Reconsiderarea rolului unui procedeu de plicaturare suburetrală repetitivă, controlată, în incontinența urinară de efort, din perspectiva medicului ginecolog

Introduction

Stress urinary incontinence (SUI) is a controversial clinical entity in gynecological pathology, afflicting between 10% and 20% of women aged 25-65, with the incidence rising to more than 40% in women over 65 years old. It causes a significant decline in patients’ quality of life, leading to social, physical, psychological, occupational and sexual suffering⁽²⁾.

As patients age, these difficulties are represented by cardiac, pulmonary, orthopedic, neurological, hepatic or renal comorbidities, which can contraindicate both anesthesia and complex, laborious surgical interventions. The treatment of SUI has sparked many controversies over time. A significant number of patients with the aforementioned comorbidities can benefit from a minor surgical procedure performed under local anesthesia to alleviate stress urinary incontinence.

Brief history

The first surgical approach to the treatment of stress urinary incontinence was performed by Howard Kelly in 1914 using the uroplication technique. Another widely accepted technique in SUI therapy – the transobturator suburethral tape (TOT) technique – experienced a surge in popularity during the first two decades of the 21^st century. However, given multiple late complications associated with this technique (decreased urethral elasticity due to fibrosis, tape migration, bladder fibrosis, vaginal erosions, tape infection, local hematomas), there is a growing trend to abandon this procedure in the United Kingdom.

Classification

The International Continence Society defines the types of urinary incontinence as follows:

• Stress urinary incontinence.
• Urgency incontinence – an overactive bladder where urine loss is preceded by an extreme urge to urinate due to detrusor contraction. It occurs in cystitis, trigonitis, endocrine cystopathies, etc., and requires medical treatment.
• Mixed urinary incontinence – a combination of varying degrees of the first two types.
• Overflow incontinence.
• Extraurethral incontinence
  • congenital – ectopic ureter
  • acquired – urovaginal fistulas, mental illnesses, neurological conditions, etc.

Identifying the etiology of urinary incontinence is important, because as patients age, a combination of etiological factors is often observed, requiring specific, personalized surgical and medical treatments to alleviate symptoms. Stress urinary incontinence is the only type that benefits from surgical intervention⁽³⁾.

The surgical treatment for SUI includes interventions classified into four categories^(9-11):

1. Anterior colporrhaphy.

2. Interventions to correct bladder neck hypermobility by subpubic suspension.

3. Interventions to correct SUI caused by decreased intrinsic sphincter resistance, requiring “sling” surgical techniques and periurethral injections.

4. Salvage interventions, in the form of intentionally obstructive slings, artificial urinary sphincter implantation, etc.

Definition

Stress urinary incontinence is the involuntary loss of urine through the urethra, occurring simultaneously with activities that increase intraabdominal pressure (physical exertion, coughing, laughing), in the absence of bladder detrusor contractions⁽¹⁾.

Pathophysiology

The determining and contributing factors for stress urinary incontinence are childbirth, menopause and factors that increase abdominal pressure acting on the cervicourethral junction, such as obesity, chronic cough, constipation, etc. Anatomically, the urethra is suspended from the pubis by the pubourethral ligaments (anterior, inferior and posterior), which are bilateral and symmetrical⁽¹⁴⁾.

Childbirth causes urethrocele by elongating the pubo­urethral ligaments and tearing the urogenital diaphragm and the puboanal fibers of the levator ani muscles. This is accompanied by a descent of the cystourethral junction concurrent with the descent of the anterior vaginal wall. A possible partial denervation of the pelvic floor, to varying degrees, is also noted. Damage to the circular musculature of the urethra – resulting from the elongation of the anterior vaginal wall – causes ovalization of the lumen and the vesicourethral sphincter, widening and shortening of the urethra, and funneling of the cystourethral junction, with the disappearance of the posterior urethrovesical angle. This results in a deficiency in coaptation and sealing of the vesicourethral sphincter.

