Surgical management for stress urinary incontinence

Women who have simple stress urinary incontinence (SUI) after conservative care has failed, or the primary stress component of mixed urine incontinence (after adequate management of the urge component) may be eligible for the surgical surgery of SUI. Regardless of the predominant symptom, women with mixed urine incontinence (MUI) should think about starting a pharmaceutical trial for urge urine incontinence (UUI). Women with MUI should be made aware that, even with surgical care, the long-term remission of urgent symptoms is unknown. Following evaluation, the decision to have surgery is decided after considering⁽¹⁾:

• the comparative severity of intrinsic sphincter deficit (ISD) and urethral hypermobility
• prior attempt at conservative care
• requirement for concurrent procedures, such as fistula repair, hysterectomy, or prolapse
• lifestyle of the patient – heavy physical activity or inactivity
• patient’s age and general state of health
• past surgery on the pelvis or retropubic area
• mesh hernia repair or prior abdominal surgery
• prior pelvic fracture, auto accident, or hip abduction issues.

They should be counseled regarding the possibility of an ineffective correction, an injury sustained during surgery, retention following surgery, erosion, infection, or difficulty voiding. In order for women to make an educated decision, they should be informed about the risks and prognosis associated with various operations.

The various options of surgical procedures are presented in Table 1:

• Retropubic colposuspension.
• Burch (open/laparoscopic/robotic).
• Marshall-Marchetti-Krantz procedure.
• Paravaginal defect repair.
• Tension-free mid-urethral slings (MUS)/synthetic tapes (TVT, TVT-O, MiniArc sling).
• Biological bladder neck (autologous) slings. 

Anterior colporrhaphy with Kelly’s stitch, needle suspensions (Pereyra, Stamey), paravaginal defect repair and the Marshall-Marchetti-Krantz procedure for the treatment of SUI are no longer offered as per latest recommendations⁽²⁾.

The goal of retropubic colposuspension is to maintain the anterior vaginal wall in a retropubic posture, around the bladder neck and proximal urethra. This permits urethral compression against a stable sub-urethral layer and inhibits their descent at elevated intraabdominal pressure. The choice between a vaginal and a retropubic approach depends on a number of factors, including the need for a laparoscopy or laparotomy due to other pelvic prolapses or diseases, the amount of prolapsed pelvic organs, the condition of the intrinsic urethral sphincter mechanism, the patient’s age and health condition, the patient’s history of mesh or sling complications, the patient’s desire for future fertility, the surgeon’s preference or expertise, and the informed patient’s preferences⁽³⁾.

In Bursch colposuspension, the urethra and anterior vaginal wall are depressed during this operation once the retropubic space has been penetrated. With the middle and index fingers on each side of the proximal urethra, the surgeon’s non-dominant hand is positioned in the vagina with the palm pointing upward. Two non-absorbable sutures (Prolene no. 1) are inserted bilaterally, lateral to the proximal part of the urethra and at the level of the bladder neck. The vaginal wall should be fully stitched, with the needle positioned parallel to the urethra. Now, each of the four sutures is passed through the Cooper’s ligament, allowing the ends to escape above the ligament. Although the fibrosis and scarring of the periurethral and vaginal tissues over the obturator internus and levator fascia are more important for the cure than the suture material itself, one does not need to worry about this when tying the sutures⁽⁴⁾.

According to a 2012 Cochrane study, the continence rates are between 85% and 90% after one year and around 70% at five years. This used to be thought of as the gold standard for treating SUI. Greater baseline urge incontinence, hypoestrogenic states, obesity, previous hysterectomy, past surgeries to repair SUI, more advanced prolapse, and intrinsic sphincter deficit are conditions that reduce the possibility of cure for incontinence following retropubic colposuspension. The complications include difficulties voiding (10.3%), overactivity of the detrusor muscle (17%), and genitourinary prolapse (enterocele, cystocele or rectocele; 13.6%). It is not advised to do laparoscopic retropubic colposuspension as a standard surgical procedure for stress urinary incontinence. Nonetheless, it may be taken into consideration for female patients who require a concurrent laparoscopic procedure performed by skilled laparoscopic surgeons. There were no appreciable variations in patients’ satisfaction at six months, 24 months, or 3-5 years of follow-up, nor in objective or subjective indices of cure when comparing laparoscopic with open Burch^(4,5). Additionally, laparoscopic colposuspension required 87 minutes, as opposed to 42 minutes, but it was linked to less discomfort, less blood loss, and a speedier return to regular activities. Because synthetic mid-urethral tapes are less invasive, more affordable, and have success rates comparable to Burch, they are becoming increasingly popular. They also reduce morbidity, with shorter hospital stays, and let patients return to work sooner.
 

