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New Treatments for Stress Incontinence

Looking at anterior colporrhaphies and Kelly-Kennedy plications, objective cures in the literature range from thirty to ninety percent with subjective cure rates paralleling this. There is very poor longevity in most series that look at these operations - Kelly-Kennedy plication specifically - five years later show success rates below fifty percent. It is not so bad at creating de novo detrusor instability; this occurs probably only in about five percent of the cases.

Talking about retropubic anti-incontinence operations, the prototype that most of us are familiar with is the Burch procedure or the MMK. The modified Burch procedure is an operation whose goal is to resupport the anterior vaginal wall and thus indirectly resupport the proximal urethra. We suture a mobile structure, the anterior vaginal wall, to an immobile source of support, Cooper's ligament, the iliopectineal line, or in the case of an MMK, we suture to the pubic

The modified Burch procedure involves the use of permanent sutures. In 1961, John Burch described the use of absorbable sutures; here we place one suture at the bladder neck, 2 cm lateral to the bladder neck on either side and then another pair distal to this. Here, we are just dermabrading and elevating the bladder neck superomedially off of the endopelvic connective tissue of the anterior vaginal wall. You can identify the bladder most easily and reliably by looking for the inferior vesical vein. If you are unsure, you can always fill the bladder retrograde

The MMK, the first retropubic urethropexy popularized, at least in the United States, is where stitches are placed from the vagina very close to the urethra or actually the urethra itself to the symphysis pubis. This has initial success rates of around ninety percent and good longevity five years later in eighty percent of people. Here, stitches typically with the

Another retropubic urethropexy of sorts is the paravaginal repair. George White originally described this procedure in 1908, calling it the obturator shelf repair using sutures from the anterolateral vaginal sulcus to the arcus tendineus fascia of the pelvis. People talk about cure rates in the ninety percent range with this procedure. However, in prospective studies that have been done of small series, the cure rate may be as low as thirty-five percent. Here again, if you

In two prospective comparative trials, both by Columbo and his group in Italy, in 1994 they reported on a prospective randomized trial looking at MMK versus Burch after two to seven years of follow up with an objective cure rate in the MMK group of sixty-five percent and eighty percent in the Burch group. These were not significant due to type 2 error and low numbers. They looked at Burch versus paravaginal repair after one to three years; they went and studied

Long-term follow up of Burch retropubic urethropexy reveal up to 10-year studies still showing eighty to ninety percent objective success in these patient populations. So this is an operation that gives us not only good success, but good long-term success.

There are other ways to do this; we can do laparoscopic retropubic urethropexy, usual Burch-type operations, but modifications thereof; we do a vaginal retropubic urethropexy; we also do vaginal paravaginal repairs, although I don't think this is a good incontinence operation.

For people of intrinsic sphincteric dysfunction, you really don't want to do normal retropubic urethropexy and you probably don't want to do needle suspensions. Many people believe in doing slings in these operations with ISD. The reason for this is that it is an operation that doesn't just resupport the proximal urethra, but it also seeks to compress or allow the urethra to compress upon itself with a more rigid backstop. With sling procedures, we suture the sling material - so we give up on the anterior vaginal wall because we say that we want something

Cure rates in objective series throughout the literature are eighty to ninety-five percent; slings are excellent at achieving cure of people with all degrees of intrinsic function. Subjective cure rates parallel that and there is great longevity. When I use heterologous materials, like Gore-Tex or Prolene to do traditional slings at the bladder neck, these materials are stronger than bone and cartilage. These materials will still be present in the body long after it has been dead and buried. Heterologous material can cause problems with erosions and infections and

Results of an old study by Peter Beck of fascia lata Oxford-type slings, including 88 women, reported an eighty-eight percent cure rate; half of them resolved their concurrent detrusor instability; seven percent developed de novo detrusor instability; one percent developed retention. This is really good; these are good results with a sling, especially

For a fascia lata sling, you can make just a small incision just above the lateral epicondyle of the knee and use a fascial stripper. If you are lucky, you get a nice piece of fascia lata. More likely, you will drop the fascial stripper and put a nick in it and then keep getting pieces of fascia with little nicks in them. So you have to be very, very careful. Unfortunately, fascia lata slings are usually done in elderly people; in a patient with venous insufficiency, you certainly aren't going to do this and then wrap their thigh for four days. I prefer taking fascia lata from dead people. We can use rectus fascia; we harvest strips of rectus fascia and we can harvest a

Slings are great for success; slings are terrible when it comes to voiding function. Traditionally, if we do slings that are tight enough to handle stress incontinence in people with ISD, almost everybody is going to take more than seven days to void. Long-term retention, in this series by

Peter Beck, reported one in four; almost all of those people are going to get infected if they are retaining urine. We can see wound infections or seromas in eight percent of people. I think that is fairly representative of what we want to see.

A study by Handa and Ostergaard was the first report in the literature of using cadaveric fascia lata for sling procedures. It was a small early study, but it shows you that you can have very good subjective and objective success.

If you are operating on someone and they have no bladder contraction or very weak bladder contraction and you put in one of these slings, you will need a lot of luck in getting these people to urinate. In those people with weak bladder contractions or no bladder contractions, they will have marked detrusor instability. In these cases, I do not want to be aggressive with slings. The vaginal wall sling is described with or without bone anchors as an operation that we can do to resupport the proximal urethra and even compressing it. This has been shown to be successful in ninety percent of people while still maintaining normal voiding function. What we do is make an inverted U incision, leaving the upper portion of the U, which actually makes an A incision. On the posterior portion of the A, or inverted U