Effective urethral closure is the result of the interaction between extrinsic urethral support and intrinsic urethral integrity, both etiologies being influenced by a multitude of factors⁽⁶⁾. Anatomically, altered extrinsic urethral support can be objectively confirmed by hypermobility of the cervicourethral junction (retrograde cystography) – Figure 1. Intrinsic urethral functioning is more complex, but less understood⁽⁷⁾. The intrinsic anatomical factors responsible for urethral closure are:

• The internal urethral sphincter (smooth muscle, a continuation of the bladder detrusor forming the bladder neck).
• The external urethral sphincter (striated muscle located below the bladder neck).
• The crista urethralis and urethral glands, which assist in the coaptation of urothelial folds.
• The elasticity, tone and vascularization of the urethra.

The clinical assessment of extrinsic support and intrinsic urethral function has led gynecologists to divide SUI into two categories⁽⁶⁾:

• Stress urinary incontinence caused predominantly by anatomical hypermobility of the cervicourethral junction (representing 80-90% of cases).
• Incontinence caused by a decrease or deficiency in intrinsic sphincter resistance (representing 10-20% of cases). This type is rarer and harder to treat, requiring sling interventions and periurethral injections.

The surgical objectives in resolving SUI are⁽⁶⁾:

• Reducing the caliber of the urethra by correcting the ovalization, primarily at the level of the cystourethral sphincter.
• Repositioning the urethrovesical junction into the correct functional-anatomical manometric zone.
• Strengthening and cementing the suburethral supporting floor to diminish cervicourethral junction hypermobility and reduce the recurrence risk.
• Elongating the urethra.

The surgical treatment is indicated only if the patient considers the stress urinary incontinence to be bothersome or inconvenient, turning it into a social or hygiene issue⁽⁸⁾. Structures like the urethral lumen epithelium, spongy tissue and bladder trigone are highly estrogen-dependent. Consequently, during the estrogen depletion characteristic of menopause, increased abdominal pressure will progressively accentuate these anatomical changes and worsen the SUI symptoms.

Objectives

In our study, we utilized and improved a minimally invasive surgical procedure requiring only local anesthesia – originally initiated by Howard Kelly over a century ago. We used a staged surgical technique that allows for the immediate, intraoperative verification of the post-procedural result. Thus, through this technique (which falls under anterior colporrhaphy), we improved SUI by the controlled, staged relocation of anatomical structures displaced by childbirth. This minimally invasive solution, utilizing local anatomical support, improved the quality of life for elderly patients with major cardiac pathologies (bypass, cardiac rhythm disorders, heart failure, etc.) or post-stroke hemiparesis, which are formal contraindications for general or regional anesthesia.

Materials and method

Between 2021 and 2025, a total of 337 patients, aged 41-86 years old, were treated surgically for stress urinary incontinence in the Gynecology Department of the “Dr. Aurel Tulbure” Municipal Hospital, Făgăraș, Romania. The specific therapeutic solution was preceded by the treatment of local inflammation and local estrogenization.

The diagnostic algorithm for stress urinary incontinence included:

