Advances in the surgical treatment of fecal incontinence

Although surgery for fecal incontinence has been shown to be effective, it is still very challenging and sometimes frustrating. Overlapping sphincteroplasty, by far the most common procedure, is effective in patients with sphincter defects; however, recent data suggest that success rates tend to deteriorate over time. A thorough preoperative evaluation incorporates numerous factors, including patient characteristics, severity of incontinence, type and size of the sphincter defect as assessed by physical examination, anal ultrasound, and anorectal physiology studies including anal manometry, electromyography, and pudendal nerve terminal motor latency assessment. The use of these evaluation methods has allowed better patient assignment for a variety of new alternative treatment options. Innovations in the surgical treatment of fecal incontinence range from simple, office-based sphincter augmentation techniques to surgical implantation of mechanical devices. This article reviews 5 alternative surgical treatment options for fecal incontinence: injection of carbon-coated beads in the submucosa of the anal canal, radiofrequency energy delivery, stimulated graciloplasty, artificial bowel sphincter, and sacral nerve stimulation.     

Reprint of: Management of fecal incontinence: Surgical treatement

Fecal incontinence is not a rare condition. In the majority of patients, no operative means result in symptom relief. Only if these fail surgical intervention is indicated. Various new surgical options have evolved over the last decades. The evidence of their efficacy varies substantially. The mainstays of surgical treatment of fecal incontinence are sphincteroplasty and sacral nerve stimulation. Data of other techniques, like posterior tibial nerve stimulation, radiofrequency energy delivery and bulking agents, are less robust. The article aims to outline the currently commonly accepted and frequently applied surgical techniques for treatment of fecal incontinence and their results and to present novel techniques, which carry potential for the future.     

Management of fecal incontinence

Fecal incontinence is not a rare condition. In the majority of patients, no operative means result in symptom relief. Only if these fail surgical intervention is indicated. Various new surgical options have evolved over the last decades. The evidence of their efficacy varies substantially. The mainstays of surgical treatment of fecal incontinence are sphincteroplasty and sacral nerve stimulation. Data of other techniques, like posterior tibial nerve stimulation, radiofrequency energy delivery and bulking agents, are less robust. The article aims to outline the currently commonly accepted and frequently applied surgical techniques for treatment of fecal incontinence and their results and to present novel techniques, which carry potential for the future.     

排粪失禁的治疗现状

排粪失禁较为常见,严重影响患者生活质量。在过去的二十年中,以治疗和减少并发症为目的的新疗法得到了一定发展。目前常用的非手术疗法包括饮食调节、药物治疗、生物反馈治疗,手术疗法包括修补术（括约肌成形术）、神经刺激疗法（骶前神经刺激等）、人工肛门括约肌替代或者自体肌肉转移术,以及排粪转流造口术。尚属起步阶段,仍存有争议的治疗手段包括射频能量疗法和注射疗法,因其创伤更小,可作为某些轻症排粪失禁患者的非手术治疗选择。医生应综合考虑肛门功能、生活质量及潜在并发症,制定个体化的治疗方案。对于重症排粪失禁患者应谨慎选择创伤较大的手术疗法。本文重点就目前排粪失禁各种治疗方法的选择策略及疗效进行系统回顾和总结。     

Neuromodulation for constipation and fecal incontinence

The evidence is consistent with permanent SNM substantially improving continence in patients with severe fecal incontinence resistant to medical treatment. This treatment has been used in patients in whom a major surgical intervention would normally have been the next stage in treatment and the option of a minimally invasive treatment, with the added advantage of testing before definitive implantation, has the potential to have a major impact on this patient group. The results of the early case series examining the use of SNM for constipation are encouraging. Patients who have failed maximal medical treatment for constipation pose considerable clinical difficulties, with current surgical treatments requiring a bowel resection or stoma formation. If SNM proves to be of benefit to a proportion of these patients, this will be of considerable importance in terms of their future treatment options. Fecal incontinence and idiopathic constipation are both conditions in which conservative treatment is the mainstay of treatment in most cases,but for a small proportion surgical intervention is warranted. The surgical procedures available,however, have a considerable invasive component with often little guarantee of symptom resolution. SNM is becoming more widely used for patients with fecal incontinence as series sizes get larger and follow-up longer. Its potential benefit in constipation has been shown in pilot studies but larger trials are still required.     

