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Simplified Operation for Stress Incontinence
Vol. 105, Feb.
THE JOURNAL OF UROLOGY
Copyright© 1971 by The Williams & Wilkins Co.
Printed in U.S.A.
SIMPLIFIED OPERATION FOR STRESS INCONTINENCE JACK LAPIDES From the Section of Urology, Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan
On the basis of experimental observations in ani.mals1 and humans,2 we devised an operative procedure, anterior urethropexy, 3 in 1958 for the treatment of the most common type of stress incontinence in female patients. Investigation revealed that the basic lesion was a shortening, telescoping or collapsing of the urethra and that rational therapy involved fastening the urethra in such a fashion so as to prevent the shortening of the urethra (or urinary sphincter) when the patient gets to her feet. In essence our technique involved placing absorbable sutures through the roof or anterior wall of the urethra and through overlying periosteum of the pubis and rectus fascia in order to fixate the urethra in an elongated position. Our results in the past 12 years have been excellent in that complete urinary continence has been established in almost 100 per cent of patients with untreated, uncomplicated typical stress incontinence preoperatively. Therapy has been less successful in women who have had previous operative procedures upon the urethra such as urethral diverticulectomy and transurethral resection of the vesical outlet and have required urethroplasty 4 in addition to anterior urethropexy. On occasion in some of the individuals subjected to either anterior urethropexy or to the combined type of operation, osteitis pubis has developed. This complication was probably related to perforation of the periosteum and pubic bone by a needle and suture contaminated with bacteria from the urethral wall or lumen. Although the osteitis pubis was readily ameliorated with the use of antimicrobial medication, Accepted for publication March 12, 1970. Lapides, J.: Structure and function of the internal vcsical sphincter. J. Urol., 80: 341, 1958. 2 Lapidcs, J., Ajemian, E. P., Stewart, B. H., Lichtwardt, J. R. and Breakey, B. A.: Physiopathology of stress incontinence. Surg., Gyncc. & Obst., 111: 224, 19GO. 3 Lapides, J.: Stress incontinence. J. Urol., 85: 1
291, 1961. 4 La pi des, J.: Surgical therapy for abnormalities of the urinary sphincter in the female. Brit.
J. Urol., 37: 609, 1965.
262
oxyphenbutazone 5 and anticoagulant therapy, it was still disconcerting to have it occur. During the evolution of the technique for anterior urethropexy, we contemplated the use of only several sutures taken through the anterior bladder wall just proximal to the urethrovesical junction in order to stabilize the urethra in a lengthened position. However, we were dissuaded by the possibility that the sutures might undergo dissolution before fibrous tissue developed between adventitia of urethra and periosteum or rectus fascia. Then 2 years ago we decided to be adventurous and approximate the urethrovesical region to overlying rectus fascia without any sutures being taken through the periosteum and bone. SURGICAL TECHNIQUE
Under spinal anesthesia and with the patient in the supine position with the knees slightly flexed and abducted (frog-leg position), the lower abdomen and vagina are prepared and draped. A 20-French self-retaining catheter, calibrated in centimeters, is passed through the urethra into the bladder and the balloon is inflated to 5 ml. capacity. Gentle traction is placed upon the catheter and the urethral length is noted. The operative approach is made through a transverse incision approximately 2 cm. above or cephalad to the superior margin of the pubis (fig. 1, A), traversing skin, subcutaneous tissue and rectus fascia. The underlying rectus muscles are freed from the rectus fascia and from each other in the midline and retracted laterally. The urethra and bladder are identified and the adventitia of the urethra is exposed by gently dissecting away the periurethral fat and plexus of veins. The urethral adventitial surface and the periosteum of the pubis are carefully scarified with a scalpel blade (fig. 1, B). 5 Lapides, J., Herwig, K. R., Anderson, E. C., Lovegrove, R. H., Correa, R. J., Jr. and Sloan, J. B.: Oxyphenbutazone therapy for mumps orchitis, acute epididymitis and osteitis pubis. J. Urol., 98: 528, 1967.