• Anamnesis – evaluating involuntary urine loss related to physical exertion, assessing risk factors (number of natural births, menopause, obesity) and conditions that increase the intraabdominal pressure (habitual constipation, smoking, bronchopulmonary diseases). A detailed history is the first step in differentiating SUI from urgency incontinence or nocturnal micturition, both of which improve with medical treatment.
• Stress test – observing urine loss during examination. Intravenous administration of methylene blue can exclude the existence of a urinary fistula.
• Objective clinical examination – evaluating pelvic support defects (cystocele, rectocele, anterior vaginal wall mobility, vaginal scars, cervical elongation, or uterine prolapsus) and assessing pudendal nerve injury via the bulbocavernosus reflex⁽⁴⁾.
• Urine culture.
• Pelviabdominal ultrasound – to exclude pelvic-abdominal tumors that might reduce bladder capacity.
• Pre- and postoperative urethral length evaluation⁽⁵⁾ – in continent patients, normal urethral length averages >3.5 cm in nulliparous and >2.5 cm in multiparous women. Postoperatively, a successful outcome is quantified by a urethral length increase of at least 1 cm.
• Functional explorations – clinical evaluations and continence tests (valve maneuver, Ulmsteen clamp maneuver, Bonney maneuver, Narik sign, Magendie maneuver).
• Urinary flow rate determination – in women, urination follows the “20-second rule” (the bladder empties in less than 20 seconds at a rate of 20 ml/s). Values below 15 ml/s at a bladder volume of 200 ml are pathological⁽⁶⁾, indicating impaired detrusor contractility or sphincter relaxation.
• Retrograde cystography – a downward displacement of the cervicourethral junction by more than 1.5 cm during increased abdominal pressure suggests hypermobility⁽⁴⁾ (Figure 1).
• Urodynamic evaluation – allows for a definitive diagnosis. Cystomanometry highlights detrusor behavior, where SUI is characterized by urine loss in the absence of detrusor contractions. It also includes uroflowmetry, leak point pressure measurement (values above 60 mm/H₂O indicate sphincter dysfunction; values above 100 mm/H₂O rule it out), and post-void residual estimation (physiological value is below 50 ml).
• Interdisciplinary consults (cardiology, nutrition, neurology, AIC, etc.) to identify medical-surgical risks and direct high-risk patients toward minimally invasive techniques under local anesthesia.

Results

Patient breakdown and surgical choices

• A total of 219 patients (65%), aged 45-72, opted for classic surgical correction of cystorectocele and SUI via anterior colporrhaphy, simple suburethral plicature, and posterior colpoperineorrhaphy with levator ani myorrhaphy. These patients had no severe comorbidities, and they received spinal anesthesia.
• A total of 97 patients (28.8%), aged 41-65, opted for a suburethral transobturator tape (TOT) for minimal cystocele, performed under spinal anesthesia. Rectocele was also corrected in 32 of these patients (33%).
• A total of 21 patients (6.2%), elderly, with severe comorbidities (myocardial infarction sequelae, cardiac shunts, rhythm disorders, or post-stroke hemiparesis). To reduce the anesthetic risk, a staged, repetitive subcervicourethral plicature technique was chosen under local anesthesia using 1% lidocaine (Xilină®) combined with i.v. acetaminophen. Chronic anticoagulant medications were substituted with low-molecular-weight heparin (Clexane®) five days preoperatively, with the last dose administered 24 hours before surgery.

Technical steps of the procedure:

1. With the patient in the gynecological position and a full bladder, urine loss is confirmed via coughing.

2. Preparatory operative steps equivalent to anterior colporrhaphy are performed, the bladder is emptied, and the urethral tract is identified from the external meatus to the bladder neck using a metal urinary sound. This step is repeated throughout the surgery to provide anatomical feedback on depth and path.

3. The anterior vaginal mucosa is incised longitudinally, starting 0.5 cm below the external urethral meatus (not 1.5 cm as classically described) for a length of 3 cm underneath the urethra toward the bladder neck. Starting at 0.5 cm ensures the correction of the middle third of the urethrocele and urethral lumen ovalization.

4. Using blunt, curved scissors, the vaginal mucosa is dissected laterally by 1.5 cm on both sides. Both ends of the sagittal incision are extended laterally by 1.5 cm to facilitate access to the healthy, undamaged portion of the Halban-Tandler fascia. This maximizes the volume of tissue available to be tucked underneath the cervicourethral zone.

5. The first suburethral plicature is performed using a non-resorbable No. 1 Biosilk suture on a 30-mm round needle. The needle enters cranially 1 cm laterourethral to the midline and 0.5 cm below the external meatus, exiting 2 cm sagittally, parallel to the urethra. The procedure is repeated symmetrically on the contralateral side using a “U” or “X” stitch.