Sacral neuromodulation for constipation and fecal incontinence in children

Sacral neuromodulation has become an established treatment option for adults with fecal incontinence, but has only been applied to children with defecatory disorders over the past decade. Unlike in adults, the primary cause of fecal incontinence in children is poorly controlled constipation. There is growing evidence that sacral neuromodulation can be effective in the treatment of children with both constipation and fecal incontinence refractory to conventional treatment, and sacral nerve stimulation appears to be a promising treatment for a population of children with limited treatment options and debilitating symptoms. However, both experience with this treatment modality and the quality of evidence for its use remain limited. Given the relatively high complication rate associated with sacral nerve stimulation, further research is needed before more widespread acceptance of this treatment in the management of children with refractory constipation and fecal incontinence.     

Anal manometric parameters: Predictors of outcome following anal sphincter repair?

Controversy exists over the utility of manometry in the management of fecal incontinence. In light of newer methods for the management of fecal incontinence demonstrating favorable results, this study was designed to evaluate manometric parameters relative to functional outcome following overlapping sphincteroplasty. Twenty women, 29 to 84 years of age (mean age 50 years), with severe fecal incontinence and large (≥50%) sphincter defects on ultrasound were studied. All participants underwent anal manometry (mean resting pressure, mean squeeze pressure, anal canal length, compliance), pudendal nerve terminal motor latency (PNTML) testing, and completed the American Society of Colon and Rectal Surgeons fecal incontinence severity index (FISI) survey before and 6 weeks after sphincter repair. Statistical analysis for all data included the Wilcoxon rank-sum test, Mann-Whitney test, and Spearman’s correlation. Significant perioperative improvement was seen in the absolute resting and squeeze pressures and anal canal length. Overlapping sphincteroplasty was also associated with significant improvement in fecal incontinence scores (FISI 36 vs. 16.4; P = 0.0001). Although no single preoperative manometric parameter was able to predict outcome following sphincteroplasty, preoperative mean resting and squeeze pressures as well as anal canal length inversely correlated with the relative changes in these parameters achieved postoperatively. These findings suggest that either the physiologic parameters studied are not predictive of functional outcome or the scoring system used is ineffective in determining function. The perioperative paradoxical changes in resting pressure, squeeze pressure, and anal canal length would support the use of overlapping sphincteroplasty in patients with significant sphincter defects and poor anal tone.     

可控性人工肛门装置的研究进展

人工肛门是结直肠外科治疗低位直肠癌的重要术式,然而其导致的粪便失节制严重影响患者生活。为了解决这个问题,国内外研究了一系列新型可控性人工肛门装置,按使用方式可分为夹闭式和封堵式,一定程度上实现了粪便的可控性。夹闭式人工肛门为植入性装置,使用较为自动化,但装置庞大复杂,患者发生感染、炎性反应和消化道不适等并发症的概率较大。相比之下,封堵式人工肛门自动化程度低,患者需每日清洗或更换装置,使用较为不便,但其舒适度、隐蔽性和安全性更好。相信随着技术的发展及研究的深入,一定能够实现人工肛门装置的更加智能化、自动化和微型化。     

Urodynamic assessment of patients with stress incontinence: how effective are urethral pressure profilometry and abdominal leak point pressures at case selection and predicting outcome?

PURPOSE OF REVIEW: Disagreement exists as to the extent of evaluation required prior to offering surgical intervention for the treatment of stress urinary incontinence in women. While few would argue that additional information can be gleaned from a properly performed urodynamic investigation, it remains unclear exactly which women would most benefit from such preoperative study, and if urodynamic evaluation definitively improves treatment outcome. Since such invasive studies may not be widely available in certain areas, can be costly, and are associated with a low, but defined risk of bladder infection, it is imperative that the appropriate indication for preoperative urodynamic evaluation be carefully defined. This review highlights recent reports and controversies concerning the use of urodynamics (focusing on leak point pressure testing and urethral pressure profilometry) prior to surgical treatment for stress urinary incontinence. RECENT FINDINGS: There remains no clear consensus as to whether urodynamic testing enhances surgical outcome of stress urinary incontinence treatments by improving case selection or altering the surgical approach based on study findings. As treatment strategies for stress urinary incontinence have developed over the last several years to a more uniform approach, it is less clear that the severity of stress urinary incontinence, based on either abdominal leak point pressure or urethral pressure profilometry will influence the choice of surgical technique. Furthermore, there is little evidence to suggest that patients with more severe forms of stress urinary incontinence by urodynamic testing fare more poorly after the most commonly offered surgical treatment than those with less severe forms. There are certain sub-populations of women who appear to be at higher risk of voiding dysfunction following incontinence surgery, and urodynamic testing may aid in identifying this group. SUMMARY: It is not apparent that either abdominal leak point pressure measurement or urethral pressure profilometry can accurately predict which patients will achieve the best outcome of surgical treatment for stress urinary incontinence. Other parameters assessed during urodynamic evaluation might provide prognostic information regarding the risk of voiding dysfunction postoperatively and the possibility of persistent urge-related leakage following surgery, though not directly predict cure. A multi-institutional randomized study comparing the outcome between patients in whom treatment was determined with the urodynamic information known, compared with patients in whom this information was unknown would further enhance our understanding of the usefulness of urodynamics in the preoperative evaluation of women with stress urinary incontinence.     

