Minimally invasive surgical treatment of female stress urinary incontinence

The purpose of this study was to evaluate the safety and efficacy of a new minimally invasive surgical procedure for the treatment of female stress urinary incontinence (SUI). Four miniature bone anchors, each attached to a suture, are inserted transvaginally into the retropubic bone using an inserter on each side of the urethra without opening the vaginal mucosa. Tying the suture on each ipsilateral side creates colposuspension, as is the aim of previously described procedures such as the Marshall-Marchetti-Krantz. Sixty-one women (mean age 52±SD 9.9 years) with a mean follow-up of more than 12 months (range 12–30 months) were treated for SUI. Fifty patients (82%) are dry, 7 (14%) reported great improvement and 4 are considered surgical failures. The data presented suggest that our new minimally invasive procedure provides an effective treatment for female SUI. Its main advantages over other procedures are the transvaginal approach and short operating time.Editorial Comment: The search for the best surgical therapy for stress urnary incontinence continues with this presentation of a minimally invasive procedure involving no vaginal incisions, bone anchors and the tying of sutures in the vagina. The study is well designed except for a few issues that are important for the long-term determination of the viability of the procedure. Of particular importance is that the authors recognized that osteomyelitis is a problem with bone anchor procedures, and therefore used a 3-day 91 day preoperative and 2 postoperative) coverage of antibiotics, consisting of a thirdgeneration cephalosporin and gentamicyin, which is required to achieve therapeutic levels of antibiotic in bone. Bone anchor procedures have to date been done in a relatively contaminated environment, either by pulling sutures in and out of the vagina into the retropubic space or, as in this study, by directly penetrating the vaginal wall with bone anchors, with the attendant risk of driving bacteria into the bone along with the anchor. Postoperative X-rays were not done routinely to detect osteomyelitis, so that the true incidence of this problem remains unknown. Patients must be informed of this major potential complication and that the frequency is low, but yet an exact estimation of this frequency cannot be made. One case in 70 has been reported with the Vesical bone anchor procedure, by Appell [1]. The two major problems with this study are the lack of prospective comparison to a standard operation for stress incontinence, and the lack of objective postoperative follow-up. The success rate stands at 80% at 12 months based on mostly subjective data. The literature is clear that objective success rates are always lower than subjective success rates, so the objective success rate of this procedure may be lower. In this study pad testingor counts were used to determine success. Unfortunately, the exact type of pad test is not specified. Objective documentation of lack of urine loss under specific volumes of bladder filling and stress maneuvers was not done. Pad counting alone introduces a new element of subjectivity into the postoperative follow-up. Of concern with any minimally invasive procedure is that the retropubic space is relatively unviolated, and little occurs that may induce scarification of the paraurethral tissue to the pelvic sidewall or the retropubis. It is well known that sutures in tissue under tension tend to pull through tissue. All retropublic urethropexies suffer from this problem, and reliance on patient rest until enough scarification occurs is necessary to ensure a reasonable chance of success. Concern with this procedure is that in the long term sutures may pull through, with little chance for scarification to occur. Future reports from the authors on this same group of patients will be necessary to answer these concerns, along with more objective postoperative determinates of success.