FIG. l. A, centimeters B, urethral scarified.
rnattress roctus fascia C several rr10re sutures are placed in sirn.ilar fnshiOn aud in sa1ne R:eneral region.
FIG. 4. [l 1 preoperative and Fm. 2. A, initial sntnre is taken of urethra and der wall in of urcthrovesicc1l B, tions and traction 1s llf)On st1ture ascertain sutures to and nrethnYvcsico.l arec1 of rectns through vvhich suture mnst be tion. B, urethropcxy taken in order to lengthen nrethrn,. 263
264
LAPIDES
A 1-zero chromic catgut suture is passed through the anterior wall of the bladder in the region of the urethrovesical junction, using a heavy round point or K needle. The bite includes about 1 cm. of tissue and enters the lumen of the bladder (fig. 2, A). Traction is applied to the 2 ends of the suture in a cephalad direction (fig. 2, B) so that the urethra is stretched and the bladder is brought into contact with the undersurface of the rectus fascia. This maneuver serves to pinpoint the area on the undersurface of the rectus fascia through which the suture must be passed in order to fix the urethra in a lengthened state. A mattress-type stitch is then taken through the rectus fascia and tied (fig. 3, A and B). Several more sutures of the same type are taken in the same general area (fig. 3, C and D). The increase in length of the urethra and the anatomical relationships of urethra, pubic bone, rectus fascia and fixating sutures are noted (fig. 4, A). Note the difference in placement of sutures
in the original operation of anterior urethropexy (fig. 4, B). A rubber drain is left in place and the various layers of the abdominal wall are closed in an appropriate fashion. The bladder is drained by a urethral catheter left inlying for 3 to 5 days. RESULTS
Twelve women have been subjected to the operative procedure and 11 have been relieved of urinary incontinence. One patient with a history of many previous operations upon the urethra and with a scarred urethral wall obtained some improvement but was not cured of enuresis. No patient exhibited osteitis pubis. SUMMARY
A simplified version of anterior urethropexy for stress incontinence is presented. The modification is easier to perform, obviates osteitis pubis and bears the same high cure rate.
THE JOURNAL OF UROLOGY
Copyright© 1971 by The Williams & Wilkins Co.
Printed in U.S.A.
SIMPLIFIED OPERATION FOR STRESS INCONTINENCE JACK LAPIDES From the Section of Urology, Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan
On the basis of experimental observations in ani.mals1 and humans,2 we devised an operative procedure, anterior urethropexy, 3 in 1958 for the treatment of the most common type of stress incontinence in female patients. Investigation revealed that the basic lesion was a shortening, telescoping or collapsing of the urethra and that rational therapy involved fastening the urethra in such a fashion so as to prevent the shortening of the urethra (or urinary sphincter) when the patient gets to her feet. In essence our technique involved placing absorbable sutures through the roof or anterior wall of the urethra and through overlying periosteum of the pubis and rectus fascia in order to fixate the urethra in an elongated position. Our results in the past 12 years have been excellent in that complete urinary continence has been established in almost 100 per cent of patients with untreated, uncomplicated typical stress incontinence preoperatively. Therapy has been less successful in women who have had previous operative procedures upon the urethra such as urethral diverticulectomy and transurethral resection of the vesical outlet and have required urethroplasty 4 in addition to anterior urethropexy. On occasion in some of the individuals subjected to either anterior urethropexy or to the combined type of operation, osteitis pubis has developed. This complication was probably related to perforation of the periosteum and pubic bone by a needle and suture contaminated with bacteria from the urethral wall or lumen. Although the osteitis pubis was readily ameliorated with the use of antimicrobial medication, Accepted for publication March 12, 1970. Lapides, J.: Structure and function of the internal vcsical sphincter. J. Urol., 80: 341, 1958. 2 Lapidcs, J., Ajemian, E. P., Stewart, B. H., Lichtwardt, J. R. and Breakey, B. A.: Physiopathology of stress incontinence. Surg., Gyncc. & Obst., 111: 224, 19GO. 3 Lapides, J.: Stress incontinence. J. Urol., 85: 1
291, 1961. 4 La pi des, J.: Surgical therapy for abnormalities of the urinary sphincter in the female. Brit.