Patients’ experience compared with physicians’ recommendations for treating fecal incontinence: a qualitative approach

Introduction and hypothesis

Using qualitative methods, we compared physician-recommended treatment options for fecal incontinence to patient knowledge of treatment options. Our hypothesis was that physician recommendations were not being communicated well to patients and that this impaired patients’ ability to cope with fecal incontinence.

Methods

Cognitive interviews were conducted with physicians who routinely care for women with fecal incontinence. Physicians were asked to describe their typical nonsurgical treatment recommendations and counseling for fecal incontinence. Women with bothersome fecal incontinence were recruited to participate in focus groups and asked about personal experience with fecal incontinence symptoms and treatment options. For both physician interviews and patient focus groups, qualitative data analysis was performed using grounded-theory methodology.

Results

Physicians identified several barriers patients face when seeking treatment: lack of physician interest toward fecal incontinence, and patient embarrassment in discussing fecal incontinence. Physicians universally recommended fiber and pelvic floor exercise; they felt the majority (approximately 70–80 %) of patients will improve with these therapies. Collectively, patients were able to identify all treatment recommendations given by physicians, although many had discovered these treatments through personal experience. Three concepts emerged regarding treatment options that physicians did not identify but that patients felt were important in their treatment: hope for improvement, personal effort to control symptoms, and encouragement to go on living life fully.

Conclusions

Whereas physicians had treatment to offer women with fecal incontinence, women had already found the best treatments through personal research and effort. Women want to hear a message of hope and encouragement and perceive personal effort from providers.     

The artificial urinary sphincter in the female: Indications for use, surgical approach and results

Female urinary incontinence is a common problem. Among the many treatment options a few patients may be suitable candidates for the artificial urinary sphincter (AUS). The indications for placement of an AUS are much more common in males: however, we review the indications, technique and potential complications of the AUS in the female population. Although few indications exist for the placement of an AUS in women, if proper patient selection is made, with strict adherence to proper surgical technique, it can be a suitable treatment option for those suffering from sphincteric incontinence.     

Neosphincter Surgery for Fecal Incontinence: A Critical and Unbiased Review of the Relevant Literature

Up until about 15 years ago the only realistic option for end-stage fecal incontinence was the creation of a permanent stoma. There have since been several developments. Dynamic graciloplasty (DGP) and artificial bowel sphincter (ABS) are well-established surgical techniques, which offer the patient a chance for continence restoration and improved quality of life; however, they are unfortunately associated with high morbidity and low success rates. Several trials have been done in an attempt to clarify the advantages and disadvantages of these methods and define their place in the second-line treatment of severe, refractory fecal incontinence. This review presents a critical and unbiased overview of the current status of neosphincter surgery according to the available data in the world literature.     

Anorektale Funktionsdiagnostik

The surgical therapy of pelvic floor insufficiency is mainly focused on two functional disorders, outlet obstruction and fecal incontinence. Surgery becomes of special significance after ineffectiveness of conservative treatment options. The indications for surgical interventions should be based on a precise preoperative evaluation. The dimension of functional impairment will be primarily assessed by an accurate anamnesis, application of disease-specific scoring systems and the clinical proctological basic examination that includes digital rectal examination and proctoscopy/rectoscopy. Imaging procedures (anorectal endosonography and dynamic defecography) are carried out as adjuncts and contribute to a visualization of morphological changes. Severity and manifestation of morphological symptoms are essential for the therapeutic algorithm due to increasingly differentiated surgical strategies. Only a thorough diagnostic investigation and patient selection enable a targeted therapy of obstruction and fecal incontinence.     

Patient selection and preoperative evaluation for fecal incontinence

Patient selection and preoperative evaluation play a vital role in the application of sacral neuromodulation (SNM) to fecal incontinence (FI). The history and physical should elucidate the nature of the incontinence, including duration, severity, type of leakage, as well as associated pathology (e.g., urinary incontinence, prolapse, etc.). Additionally, the use of a validated incontinence scoring system in obtaining an objective measure is recommended as a way to monitor an individual patient’s response to treatment over time. Despite dramatic success with SNM for severe incontinence, medical therapies should remain first-line treatment, especially for mild to moderate FI. In addition to idiopathic causes of FI, small series have reported successes in patients with disrupted anal sphincters, spinal cord injury, rectal prolapse, and low anterior resection syndrome. In general, studies on sacral neuromodulation have failed to identify consistent predictors correlating with response to treatment. Two considerations unique to SNM, cardiac pacemakers and anomalous anatomy, are not absolute contraindications but do mandate thorough preoperative planning and counseling.     

