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Surgical Treatments of Urinary Incontinence

In people who have normal pressures - normal closure pressure, normal leak point pressure and don't have detrusor instability, we want to do retropubic urethropexy sort of as our gold standard, whether we are doing this abdominally or trying to do this transvaginally. We also do transvaginal slings in some of these people, whether they are bone anchored or using the Capio device or the tension-free vaginal tape procedure. If someone does have concurrent detrusor instability and they have reasonable intrinsic function, Burch procedure will cure this in our hands fifty-five percent of the time on objective testing and seventy percent of the time subjectively. Transvaginal Capio sling will be used.

If somebody has intrinsic sphincteric dysfunction, low pressure urethra, and they have hypermobility or low leak point pressures with hypermobility and there is detrusor instability, we can use a full abdominal vaginal sling. Often time, I will use a vaginal wall sling. The transvaginal slings may be better for this, because we see resolution of detrusor instability in nearly fifty percent of people with hour transvaginal slings, whether they are bone anchored or sutured to Cooper's ligament and this may be a better way to go.

If someone doesn't have detrusor instability, we would typically use full abdominal vaginal slings or the modified patch sling. The minimally invasive side of this is just to use transvaginal slings. This has been sort of an evolution for us and I think a lot of people around the world. It is very rare now that I do a full abdominal vaginal sling. Our transvaginal slings are working so well and patients prefer, when offered a choice, the minimally invasive alternative, that we don't end up doing many traditional abdominal vaginal slings anymore. In our population, almost sixty percent of the people we see in referral have ISD, so we do far more slings than we do retropubic urethropexy or needle suspension to begin with.

How do we approach the woman with genuine stress incontinence? The first minimally invasive surgery in the United Stated for genuine stress incontinence really is the Kelly-Kennedy plication. Think about it - one, two, three stitches through the vagina, no abdominal incision. The problem is the longevity of this surgery and sometimes even the initial cure rate as we discussed before. The second - and the first operations we really thought of as sort of minimally invasive alternatives to retropubic urethropexy and full abdominal slings.

You need to elevate the bladder neck somewhat to achieve continence, but if you elevate it too much and create too much suture tension, you are going to have increased risk of suture pull through and poor longevity. That really is the limitation of needle suspensions. That is why most people, at least in North America, have come to the conclusion.

In surgery, we are always striving for a better way to do things. The advantages of a laparoscopic retropubic urethropexy over an open procedure are smaller incisions, decreased pain, magnification to allow you to control bleeding or better place sutures. The disadvantages would include increased O.R. time, which leads to increased expense, especially if you are using disposable equipment, the question of the longevity of the repair and complications, especially in the hands of an experienced laparoscopist. In the original report by Schusler et al., they actually did an MMK through the scope, going up to the pubic symphysis.

I have used a Stamey needle like a sewing needle and took transcutaneous transvaginal bites going back and forth with the Stamey needle between two operators - one in the vagina and one on the scope - to get wide, full-thickness bites. Initially, there was a ninety-two percent subjective cure rate. Surgery took in excess of two hours and a one-day hospital stay. In follow up some years later, we looked at three-month success, which subjectively was eighty-nine.

Prospective randomized data is more meaningful to me if the operator is experienced with both operations, as Gil Burton has been, in showing us that the one-year success rate of an open Burch versus the scope Birth in this study reported by Burton in 1994 was significantly different. You have to make your own decisions, but there are a number of minimally invasive surgeries and you have to find the advantages and look at the disadvantages. Disadvantages for me are the steep learning curve , special instrumentation is required, there is a risk of hernia through the incisions and it is difficult sometimes to close these carefully in order to avoid it. There certainly is increased cost. The operative time with an open Burch can be done.

There was a Brazilian group a number of years ago that reported on a vaginal retropubic urethropexy. Back in the 1980's, a group in Tel Aviv, Israel, reported on doing a transvaginal Burch procedure in steep Trendelenburg with typical Heaney needle holders - this is very difficult to do. The Brazilian group used flaps of anterior vaginal wall that they crossed across the bladder neck and brought up to Cooper's ligament, actually suturing this abdominally. They had a ninety-two percent five-year success rate. This work was repeated by another group, but they did not do nearly as well. Over the last five years, at our center, we have worked with one company in trying to develop special instrumentation.

Tension-free vaginal tape procedure, developed in 1995, took Prolene mesh and put in without sutures at the level of the mid urethra to fulfill the expectation of unified pelvic floor therapy. This has gained tremendous support and acceptance throughout Europe, with now over 45,000 cases being performed in Europe and close to 20,000 cases being performed in North America just since its introduction five years ago. Little sharp prongs with a plastic covered Prolene mesh.

The last thing I want to touch on are transvaginal slings, bone anchored and non-bone anchored; I am just going to talk about the transvaginal slings using cadaveric fascia or cadaveric dermis, Alloderm. We suspend these directly to Cooper's ligament. We do a test sling with a tape measure. It is very reproducible, can be done under local, regional or general anesthetic and because it doesn't go to the abdominal wall, it doesn't change intraoperatively as compared to postoperatively. It is very quick and can be done in about 25 to 35 minutes. Again, you reach up with a Capio device , this curved delivery system, put a suture in Cooper's ligament, one on either side and you can get very good bites with this. Then we can use a tape measure to test this and measure it.