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.     

Stem cell therapy for stress urinary incontinence

The rhabdosphincter at the mid urethra is critical for maintaining urinary continence. In a setting of stress urinary incontinence stem cells transplanted into the site of the rhabdosphincter may augment sphincter regeneration and also release trophic factors promoting muscle and nerve integration of this muscle. We hereby review the use of cellular therapy for SUI and our experience with the development of muscle‐derived stem cells (MDSCs). Neurourol. Urodynam. 29:S36–S41, 2010. © 2010 Wiley‐Liss, Inc.     

压力性尿失禁的细胞治疗

目的综述压力性尿失禁(stress urinary incontinence,SUI)细胞治疗的研究现状及临床应用进展。方法广泛查阅近年来有关SUI细胞治疗的文献并进行综述。结果软骨细胞和成肌细胞因不具有或仅有较差的再生修复能力,限制了二者的临床应用;干细胞因具有较强的自我更新和再生修复能力被认为是治疗SUI的理想种子细胞,已在动物实验及初步临床研究中取得了令人振奋的成果,为SUI细胞治疗可行性奠定了理论基础。结论细胞治疗尤其是干细胞治疗为SUI提供了一种新的治疗手段,其具体作用机制还有待进一步研究。     

Future treatment for the female stress urinary incontinence

Stress urinary incontinence (SUI) is a major urologic health problem and the number of patients with SUI will rise dramatically as the population of elderly people continues to increase in Japan. This condition causes unnecessary and detrimental psychological distress, social isolation, and public expense for care. Surgery remains the cornerstone of treatment for female SUI and also in those who have failed to improve with conservative measures. Many surgical procedures, however, have been described with varying degree of success. The ideal surgical treatment for this disease should be effective in QOL improvement, minimal invasive and durable for the long-term. Based on a new understanding of the pathophysiology of SUI as well as the development of surgical techniques and devices, mid urethral sling operations such as TVT (tension-free vaginal tape) have become widely used and they provide significant short-term and long-term cure rates. However, perioperative complications, including serious problems like bowel, vascular and bladder injuries have been reported. Most complications are related to blind trocar passage in the retropubic space. The alternative procedure transobturator procedure was developed to minimize these complications, in which tape is introduced through the obturator foramen. This technique provides high short-term cure rates, similar to those achieved with TVT, but with fewer complications. A number of injectables have been used for the treatment of SUI, including collagen, coated-beeds and Teflon. Although injectable treatment is convenient and minimally invasive, efficacy and durability are lower than other surgical procedures. Modification by tissue-engineering techniques using autologous stem cells or precursors of mature cells showed regeneration and reconstitution of urinary sphincteric function. In the future this strategy may be an attractive therapy for SUI. The choice of operation should be tailored to suit each individual case based on the clinical and urodynamic findings, as well as the age and the expectations of treatment outcome.     

Extracorporeal magnetic innervation therapy for stress urinary incontinence

Objectives. To report the first data from a prospective clinical study to determine the feasibility of using extracorporeal magnetic innervation (ExMI) for the treatment of stress urinary incontinence.Methods. We studied 83 women with demonstrable stress urinary incontinence. Treatments were for 20 minutes, twice a week for 6 weeks. For treatment, the patient sits fully clothed on a special chair; within the seat is a magnetic field generator that produces the rapidly changing magnetic field flux. Objective measures included bladder diaries, dynamic pad weight testing, urodynamic studies, and quality of life survey.Results. Fifty patients have been followed up for longer than 3 months (33 patients for less than 3 months); 17 patients (34%) were dry, 16 (32%) were using not more than 1 pad per day, and 17 (34%) were using more than 1 pad per day. Pad use was reduced from 2.5 to 1.3 (P = 0.001) and leak episodes per day were reduced from 3.3 to 1.7 (P = 0.001). The pad weight was reduced from 20 to 15 g. Detrusor instability was found in 5 patients before but was demonstrated in only 1 patient after treatment.Conclusions. ExMI therapy offers a new effective modality for pelvic floor muscle stimulation. ExMI is painless, there is no need for a probe, and no need to undress for treatments. Longer follow-up is required to determine how long the benefits of treatment last and whether retreatment will be necessary.     

Conservative strategies for the treatment of stress urinary incontinence

The conservative treatment of stress urinary incontinence for women has many facets. Each intervention may have value and patients may benefit from simple, reversible recommendations and techniques versus invasive surgery. Starting with a thorough history, lifestyle modifications may lead to decreased incontinence. Depending on the patient’s goals and clinical situation, they may benefit from a pessary or anti-incontinence device. Finally, the use of pelvic floor muscle exercises has been shown to benefit a significant number of patients. Regardless of the degree of stress urinary incontinence, conservative strategies should be considered a fundamental part of the treatment plan.     

Sub-urethral slings for treatment of stress urinary incontinence

Sling surgery is considered to be the gold standard for the treatment of incontinence resulting from internal sphincter deficiency. A century of experience is reviewed and evolving new concepts and techniques are presented.     