Management options for sphincteric deficiency in adults with neurogenic bladder

Neurogenic bladder is a very broad disease definition that encompasses varied disease and injury states affecting the bladder. The majority of patients with neurogenic bladder dysfunction do not have concomitant intrinsic sphincteric deficiency (ISD), but when this occurs the challenges of management of urinary incontinence from neurogenic bladder are compounded. There are no guidelines for surgical correction of ISD in adults and most of the literature on treatment of the problem comes from treatment of children with congenital diseases, such as myelomeningocele. Our goal, in this review, is to present some of the common surgical options for ISD [including artificial urinary sphincters, bladder slings, bladder neck reconstruction (BNR) and urethral bulking agents] and the evidence underlying these treatments in adults with neurogenic bladder.     

Implantable neuromodulation for urinary urge incontinence and fecal incontinence: a urogynecology perspective

Implantable sacral nerve stimulation is a minimally invasive, durable, and reversible procedure for patients with urinary urge and fecal incontinence who are refractory to conservative therapy. The therapy is safe compared with other surgical options. An intact external or internal rectal sphincter is not a prerequisite for success in patients with fecal incontinence.     

The current role of the artificial urinary sphincter for the treatment of urinary incontinence

PURPOSE: The introduction of the artificial urinary sphincter (AUS) in 1972 was heralded as a revolution for the treatment of genuine stress incontinence. Initial enthusiasm was tempered by disappointment as complications occurred. The device has now been in routine clinical use for more than 30 years, and the indications and surgical principles involved in its use along with short-term and long-term outcomes are more clearly defined. Hence, we reviewed the literature to clarify the role of the AUS and offer a possible solution to its problems in the guise of a new sphincter. MATERIALS AND METHODS: A MEDLINE search was performed and all articles relating to the role of the AUS for the treatment of urinary incontinence were reviewed. RESULTS: The AMS 800 (American Medical Systems, Minnetonka, Minnesota) provides urinary continence in 73% of cases (range 61% to 96%) and it has a complication rate of 12% (range 3% to 33%) for mechanical failure, 4.5% to 67% for early infection/erosion, 15% for late erosion and 7% for delayed recurrent incontinence. The literature supports the role of the AUS as an important and reliable treatment modality for stress urinary incontinence and intrinsic sphincter deficiency. However, it is not suitable in all patients and its use for the management of hypermobility is controversial. Hence, careful patient selection according to indication is required with full preoperative counseling. CONCLUSIONS: Despite its reliability for achieving urinary continence the AMS 800 is not perfect. Newer devices, such as that being developed at our institution, may offer improved outcomes and decreased complication rates.     

Overview on the management of adult urinary incontinence

Urinary incontinence is a common presentation and can manifest either as stress, urge or mixed incontinence. Though primarily a condition affecting women, the increasing uptake of prostate surgery for benign disease and cancer, whereupon up to one in five patients end up experiencing stress incontinence, means the prevalence of incontinence in men is increasing. A thorough assessment is necessary to identify the underlying urological abnormality and to guide appropriate management. Conservative approaches consist of treating constipation, the use of containment devices, weight loss, bladder training and pelvic floor muscle training. Medical management frequently consists of the use of antimuscarinics and newer agents such as mirabegron. Surgical management is considered if previous therapies fail. Urodynamic assessment and subsequent multidisciplinary team review is commonly undertaken prior to invasive therapy. Surgical options include slings, bulking agents, botulinum toxin A, neuromodulation, artificial urinary sphincter, augmentation cystoplasty and urinary diversion. To note, the recent controversies with mesh has meant a sharp drop off in their use and higher uptake of autologous options. All these options are discussed in this article, including indications, outcomes and side-effects. For all patients, a stepwise approach is recommended, beginning with the least invasive options before moving onto more complex surgery with higher risk of severe complications. Patients with refractory urinary incontinence should be considered for entry into clinical trials where novel therapies are being assessed.     

Incontinencia fecal en el paciente anciano. Revisión de conjunto

Fecal incontinence is one of the leading causes for the institutionalization of people in the last decades of life, associated with a great psychosocial and economic burden. The literature is scarce in this population group, due to the absence of universally accepted criteria to define “elderly patients” and difficulties in detection and diagnostic. The aim of this article was to conduct a narrative review of the main aspects related to fecal incontinence in older patients, providing management support. Toileting assistance, dietary change, controlling stool consistency and medical treatment can be used to treat these patients. Nevertheless, other therapies, such as biofeedback, neuromodulation or surgical treatment, can be considered in selected patients.     

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.