Surgical treatment for stress urinary incontinence

Abstract:   The prevalence of stress urinary incontinence is quite significant with large numbers of women affected. Many of these women will not seek medical help in the belief that they will not be cured or improved. With the increasing numbers of procedures now available we present a review of both established and novel surgical techniques that is intended to help both urologists and primary care physicians in the counselling of patients complaining of stress incontinence. We compare the "gold standards" of surgical treatment for all types of stress incontinence with the newer techniques that have recently become popular among urologists and gynaecologists.     

Surgical treatment of stress urinary incontinence in women

INDICATION FOR SURGERY: Exercise-induced urinary incontinence is responsible for more than 75% of all cases of urinary incontinence in women. Surgery can provide excellent cure if the initial indication is established properly. SURGICAL PROCEDURES: The aim is to correct the mechanical alterations leading to urine leakage: sphincter anomalies and cervico-urethral hypermobility. Colpo-suspension using the indirect Burch procedure and the direct Goebell-Stoeckel procedure are indicated for physically active patients. For sphincter failure, an artificial sphincter with a fixed bladder neck is indicated. Simplified transvaginal colpo-suspension is indicated for elderly women. TENSION FREE VAGINAL TAPE: The recently developed, this new technique appears extremely promising for the treatment of urethral hypermobility.     

Surgical treatment possibilities of severe urinary incontinence in women

Severe female urinary incontinence type 3 is a most difficult challenge to a urologic surgeon. In 40 of more than 800 patients evaluated for stress incontinence, type 3 urinary incontinence was diagnosed by clinical, urodynamic, and radiographic examination. The etiology was neurogenic or non-neurogenic. The first step of treatment in all patients was a modified pubovaginal sling to increase urethral resistance; this procedure was successful in 65%. Severely damaged periurethral tissues resulting from earlier multiple pelvic surgery (111 operations in 28 patients with non-neurogenic etiology), radiation, or prior local infections were responsible for failures. Patients whose incontinence was not corrected by this initial treatment required further surgical procedures, such as suburothelial Teflon injection, urethral reconstruction, and continent urinary diversion. This additional surgery resulted in an overall 92% success rate after a minimum follow-up of 18 months. In view of the severe nature of the incontinence of these individually problematic patients, this is a satisfactory results.     

Surgical treatment of stress urinary incontinence after radical hysterectomy

Stress urinary incontinence is not infrequent after radical hysterectomy for cervical cancer. Eight women who underwent surgery for correction of stress incontinence after radical hysterectomy were studied with urodynamic techniques before and 1 year after incontinence surgery. Five patients underwent a Marshall-Marchetti-Krantz (MMK) operation, 1 a Burch colposuspension, 1 a sling procedure and 1 an anterior repair. Two patients remained incontinent after an MMK operation, as did the patient who had an anterior repair. The patient who underwent a sling procedure had to practice intermittent selfcatheterization. We conclude that an appropriate operation can cure stress incontinence after radical hysterectomy, but that patients should be selected carefully.     

Therapy of mixed urinary incontinence

The therapy of mixed urinary incontinence is still discussed controversially. Surgical procedures were seen as a minor opinion in these cases, because the urge-symptoms remain stable or even become worse after incontinence-surgery. We here present a prospective-randomized double-blinded multi-center trial with Tolterodine extended-release 4 mg once daily in 410 female patients with mixed incontinence treated in Germany. After 8 weeks of treatment we saw a nearly 60% significant regression of the symptoms of mixed incontinence. Therefore the anticholinergic treatment with tolterodine extended-release of women is a successful treatment option in mixed incontinence.     

