排尿障礙治療中心版權所有 Surgical Treatment of Stress Urinary Incontinence Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital

排尿障礙治療中心版權所有

Surgical Treatment of Stress Urinary Incontinence

Hann-Chorng Kuo

Department of Urology

Buddhist Tzu Chi General Hospital


Surgical Goals for Stress Urinary Incontinence

• To restore urinary continence

• To preserve normal micturition

• Free of bladder outlet obstruction

• Not to create newly developed urge incontinence or exacerbate existing urge incontinence

• Not to jeopardize renal function


Historical surgical procedures for stress urinary incontinence

• Kelly plication procedure

• Marshall-Marchetti-Kratz procedure

• Pereyra procedure

• Stamey bladder neck suspension

• Raz bladder neck suspension

• Gittes bladder neck suspension


Marshall Marchetti Krantz Procedure


Repair of Paravaginal defect


Current popular surgical procedures for SUI

• Burch colposuspension procedure

• Fascial pubovaginal sling procedure

• Vaginal sling procedure

• Collagen, Teflon, fat injection

• Synthetic pubovaginal sling procedure

• Tension free vaginal tape

• Laparoscopic bladder neck suspension


Burch colposuspension


Periurethral injection for SUI


Laparoscopic Bladder neck suspension


Laparoscopic Colposuspension


Long term (5-year) results of Anti-incontinence surgery

n(a)Gittes BNS (n=62)

(b) Raz BNS (n=53)

(c)Pubovaginal sling(n=42)

Statistics

n % n % n %

Dry 60 25 40.3 12 22.6 23 54.8 (a)vs.(b)p<0.05

Improved 61 20 32.3 25 47.2 16 38.1 (b)vs.(c)p<0.05

Success rate 45 72.6 37 69.8 39 92.9 (a)vs.(c)p<0.05

Moderate SUI 21 11 17.7 8 17.0 2 4.8 (b)vs.(c)p<0.05

Severe SUI 15 6 9.7 8 15.1 1 2.3


Surgical results by Types of stress incontinence

n(a)Type I SUI (n=12)

(b)Type SUI Ⅱ(n=111)

(c)Type ⅢSUI (n=34)

Statistics

n % n % n %

Dry 60 6 50.0 40 36.0 14 41.2 nonsignificant

Improved 61 4 33.3 48 43.2 9 26.5

Success rate 10 83.3 88 79.2 23 67.7nonsignificant

Moderate SUI 21 2 16.7 13 11.7 7 22.6

Severe SUI 15 0 10 9.0 6 19.4


Success rates of SUI in Different surgical procedures

n(a)Gittes BNS (n=62)

n(b)Raz BNS (n=53)

(b)Pubovaginal sling(n=42)

Statistics

n % n % n %

Type I SUI 12 8/10 80.0 2/2 100.0

Type II SUI 111 32/41 78.0 33/47 70.2 23/23 100.0 nonsignificant

Type III SUI 34 5/11 45.5 2/4 50.0 16/19 84.2 (a)vs.(c)P<0.05

(b)vs.(c)P<0.05


Goals for Surgical correction of Stress incontinence

• Adequate vaginal support of the urethra and bladder neck for urethral hypermobility

• Restoration of hammock effect during stress for damages in attachments to fascia pelvis

• Increase urethral coaptation if intrinsic sphincteric deficiency exists

• Correct prolapse concomitantly• Do not create bladder outlet obstruction


Elevated bladder neck after Incontinence surgery


Defects in vaginal attachment and vaginal wall weakness


Anterior colporrhaphy with pubovaginal sling procedure


Pubovaginal Sling procedures

• Fascial sling – rectus fascia, fascia lata

• Sling on a string

• Artificial sling - mersilene silastic dacron marlex

• Cadaveric or porcine collagen sling

• Bone anchor sling

• TVT / SPARC – polypropylene mesh


Techniques of Pubovaginal sling procedure


Fascial and Silastic slings

• Silastic and fascial slings are not elastic

• Both form rigid support at bladder neck

• Move very little – 1 to 2 mm only

• Produce proximal compression

• More likely to be obstructive

• Mersilene more likely to erode


TVT – tension-free vaginal tape

• First published 1996 by Ulmsten

• >200,000 performed worldwide to date

• Innovative in:– Midurethral positioning– Stretchable woven Prolene™ mesh– Rough edge for fixation to tissues– Local or regional anaesthesia / day surgery


MECHANICAL PROPERTIES OF IMPLANT MATERIALS

0

10

20

30

40

50

60

70

80

90

100

0 20 40 60 80 100 120

Displacement (mm)

Load

(N)

