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Surgical treatment for stress urinary incontinence
HO T O FF TH E PO D I UM
Surgical treatment for stress urinary incontinence Urogynecology highlights from the American College of Obstetricians and Gynecologists (ACOG) 48th Annual Clinical Meeting, San Francisco, CA, USA, May 2000
INTRODUCTION Choosing the optimal surgery for treating stress incontinence remains an area of debate. A multitude of different operations for the treatment of stress incontinence have come and gone over the years, yet none has achieved objective or subjective cure rates that are both high and durable. Several operations have withstood the test of time with consistently reported, long-term objective cure rates of 80–90% and these have become our ‘gold standard’ procedures. There were three presentations at the ACOG meeting regarding the outcomes of incontinence surgery. Although early results were presented, long-term follow-up is essential before these new surgical techniques can be accepted. 1. RANDOMIZED COMPARISION OF LAPAROSCOPIC AND TRANSABDOMINAL BURCH URETHROPEXY FOR THE TREATMENT OF STRESS INCONTINENCE. R.L. Summitt, V. Lucente, M.M. Karram, B.L. Shull, A.E. Bent, Memphis, TN, USA In a multicenter study, women with pure genuine stress incontinence (GSI), recurrent GSI after anterior colporrhaphy or mixed incontinence after successful treatment of detrusor instability (DI) were randomized to Tanagho’s modification of the Burch urethropexy or laparoscopic transperitoneal Burch urethropexy using two permanent sutures on each side. Women with previous retropubic surgery, pelvic organ prolapse, intrinsic sphincter deficiency, or untreated DI were excluded. Sixty-two women were available for follow-up – 28 who underwent the laparoscopic Burch procedure and 34 who underwent the open Burch procedure. Patients undergoing laparoscopic Burch urethropexy had significantly longer operating times (173.2 vs 118.6 min) and shorter hospital stays (1.4 vs 2.1 days) than those undergoing open Burch urethropexy. There were no significant differences between the groups in postoperative voiding dysfunction, de novo DI, fever, or complications. Patients were evaluated with multichannel urodynamic testing 1 year after surgery. Objective surgical cure rates were not significantly different between the groups. Ninety-two percent of subjects undergoing the open Burch procedure and 88% of those undergoing the laparoscopic Burch procedure were objectively cured. This study provided level 1 evidence for the short-term efficacy of these two routes of urethropexy. 2. INITIAL EXPERIENCE WITH A BONE-ANCHORED SLING FOR STRESS URINARY INCONTINENCE. C.J. Ascher-Walsh, E. DeMarco, A. Bloomgarden, J.S. Blanco, New York, NY, USA Subjective outcome data were presented for 42 women who underwent the Vesica bone-anchor sling technique for treatment of stress incontinence. Twenty-seven of the women were reported to
112
Evidence-based Obstetrics and Gynecology (2000) 2, 112 doi:10.1054/ebog.2000.0184, available online at http://www.idealibrary.com on
have stress urinary incontinence, nine had intrinsic sphincter deficiency, and six had mixed incontinence. The type and specific details of the preoperative examination (i.e. urodynamic tesing), presence of pelvic organ prolapse, and concomitant reconstructive surgery were unclear. Three different materials were used for the slings in these 42 women – 10 women had protogen slings, nine had donor fascia slings, and 23 had alloderm slings. The mean length of follow-up was 267 days (approximately 9 months). Three subjects required a second operation during this period – two for rejection of the protogen sling and one for prolonged voiding dysfunction – and three subjects underwent cystotomy during the procedure. Outcome was based on the subjects’ ‘incontinence scores’ which ranged from 1 to 10 with 5 being equal to subjects’ preoperative level of incontinence and 10 being the perception that they were completely dry. The mean incontinence score was 9.78. Thirty-seven subjects were ‘completely dry’, four were ‘improved’, and only one woman was ‘worse’. This case series has many design issues, limiting its contribution to the surgical literature. 3. RETURN OF NORMAL VOIDING FUNCTION AFTER VESICA BONE-ANCHORED SLING PROCEDURE FOR STRESS URINARY INCONTINENCE. C.J. Ascher-Walsh, E. DeMarco, J. Blanco, New York, NY, USA This presentation included the same women who underwent the Vesica bone-anchor sling procedure for stress incontinence described above and reported on the subjects’ length of postoperative catheterization. The authors’ voiding protocol was to remove the Foley catheter on postoperative day 3 and check a post-void residual volume after the subject’s second void. If the volume was more than 175 mL, the catheter was replaced and a voiding trial was repeated in 3–7 days. The mean time-to-catheter-removal in the three sling groups was 11 days for the protogen group, 8 days for the donor fascia group, and 10 days for the alloderm group. These were not significantly different. Only one woman required catheterization beyond 33 days, and she underwent sling revision on day 248. Again, this case series has design issues, which limit its applicability. SUMMARY Surgical outcome studies are notoriously difficult. Yet, as new techniques or routes of assess become available for the treatment of stress incontinence, long-term objective, as well as subjective, cure rates and complication rates should be reported in order to use an evidence-based approach to reconstructive pelvic surgery. Kim Kenton, MD and Linda Brubaker, MD Loyola University Medical Center, Maywood, IL, USA