6. Tightening the suture creates a tissue plicature that supports the middle third of the urethra and bladder neck, elongating the urethra and reducing hypermobility with each step (Figure 2). To avoid strangulating the urethra, the depth of the first two sutures must not exceed the median longitudinal axis plane of the urethra (i.e., less than 1 cm).

7. Intraoperative verification – the bladder is filled with 250-300 ml of saline colored with methylene blue via a Foley catheter. The catheter is removed, and the patient is asked to cough. If leakage persists, another plicature is performed using the same technique. Most patients required an average of three plicatures, though some obese patients with grade III SUI required up to seven.

8. Once continence is achieved, excess suburethral vaginal mucosa is excised. To prevent recurrence, the intact lateral portions of the Halban-Tandler fascia are brought to the midline using separate non-resorbable “U” sutures, forming a strong supporting column.

9. The procedure concludes with colporrhaphy using absorbable sutures.

Postoperative care

The Foley catheter is removed 24 hours postoperativ­ely, and the patient is mobilized. Spontaneous urinations are monitored to detect bladder distension, overflow incontinence, or high post-void residual volume (>50 ml). If these issues occur, the Foley catheter is reinserted with a plug at the free end. The patient removes the plug when they feel the urge to urinate and replaces it afterward, which provides motor re-education to the detrusor and sphincters within 48-72 hours.

A successful outcome is evidenced immediately by:

• absence of stress urinary incontinence
• slight resistance at the urethrovesical junction during the Foley catheter insertion
• urethral elongation of at least 1 cm
• hypermobility reduced below 1.5 cm on retrograde cystography (Figure 1).

Discharge recommendations include weight loss, smoking and coffee cessation, avoiding fluids before bedtime, bladder reeducation (Frewen, 1979), and performing pelvic floor muscle exercises (Kegel) for at least three months. In postmenopausal women, periodic local estrogenization is added to increase the efficiency of alpha-adrenergic receptors, maintaining urethral tone and relaxing the detrusor^(12,13).

Advantages of the procedure

• Minimally invasive, performed under local anesthesia, and allows same-day discharge.
• Allows associated corrections (cystocele, rectocele).
• Easy to perform, safe, and avoids bleeding from perforating vessels near the retropubic space.
• Continence can be verified immediately intraoperatively.
• Offers better predictability than Urodex injections, vaginal lasers (Er:YAG, CO₂), radiofrequency, or intravaginal pessaries.
• Avoids abdominal incisions, causes no foreign body reactions, and it is highly repeatable.
• Optimal indication for elderly patients with multiple severe cardiac comorbidities.

Major disadvantage

The primary drawback is the lack of long-term maintenance of the subcervicourethral support, partly due to tissue atrophy and decreased muscle tone caused by estrogen deficiency during menopause. Classic studies on traditional anterior colporrhaphy report a five-year recurrence rate of 35-65%. The relatively small sample size in this study does not yet allow for a definitive statistical estimation of the recurrence risk.

Conclusions

Although the incidence of stress urinary incontinence exceeds 40% after the age of 65 years old, the appetite for surgical intervention remains low from both doctors and patients. Surgery is dictated by the level of discomfort, and beyond a certain age, urine loss may no longer be perceived as a major inconvenience. Furthermore, aging increases the prevalence of functional incontinence of neurological or psychological origin (such as dementia), meaning a standalone SUI surgery provides limited overall relief.

Multifactorial incontinence in elderly patients requires a combination of local estrogens (to proliferate the urothelium and submucosal vascular plexus), anticholinergics (propantheline, imipramine, solifenacin, oxybutynin for nocturnal and overactive bladder symptoms), or alpha-adrenergic agonists to increase urethral pressure. A rigorous patient selection process based on objective clinical and paraclinical criteria ensures a high incidence of favorable results.  

Autor corespondent:   Cristian Baiulescu E-mail: baiulescucristian@yahoo.com

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

This work is permanently accessible online free of charge and published under the CC-BY.