Depending on the orientation of the trocar passage, there are two types of tension-free vaginal tape (TVT) retropubic MUS techniques: bottom-up (TVT Exact, RetroArc) and top-down (SPARC). On the vagina, a 2-3 cm mid-urethral vertical incision is created. There are tiny tunnels created to the pubic ramus inferior. On either side of the urethra, a polypropylene tape fitted to two sharply curved trocars measuring 5 mm is inserted into the retropubic space and out through two exit sites in the suprapubic region of the anterior abdominal wall. Cystoscopy is used to exclude bladder damage. The plastic sheaths covering the mesh matrix are taken off, and the mesh’s tension is verified once again. The vaginal incision is closed at this point. The success rate of this treatment is around 87%^(4,5) (Figure 2).
 

Transobturator tape (TVT-O): this transobturator method, as described by DeLorme, almost avoids the risk of significant vascular damage and bladder or bowel perforation, which are estimated to occur in 3% to 5% of TVT procedures due to the blind passage of trocars. In this case, specifically made needles are inserted either from the vaginal incision into the inner groin (inside-out method, as seen at the American Medical Systems) or from the inner groin into the vaginal incision (inside-out technique; e.g., Gynecare, Sommerville). The surgeon’s preference and level of expertise will determine which strategy is best. After the vaginal incision has been previously dissected, the trocar tip is entered and gently advanced while the trocar handle is rotated, hugging the pubic rami to ultimately emerge at the exit point previously designated at the level of the clitoris. The vaginal sulcus is examined to make sure there hasn’t been a perforation. Following a cystourethroscopy, if everything checks out okay, the vaginal incision is sutured following the proper sling tensioning. The range of its success rate is 73% to 92%⁽⁶⁾ (Figure 3).
 

In the event of an unintentional bladder perforation, the patient can continue with postoperative voiding trial without the requirement for an indwelling catheter since the rupture is often tiny and located in a high, independent area of the bladder. An indwelling catheter should be used for a few days if there is significant hematuria or if the base or trigone of the bladder is punctured. In order to lessen the possibility of mesh erosion into the urethra, urethral injuries should preferably be treated with no further intervention until full healing has taken place. When possible, provide mid-urethral slings as the recommended surgical intervention for women with simple SUI. Because there is less chance of bladder perforation and post-voiding dysfunction with TOT (transobturator tape) than with TVT (retropubic route), it is recommended for less complicated and less severe SUI. Patients with more severe or recurring SUI or ISD are more likely to benefit from TVT. Synthetic slings are typically safe, effective, and have a low rate of problems. However, there is a minor chance of tape-related adverse outcomes that cannot be reversed^(6,7). The long-term effectiveness of the MiniArc single-incision sling is yet unknown, thus women considering it should be informed of this. The mesh implant is permanent and does not pierce the obturator membrane; but, if the removal is required due to difficulties, the anchoring mechanism may make the device extremely challenging to remove.