IVS

TVT

Nylon 66

Sparc


Obstruction of TVT Sling


Operative success rate in SUI

TVT Colpo PVS

Cure rate

<12 months80-100% 84-100% 64-100%

Cure rate

1-3 yr80 –95% 84% 82%

Cure rate

>3 yr85% 84% 83%


Prolene mesh Pubovaginal sling procedure

• 64 patients, aged 37 – 82 years

• Mean follow-up 24 months

• 52 were dry, 2 were dry after a second sling, 10 had improvement but mild SUI

• Satisfactory rate 86%

• Persistent DI in 3, resolution of DI in 3,

De novo DI in 4


Polypropylene mesh sling


Techniques in performing prolene mesh pubovaginal sling


Urodynamic results after pubovaginal sling procedure

Mean (SD) variableA (before)

B (at 7 days)

C (at 3 months)

P<0.05

Qmax (mL/s) 13.0(7.3) 13.1(6.5) 17.5(5.7) A vs C,B vs C

Capacity (mL)275(11

3)253(61.3

2) 269(67.1) NS

Pdet (cmH2O) 20.3(10.5)

21.9(10.3) 21.3(7.1) NS

BN opening time (s) 8.5(8.1) 24.3(27.1) 12.1(10.3) A vs B

Residual vol. (mL)47.9(53.

7)38.5(62.

1) 15.7(23.9) NS


Videourodynamic results after Pubovaginal sling procedure


Detailed surgical techniques for Prolene pubovaginal sling























Bladder neck after Pubovaginal sling procedure


Transrectal sonography after PVS

IncompetentBladderNeck

Symphysispubis

Urethra

* *Sling

BA

BladderNeck

Urethra

Preoperative PostoperativeSymphysispubis


Histology of prolene mesh sling


Injection Therapy for ISD

• Facilitate coaptation of urethral mucosa

• Create some degree of outlet obstruction

• De novo urge in 12.6 – 28%

• 3% of patients had allergic reaction

• A second injection is needed in 11-25%

• A higher failure rate in fat injection

• The depth of injection relates to success rate


Surgical Therapy for SUI

• Sling and retropubic procedures had 82-84% success rate beyond 48 months

• Needle suspension 65-70% success

• Sling appears to be the most efficacious over time for all types of SUI

• Success rate should be determined at least 24 months after procedure


Complications of Sling procedure

• Bladder perforation

• De novo urge incontinence

• Urinary retention after operation

• Sling erosion and infection

• Granuloma formation in vaginal wall

• Abdominal wall herniation

• Persistent wound pain and lump sensation


How to prevent surgical failure

• Accurate diagnosis of types of SUI before operation

• Concomitant correction of cystocele and vesiceral prolapse

• Minimal dissection of suburethral endopelvic fascia

• Properly identify the bladder neck• Hemostasis and sterile surgical procedures• Adjust the suspension tension to avoid obstruction


Low contractility in patient with SUI with cystocele


Recurrence of Incontinence

• Identify the cause of recurrent incontinence

• Investigate anatomical defects in urethra

• Use of prolene mesh for definite correction

• Treating denovo urge with anticholinergics

• Release of sling if presence of obstruction

• Apply a second sling for persistent ISD after the first anti-incontinence surgery


A second sling to cure persistent stress incontinence due to ISD

Sling1

Sling2

Urethra

Synphysis pubis

Bladder

Bladder

Sling1Sling2

Urethra

Synphysis pubis


When urine retention develops

• Pressure flow study to determine the cause

• Most of patients can void within 2 weeks

• On CISC or trocar cystostomy for training

• Give alpha-blocker and baclofen

• Give NSAID to eradicate inflammation and relieve wound pain

• Have more patience than the patients do


Postoperative Outlet Obstruction

• An elevated and semi-open bladder neck without difficulty in cystoscopy will prevent

• Patients present with dysuria, urge, and large residual urine

• High detrusor pressure and low flow rate• Transrectal sonography to detect angulation• Lysis of sling tension can be performed wit

hin 7 postoperative days


Adequate thickness of endopelvic fascia prevent sling compression

Urethral Striated muscle

Incompetent urethra

Sling

A B

Urethral Striated muscle

Competent urethra

Sling


Videourodynamics in Post-incontinence surgery BOO


Transvaginal urethrolysis

• A tolerable way to relieve sling tension

• Midline vaginal incision under local anesthesia

• Find the sling and cut it at midline

• Suture the sling edges to prevent complete slippage of the sling

• A high continence rate remains


Management of areflexic bladder following incontinence surgery

• Pressure flow to determine cause of SUI

• Avoid incontinence surgery in low compliant bladder

• Use of fascial sling instead of EBNS

• Select a procedure easy for urethrolysis

• Apply the sling loosely at proximal urethra

• Teach patient to use CISC for evacuation

Documents

排尿障礙治療中心 版權所有 Surgical Treatment of Stress Urinary Incontinence Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital

排尿障礙治療中心版權所有 Surgical Treatment of Stress Urinary Incontinence Hann-Chorng Kuo Department of Urology Buddhist Tzu Chi General Hospital