J. Urol., 37: 609, 1965.
262
oxyphenbutazone 5 and anticoagulant therapy, it was still disconcerting to have it occur. During the evolution of the technique for anterior urethropexy, we contemplated the use of only several sutures taken through the anterior bladder wall just proximal to the urethrovesical junction in order to stabilize the urethra in a lengthened position. However, we were dissuaded by the possibility that the sutures might undergo dissolution before fibrous tissue developed between adventitia of urethra and periosteum or rectus fascia. Then 2 years ago we decided to be adventurous and approximate the urethrovesical region to overlying rectus fascia without any sutures being taken through the periosteum and bone. SURGICAL TECHNIQUE
Under spinal anesthesia and with the patient in the supine position with the knees slightly flexed and abducted (frog-leg position), the lower abdomen and vagina are prepared and draped. A 20-French self-retaining catheter, calibrated in centimeters, is passed through the urethra into the bladder and the balloon is inflated to 5 ml. capacity. Gentle traction is placed upon the catheter and the urethral length is noted. The operative approach is made through a transverse incision approximately 2 cm. above or cephalad to the superior margin of the pubis (fig. 1, A), traversing skin, subcutaneous tissue and rectus fascia. The underlying rectus muscles are freed from the rectus fascia and from each other in the midline and retracted laterally. The urethra and bladder are identified and the adventitia of the urethra is exposed by gently dissecting away the periurethral fat and plexus of veins. The urethral adventitial surface and the periosteum of the pubis are carefully scarified with a scalpel blade (fig. 1, B). 5 Lapides, J., Herwig, K. R., Anderson, E. C., Lovegrove, R. H., Correa, R. J., Jr. and Sloan, J. B.: Oxyphenbutazone therapy for mumps orchitis, acute epididymitis and osteitis pubis. J. Urol., 98: 528, 1967.
FIG. l. A, centimeters B, urethral scarified.
rnattress roctus fascia C several rr10re sutures are placed in sirn.ilar fnshiOn aud in sa1ne R:eneral region.
FIG. 4. [l 1 preoperative and Fm. 2. A, initial sntnre is taken of urethra and der wall in of urcthrovesicc1l B, tions and traction 1s llf)On st1ture ascertain sutures to and nrethnYvcsico.l arec1 of rectns through vvhich suture mnst be tion. B, urethropcxy taken in order to lengthen nrethrn,. 263
264
LAPIDES
A 1-zero chromic catgut suture is passed through the anterior wall of the bladder in the region of the urethrovesical junction, using a heavy round point or K needle. The bite includes about 1 cm. of tissue and enters the lumen of the bladder (fig. 2, A). Traction is applied to the 2 ends of the suture in a cephalad direction (fig. 2, B) so that the urethra is stretched and the bladder is brought into contact with the undersurface of the rectus fascia. This maneuver serves to pinpoint the area on the undersurface of the rectus fascia through which the suture must be passed in order to fix the urethra in a lengthened state. A mattress-type stitch is then taken through the rectus fascia and tied (fig. 3, A and B). Several more sutures of the same type are taken in the same general area (fig. 3, C and D). The increase in length of the urethra and the anatomical relationships of urethra, pubic bone, rectus fascia and fixating sutures are noted (fig. 4, A). Note the difference in placement of sutures
in the original operation of anterior urethropexy (fig. 4, B). A rubber drain is left in place and the various layers of the abdominal wall are closed in an appropriate fashion. The bladder is drained by a urethral catheter left inlying for 3 to 5 days. RESULTS
Twelve women have been subjected to the operative procedure and 11 have been relieved of urinary incontinence. One patient with a history of many previous operations upon the urethra and with a scarred urethral wall obtained some improvement but was not cured of enuresis. No patient exhibited osteitis pubis. SUMMARY
A simplified version of anterior urethropexy for stress incontinence is presented. The modification is easier to perform, obviates osteitis pubis and bears the same high cure rate.