use of injectable bulk forming agents to increase
  the urethral closure pressure

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Peri-urethral Injection

• Material
• Fat
• Collagen
• Silicone

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Peri-urethral Injection

• Advantages
• Safe
• Disadvantages
• Low success rate 25 60
• Expensive
• Need to be repeated every 1-2 year

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Artificial Sphincter

• Last resort
• Use when all the other operation have failed

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Artificial Sphincter
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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 womens QoL

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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

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• 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.

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