Established treatment options for male stress urinary incontinence

Nowadays, male stress urinary incontinence is rare and almost always of iatrogenic origin (radiotherapy, pelvic surgery). However, the prognosis of urinary incontinence following surgery is good and can be improved by pelvic floor muscle exercises in combination with biofeedback systems. For the remaining patient cohort with persistent urinary incontinence, several established surgical treatment options are available. Suburothelial injections of bulking agents can easily be performed in an ambulatory setting. However, regardless of the material used, long-term results are disappointing. Moreover, the residual urethral function deteriorates due to cicatrization of the suburothelial plexus with consequent loss of urethral elasticity.The fascial sling procedure in males has to be performed in preoperated areas and is as technically demanding for the surgeon as it is burdening for the patient. Alloplastic material is not used, thus minimizing risks for arrosion or infection. Since the sling tension can neither be standardized nor postoperatively readjusted, the risk of overcorrection is considerable and the success of the procedure is heavily dependent on the surgeon's experience. Despite wear and high revision rates, the technically mature artificial sphincter produces excellent continence results and has become the gold standard in the therapy of male stress urinary incontinence. The circumferential and continuous urethral compression by the cuff is highly effective, but at the price of an almost inevitable urethral atrophy. To overcome this problem, various surgical techniques have been developed (tandem cuff, cuff downsizing, transcorporal cuff placement). However, the expensive artificial sphincter is not a nostrum for every incontinent man, since it requires certain minimal cognitive and manual capabilities. Therefore, the search for less demanding treatment alternatives seems to be necessary, even if one has to accept lower continence rates.     

Biofeedback therapy technique for treatment of urinary incontinence

Biofeedback treatment of urinary incontinence is a management method that has low risk and therapeutic efficacy for selected patients. Biofeedback therapy techniques vary widely and have not been well described or standardized. A technique for biofeedback therapy is described that allows accurate signal monitoring and assures appropriate biofeedback to the patient. External anal sphincter electromyographic performance is presented to the patient as a color line graph with pitch variable audio feedback. The method has complete flexibility in providing biofeedback training according to patient performance level and is one that can be easily interpreted by patients who have voiding dysfunctions.     

Myoblast therapy for stress urinary incontinence and bladder dysfunction

The field of tissue engineering and gene therapy has an exciting and promising future. During the past few years we have begun a comprehensive effort to investigate the use of myoblasts to improve and expand the treatment of stress urinary incontinence and bladder dysfunction. Moreover, we can expect the application of myoblast-mediated ex vivo gene transfer in the field of urology. In this paper we discuss the compositions of and methods involving the use of myogenic or muscle-derived cells for tissue engineering and cell-mediated gene therapy.     

Muscle derived stem cell therapy for stress urinary incontinence

AIM: The aim of this article is to discuss the potential of muscle-derived stem cells (MDSCs) for rhabdosphincter regeneration and to review the early clinical experiences with its application in patients with stress urinary incontinence. RESULTS: In anatomical and functional studies of the human and animal urethra, the middle urethral contained rhabdosphincter is critical for maintaining continence. Transplanted stem cells have the ability to undergo self-renewal and multipotent differentiation, leading to sphincter regeneration. In addition, such cells may release, or be engineered to release, neurotrophins with subsequent paracrine recruitment of endogenous host cells to concomitantly promote a regenerative response of nerve-integrated muscle. CONCLUSION: Cell-based therapies are most often associated with the use of autologous multipotent stem cells, such as bone marrow stromal cells. However, harvesting bone marrow stromal stem cells requires a general anesthetic, can be painful, and has variable yield of stem cells upon processing. In contrast, with appropriate experience, alternative autologous adult stem cells such as muscle-derived stem cells and adipose-derived stem cells can be obtained in large quantities and with minimal discomfort.     

Pixel-CO2 laser for the treatment of stress urinary incontinence

Lasers in Medical Science - The aim of this study was to assess the safety and efficacy of a minimally invasive pixel-CO2 laser procedure for the treatment of stress urinary incontinence (SUI)....     

Radiofrequency for the treatment of stress urinary incontinence in women

Stress urinary incontinence (SUI) is a socially disabling disorder that affects a large population of women around the world. Surgical treatments for SUI typically seek to recapitulate the support of the endopelvic fascia and reduce urethral hypermobility or improve urethral compressive forces. Radiofrequency energy is a potent tool for such treatment, as it is in other medical specialties. The development of transurethral approach techniques affords a major advantage because this nonsurgical procedure can be performed in an office setting with the use of an oral sedative and local anesthesia. The data collected to date suggest that radiofrequency treatment of SUI has promising efficacy and entails a minimal risk of adverse events. Further randomized studies with longer follow-up are needed to assess the ultimate role of this procedure in future urology practice.     

Individualized pelvic physical therapy for the treatment of post-prostatectomy stress urinary incontinence and pelvic pain

International Urology and Nephrology - The rehabilitation of post-prostatectomy urinary incontinence has traditionally focused on pelvic floor strengthening exercise. The goal of this study was to...     

Transurethral collagen injection for treatment of stress urinary incontinence

Summary Minimally invasive treatment of urinary incontinence has become a subject of major interest in recent years. We examined the use of transurethral collagen injection for incontinence treatment. A total of 48 patients were selectet for this procedure from April 1993 to February 1997 – 26 male patients (19 post-RPX incontinence and 7 post-TUR incontinence) and 22 female patients (all after previous incontinence surgery) were treated by injection of collagen into the continence region. The whole group underwent an average of 1.8 sessions, and a mean collagen injection volume of 14.5 ml was delivered per session. Mean follow-up was 9.2 months. Of the female population, 68.2 % were cured or greatly improved. In the male population only 47.3 % of the post-RPX patients and 6/7 of the post-TUR patients benefited from the procedure. In males, treatment outcome depends on the degree of pretreatment incontinence, because all grade III incontinence patients did worse. Therefore we conclude: transurethral collagen injection is an interesting method in the treatment of urinary incontinence if proper patient selection is assured.