^ 2000 Harcourt Publishers Ltd
Surgical treatment for stress urinary incontinence Urogynecology highlights from the American College of Obstetricians and Gynecologists (ACOG) 48th Annual Clinical Meeting, San Francisco, CA, USA, May 2000
INTRODUCTION Choosing the optimal surgery for treating stress incontinence remains an area of debate. A multitude of different operations for the treatment of stress incontinence have come and gone over the years, yet none has achieved objective or subjective cure rates that are both high and durable. Several operations have withstood the test of time with consistently reported, long-term objective cure rates of 80–90% and these have become our ‘gold standard’ procedures. There were three presentations at the ACOG meeting regarding the outcomes of incontinence surgery. Although early results were presented, long-term follow-up is essential before these new surgical techniques can be accepted. 1. RANDOMIZED COMPARISION OF LAPAROSCOPIC AND TRANSABDOMINAL BURCH URETHROPEXY FOR THE TREATMENT OF STRESS INCONTINENCE. R.L. Summitt, V. Lucente, M.M. Karram, B.L. Shull, A.E. Bent, Memphis, TN, USA In a multicenter study, women with pure genuine stress incontinence (GSI), recurrent GSI after anterior colporrhaphy or mixed incontinence after successful treatment of detrusor instability (DI) were randomized to Tanagho’s modification of the Burch urethropexy or laparoscopic transperitoneal Burch urethropexy using two permanent sutures on each side. Women with previous retropubic surgery, pelvic organ prolapse, intrinsic sphincter deficiency, or untreated DI were excluded. Sixty-two women were available for follow-up – 28 who underwent the laparoscopic Burch procedure and 34 who underwent the open Burch procedure. Patients undergoing laparoscopic Burch urethropexy had significantly longer operating times (173.2 vs 118.6 min) and shorter hospital stays (1.4 vs 2.1 days) than those undergoing open Burch urethropexy. There were no significant differences between the groups in postoperative voiding dysfunction, de novo DI, fever, or complications. Patients were evaluated with multichannel urodynamic testing 1 year after surgery. Objective surgical cure rates were not significantly different between the groups. Ninety-two percent of subjects undergoing the open Burch procedure and 88% of those undergoing the laparoscopic Burch procedure were objectively cured. This study provided level 1 evidence for the short-term efficacy of these two routes of urethropexy. 2. INITIAL EXPERIENCE WITH A BONE-ANCHORED SLING FOR STRESS URINARY INCONTINENCE. C.J. Ascher-Walsh, E. DeMarco, A. Bloomgarden, J.S. Blanco, New York, NY, USA Subjective outcome data were presented for 42 women who underwent the Vesica bone-anchor sling technique for treatment of stress incontinence. Twenty-seven of the women were reported to
112
Evidence-based Obstetrics and Gynecology (2000) 2, 112 doi:10.1054/ebog.2000.0184, available online at http://www.idealibrary.com on
have stress urinary incontinence, nine had intrinsic sphincter deficiency, and six had mixed incontinence. The type and specific details of the preoperative examination (i.e. urodynamic tesing), presence of pelvic organ prolapse, and concomitant reconstructive surgery were unclear. Three different materials were used for the slings in these 42 women – 10 women had protogen slings, nine had donor fascia slings, and 23 had alloderm slings. The mean length of follow-up was 267 days (approximately 9 months). Three subjects required a second operation during this period – two for rejection of the protogen sling and one for prolonged voiding dysfunction – and three subjects underwent cystotomy during the procedure. Outcome was based on the subjects’ ‘incontinence scores’ which ranged from 1 to 10 with 5 being equal to subjects’ preoperative level of incontinence and 10 being the perception that they were completely dry. The mean incontinence score was 9.78. Thirty-seven subjects were ‘completely dry’, four were ‘improved’, and only one woman was ‘worse’. This case series has many design issues, limiting its contribution to the surgical literature. 3. RETURN OF NORMAL VOIDING FUNCTION AFTER VESICA BONE-ANCHORED SLING PROCEDURE FOR STRESS URINARY INCONTINENCE. C.J. Ascher-Walsh, E. DeMarco, J. Blanco, New York, NY, USA This presentation included the same women who underwent the Vesica bone-anchor sling procedure for stress incontinence described above and reported on the subjects’ length of postoperative catheterization. The authors’ voiding protocol was to remove the Foley catheter on postoperative day 3 and check a post-void residual volume after the subject’s second void. If the volume was more than 175 mL, the catheter was replaced and a voiding trial was repeated in 3–7 days. The mean time-to-catheter-removal in the three sling groups was 11 days for the protogen group, 8 days for the donor fascia group, and 10 days for the alloderm group. These were not significantly different. Only one woman required catheterization beyond 33 days, and she underwent sling revision on day 248. Again, this case series has design issues, which limit its applicability. SUMMARY Surgical outcome studies are notoriously difficult. Yet, as new techniques or routes of assess become available for the treatment of stress incontinence, long-term objective, as well as subjective, cure rates and complication rates should be reported in order to use an evidence-based approach to reconstructive pelvic surgery. Kim Kenton, MD and Linda Brubaker, MD Loyola University Medical Center, Maywood, IL, USA
^ 2000 Harcourt Publishers Ltd