Surgical correction of urinary incontinence

Over the last 6 years, 114 patients have undergone surgery for urinary incontinence. The majority (79%) had neurologic dysfunction of the bladder because of spinal malformation (myelodysplasia, sacral agenesis, or trauma) and the remaining were a mixed group including exstrophy/epispadias, urethral valves, pelvic fractures, etc. The patients were grouped in six categories. Those with lower urethral resistance underwent bladder neck reconstruction with Young-Dees-Leadbetter procedure (five patients) or had placement of an artificial urinary sphincter (27 patients). Those with poor bladder compliance underwent primary bladder augmentation (21 patients). Those with combined urethral problems and poor compliance had combined procedures (14 patients). Thirty-seven patients previously diverted for incontinence and undergoing undiversion were considered separately, as were ten patients without any bladder precluding preoperative assessment. Of the entire group, continence was achieved in 83 patients with the initial procedure (73%). Secondary procedures have resulted in continence in 101 patients (89%). Three patients were improved but unsatisfactory, and nine remain wet; one is unknown.     

Solifenacin: as effective in mixed urinary incontinence as in urge urinary incontinence

Patients with mixed urinary incontinence (MUI) are frequently treated with antimuscarinic therapy, despite little data being previously published for this patient group. We present a subgroup analysis of patients with overactive bladder syndrome, assessing the efficacy of once-daily solifenacin succinate in patients with MUI (n=1041) or urge urinary incontinence (UUI; n=1648) only. A greater proportion of patients receiving solifenacin achieved resolution of incontinence in both the MUI and UUI groups (MUI: 5 mg=43%, 10 mg=49%; UUI: 5 mg=55%, 10 mg=54%) compared with patients receiving placebo (MUI 33%, UUI 35%). Baseline to endpoint improvements in all other symptoms were statistically significant vs placebo for both solifenacin doses in both cohorts. The incidence of adverse events was comparable between the MUI and UUI cohorts. This analysis shows that once-daily solifenacin was as effective and well tolerated in patients with MUI as in patients with UUI.     

Urodynamic characteristics of mixed urinary incontinence and idiopathic urge urinary incontinence

PURPOSE: To evaluate and compare the clinical and urodynamic findings in patients with either mixed urinary incontinence (MUI) or simple urge urinary incontinence (UUI). MATERIALS AND METHODS: A series of 100 consecutive female patients with MUI and UUI were identified from a database. Patients with neurogenic bladder, fistula, urethral diverticulum, prior urologic surgery or known urinary tract obstruction were excluded. All patients were classified according to the urodynamic classification of overactive bladder of Flisser et al. and all patients underwent history, physical examination, validated incontinence questionnaire, 24-hour voiding diary, 24-hour pad test, video urodynamic study (VUDS), and cystoscopy. RESULTS: A significantly higher proportion of patients with UUI exhibited detrusor overactivity at VUDS, (67% of the patients with UUI vs. 24% of the MUI, P < 0.05). Patients with UUI had fewer episodes of incontinence (6.7 vs. 4.2, P < 0.05) with slightly less objective urine loss (24-hour pad test 94 gm vs. 128 g of loss, P < 0.05) and voided at higher pressures (p(det) at Q(max) 21.4 vs. 15.6 cm H(2)O, P < 0.05). Patients in both groups had functional and urodynamic bladder capacities that were not statistically different. CONCLUSIONS: Women with UUI were more likely to exhibit detrusor overactivity but experienced fewer episodes of incontinence and less urinary loss when compared with women who had MUI. The "urge incontinence" component of MUI appears to be different than that of UUI, and suggests that urge incontinence may be overdiagnosed in patients with SUI who misinterpret their fear of leaking (because of SUI) for urge incontinence.     

Surgical management of urinary incontinence in children

The field of continent reconstruction continues to expand rapidly, as new innovations are introduced by imaginative surgeons. Today, review of previous experience and knowledge of physiology permit creation of solutions to previously insoluble problems. It must be stressed that long-term results are not available for many of these procedures, but with careful follow-up, the outlook is promising.     

Ventral hernia of the urinary bladder with mixed urinary incontinence: treatment with herniorrhaphy and allograft fascial sling

Abdominal hernias are not rare in women with urinary incontinence, but incisional bladder hernia is uncommon. The presenting symptoms in the rare cases reported included suprapubic discomfort, irritative voiding symptoms, and urinary incontinence. We present a patient with bladder herniation and severe mixed urinary incontinence. The pathophysiology of the urinary symptoms and the surgical alternatives for the correction of this condition are discussed.     