Fascial sling (autologous): the proximal urethra and bladder neck are the intended locations for pubovaginal sling placement. It accomplishes continence via either directly compressing the urethra or by re-establishing a hammock or re-enforcing platform against which the urethra is pushed when belly pressure is elevated. Three to five centimeters above the pubic bone, a 10-cm Pfannenstiel incision is made, and the dissection is carried to the rectus fascia level. A surgical marking pen is used to demarcate the area before harvesting a fascial segment that is at least 8 cm long and 2 cm broad. The ends of the sling are secured with a permanent suture (Polypropylene no. 1). A midline incision is made before lifting flaps to proceed with vaginal dissection. The process of dissection continues till endopelvic fascia is reached. Through the vaginal incision, long clamps are inserted under finger guidance from the open abdomen wound posterior to the pubic bone, or around 4 cm apart. Cystoscopy is required to rule out bladder injury that happens by accident. The free ends of the sutures attached to the sling are clamped, and each suture is drawn into the retropubic area and up against the anterior abdominal wall. Next, a right-angle clamp is held between the posterior urethral surface and the sling material as the sutures are knotted across the midline. The wounds in the abdomen and vagina are then closed. Hematomas are frequently encountered in the absence of adequate wound irrigation; hence, it is recommended that a drain be inserted into the subcutaneous tissue area. Twenty-four hours later, an indwelling bladder catheter is taken out. The bladder catheter is retained in the patient for one week if they are unable to urinate. In patients who decline to have a synthetic material implanted or who have experienced a complication following the placement of a synthetic sling (vaginal erosion), past history of radiation therapy, repair of urethral injuries/urethrovaginal fistulae/diverticulum, and recurrent SUI, autologous fascial sling (AFS) is indicated as a primary therapy for SUI (both for ISD and urethral hypermobility). Other biological and synthetic slings may not be as successful as AFS, which is a long-lasting and efficient therapy for stress urinary incontinence. Porcine dermal grafts have a worse cure rate than AFS and MUS, and they seem to progressively decrease tensile strength with time. The women who choose this method should be made aware of the necessity of clean intermittent self-catheterization, which typically resolves in 2-4 weeks and has a reported incidence of 1.5% to 7.8%⁽⁸⁾. However, there is a higher risk of voiding difficulties with this modality than with MUS.

Bulking agents: due to urethral hypermobility, the majority of the aforementioned procedures are more effective for SUI and less effective for intrinsic sphincter deficit (ISD). In order to treat ISD, periurethral injections of synthetic bulking agents – silicone, carbon-coated zirconium beads, or a hyaluronic acid/dextran copolymer – are given in the submucosa of the proximal and mid-urethra prior to cystourethroscopy. Urethral coaptation is heightened by this. Two main drawbacks are represented by the reduced long-term effectiveness and the need for several sessions. Moreover, India does not yet have access to them.

Surgical care under unique clinical cir­cum­stances⁽⁹⁾

Offer pubovaginal slings/bladder neck slings, retropubic MUS, urethral bulking agents, or AUS for SUI and an immobile, fixed urethra (often referred to as “ISD”).

Unintentional urethral damage during a scheduled MUS procedure: steer clear of mesh slings.

Synthetic mid-urethral slings (MUS) are not advised for patients having concurrent urethral diverticulectomy, urethrovaginal fistula repair, or urethral mesh excision and SUI surgery.

Mesh slings are not advised for patients who are at risk of poor wound healing (such as those who have undergone radiation therapy, who have substantial scarring, or have poor tissue quality).

Patients undergoing concurrent surgery for the treatment of a pelvic prolapse and stress urinary incontinence may undergo any anti-incontinence procedure (e.g., pubovaginal sling, MUS, Burch colposuspension); however, prolapse surgery should be done initially to prevent sling displacement if it is done later.

Surgical treatment of stress urinary incontinence is recommended for patients with SUI who also have a concurrent neurologic condition that affects lower urinary tract function (neurogenic bladder), following adequate examination and counseling.

Postsurgical assessment

Early postoperative care should include a first follow-up visit to see whether patients are experiencing any substantial discomfort, difficulty voiding, or other unexpected occurrences. In order to prevent any complications, early action is necessary. After surgery, asymptomatic individuals must be visited and evaluated within six months. Patients should be inquired concerning pain, sexual function, recent UTI, ease of voiding/force of stream, and new or worsening overactive bladder symptoms^(10,11). The majority of doctors advise against attempting surgical repair of stress incontinence until the patient has completed childbearing. If a patient decides to get pregnant, an elective caesarean birth might be a viable option after carefully weighing the associated risks and advantages⁽¹²⁾. 

Autori pentru corespondenţă: Smit Bharat Solanki E-mail: drsmitbharat@gmail.com

CONFLICT OF INTEREST: none declared.

FINANCIAL SUPPORT: none declared.

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