Functional magnetic stimulation for mixed urinary incontinence

PURPOSE: In this study we determined the efficacy of functional magnetic stimulation (FMS) compared to placebo for treating women with mixed urinary incontinence (MUI). MATERIALS AND METHODS: A total of 39 women with MUI were randomly assigned to the FMS group (23 patients) or to the placebo group (16 patients). FMS was applied continuously at 18.5 Hz day and night for 2 months. Conventional urodynamic studies were performed before and after stimulation. Outcome measures assessed were clinical (daytime frequency, nocturia, pad use, pad weight) and urodynamic variables (first sensation of bladder filling, maximum cystometric capacity, maximum urethral closure pressure), and patient subjective assessment (visual analogue scale). RESULTS: After 2 months of FMS significant decreases in voiding frequency (from 9.0 to 6.7, p = 0.0002), nocturia (from 2.6 to 1.4, p = 0.0007) and pad use (from 3.9 to 2.2, p = 0.007) were observed only in the FMS group. First sensation of bladder filling and maximum cystometric capacity increased significantly after stimulation compared with prestimulation levels only in the FMS group, p = 0.003 (from 118 to 174 ml) and p = 0.00004 (from 267 to 396 ml), respectively. A total of 18 women (78.3%) reported an improvement in symptoms after FMS with an average success rate of 41.9%. The success rate was significantly lower in the placebo group (p = 0.021) at 22.9%. CONCLUSIONS: Functional magnetic stimulation was useful and safe for treating women with MUI.     

Surgical treatment for female stress urinary incontinence: what is the gold-standard procedure?

In the last few years, the Burch colposuspension and the fascial slings were often defined from the pages of the most relevant journals of general medicine, as gold-standard procedures for the surgical treatment of stress urinary incontinence (SUI), whereas mid-urethral slings (tension-free vaginal tape (TVT) and tension-free vaginal tape obturator) were attributed a marginal and almost experimental role in this field. This poorly reflect the current scenario of the surgical management of SUI: Recently, a number of meta-analysis have demonstrated that TVT is significantly more effective if compared to colposuspension and that it is followed by significantly lower perioperative morbidity if compared to pubovaginal slings. It is not realistic to suggest to general practitioners that the surgical gold standard for SUI includes the performance of a wide laparotomy, long hospital stays and a high risk of long-lasting intermittent self-catheterisation. This would inevitably discourage women from embarking on surgical treatment, which instead could actually improve their quality of life.     

Surgical treatment for stress urinary incontinence associated with valsalva induced detrusor instability

PURPOSE: Detrusor instability initiated by increased intra-abdominal pressure that results in incontinence has always been difficult to treat. This form of incontinence may be due to traction on the pelvic nerves when increased abdominal pressure is applied to already weakened pelvic supportive tissue. In most patients pharmacological attempts to correct this problem fail. We describe a pubovaginal sling designed to stabilize the urethrovesical junction during the Valsalva maneuver, which is our treatment of choice for such patients. MATERIALS AND METHODS: From 1994 to 1998 we treated 36 patients with a pubovaginal sling procedure for Valsalva induced detrusor instability diagnosed on preoperative urodynamics. The sling material was in situ vaginal wall in 20 cases, free swing vaginal wall in 6, rectus fascia in 4, cadaveric fascia in 3 and synthetic material in 3. Urodynamic evaluation was performed preoperatively in all patients. Followup of 6 months to 4 years involved subjective questions and objective examination. RESULTS: Cure was achieved in 33 of the 36 patients (92%), of whom leak point pressure was less than 50, 50 to 100 and greater than 100 cm. water in 9, 17 and 7, respectively. In the 3 failed cases leak point pressure was 50 to 100 cm water, including 2 in which cotton swab test results were less than 30 degrees. Urge incontinence resolved in 75% of the patients. CONCLUSIONS: The pubovaginal sling procedure may cure Valsalva induced detrusor instability. Leak point pressure does not determine which patients do well. Evaluation for hypermobility may help to predict the success or failure of a procedure by identifying those in whom Valsalva induced detrusor instability results from traction on the pelvic nerves.