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Current concepts in female stress urinary incontinence
review article
R. M. Long S. K. Giri H. D. Flood Dept. of Urology, Mid Western Regional Hospital, Dooradoyle, Ireland Correspondence to: Ronan Long, 5 Threadneedle Road, Salthill, Galway, Ireland Tel: +353(0)877817504 email: ronanlong@hotmail. com
CURRENT CONCEPTS IN FEMALE STRESS URINARY INCONTINENCE Urinary incontinence is a social burden for up to one-third of the adult female population. Careful assessment, a methodical approach and appropriate treatment can lead to long-term success in the management of these patients. This article gives an outline of current concepts in the evaluation and treatment of stress urinary incontinence. keywords: sling, stress incontinence, periurethral Surgeon, 1 December 2008, pp.366-72
Introduction Stress urinary incontinence (SUI) is a common problem with an overall prevalence of 10% to 30% in females between the ages of 15 and 64 years.1 It has a significant psychosocial impact on individuals and families and is frequently suffered in silence with low consultation and treatment rates.2,3 SUI is defined by the International Continence Society as involuntary leakage of urine on effort or exertion, or on sneezing or coughing.3 The clinical finding of SUI is generally confirmed with a urodynamic study demonstrating stress leak in the absence of a detrusor contraction. Pathogenesis The pathogenesis of SUI is multifactorial and is thought to relate to a general weakening of the pelvic musculature and the collagen-dependent tissues involved in pelvic support as a result of pregnancy and parturition. Other important factors relate to bladder neck position, the intrinsic closing ability, or coaption, of the urethra, the reflex contraction of the pelvic floor musculature at the time of cough and strain, and miscellaneous factors such as the neurological and hormonal milieu within the pelvis. While loss of only one of these factors might not upset the normal balance, it appears that when enough components are dysfunctional, leakage ensues. SUI can affect any age group, but is most often a disease of older, parous women. Risk factors for urinary incontinence in women Urinary incontinence (UI) is very common among older women and is often regarded as a normal and inevitable part of the ageing process. Most studies indicate that UI is indeed correlated with age.4,5 Some studies have found that age was a significant risk factor for urge incontinence, but not for stress incontinence.6,7 366
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UI in women is often assumed to be attributable to the effects of pregnancy and childbirth. The literature shows that UI is a more common occurrence among pregnant women compared with other groups of women. Prevalence of 31% and 60% have been reported.8 Viktrup et al. found a prevalence of 28% for SUI during pregnancy, and 16% of these women became free of symptoms in the puerperium.9 Iosif and Ingemarsson found a prevalence of 9% of persisting SUI after caesarean deliveries.10 Viktrup et al compared continent women having delivered vaginally with women who underwent a caesarean section and found a difference in favour of cesarean section.9 However, three months after delivery, the difference became statistically insignificant. It is becoming clear that both pregnancy and vaginal delivery are risk factors for UI. Recently, Rortveit et al reported the results of the Norwegian EPINCONT study on urinary incontinence after vaginal delivery or caesarean section.11 The risk of urinary incontinence was higher among women who had caesarean sections than among nulliparous women and was even higher among women who have had vaginal deliveries. Obesity is well established as a factor for UI that may contribute to the severity of the condition. Data from several studies indicate that UI in women is associated with higher BMI and greater weight.6,12 Clinically, it has long been assumed that urinary symptoms are an integral part of the transition from the pre-menopausal to the post-menopausal state. Rekers et al. compared pre-menopausal women with post-menopausal and found no significant difference in the prevalence of UI between the two groups.1 Other studies have found no significant differences between post-menopausal © 2008 Surgeon 6; 6: 366-72
Figure 1. (a) Demonstrates urethral hypermobility and descent of the bladder with increased abdominal pressure which causes opening of the urethra and leakage of urine. (b) Demonstrates leakage of urine with low abdominal pressures due to an intrinsic sphincter malfunction
and pre-menopausal women in the prevalence or the frequency of incontinence.14,15 Further, recent studies of risk factors have found that incontinence is not associated with the number of years since menopause, nor age at menopause.6,12 While one might expect lower rates of incontinence in women taking hormone replacement therapy, three studies have reported a two to three times increased risk of incontinence in older women taking oestrogen.16-18 Smoking along with concomitant rectocele repair, diabetes mellitus and pelvic organ prolapse are associated with an increased risk of recurrent SUI following incontinence surgery.19 Types (classication) of stress incontinence Micturition is a complex series of finely tuned and integrated neuromuscular events that involve anatomical and neurological mechanisms. Alterations in any of these components may result in dysfunctional voiding and/or urinary incontinence. The unique properties of the bladder and sphincter that are responsible for continence are detrusor accommodation, sphincteric mechanism and anatomical support. The International Continence Society (ICS) originally defined urinary incontinence as ‘involuntary loss of urine that is objectively demonstrable and a social or hygienic problem’.20 The ICS has recently redefined UI as ‘complaint of any involuntary leakage of urine’. In the assessment of female UI there are three primary types of incontinence that concern us: stress, urge and mixed incontinence. The symptom of SUI is the complaint of involuntary loss of urine during coughing, sneezing, or physical exertion such as sporting activities and sudden changes of position. The symptom of urge UI is the complaint of involuntary leakage accompanied by or immediately preceded by a sudden, strong desire to void (urgency). Mixed incontinence is where both stress and urge incontinence coexist. It is important to distinguish which type of incontinence a patient has and if mixed which is the predominant symptom. Patients with predominant urge incontinence do poorly following surgery for SUI.21 There are two generic types of stress incontinence: urethral hypermobility and intrinsic sphincter deficiency (ISD) as demonstrated in Figure 1.22,23 In urethral hypermobility, the basic abnormality is a weakness of pelvic floor support. Because of this weakness, there is rotational descent of the bladder neck and proximal urethra during © 2008 Surgeon 6; 6: 366-72
increases in abdominal pressure. If the urethra opens concomitantly, SUI ensues. The abdominal pressure can be estimated during urodynamics by recording the abdominal leak point pressure (ALPP), i.e. the increase in abdominal pressure required to produce leakage of urine. Urethral hypermobility is generally related to pressures above 60cm of H2O. ISD denotes an intrinsic malfunction of the urethral sphincter itself and is generally associated with minimal urethral mobility and ALPPs below 60cm of H2O. Hypermobility and ISD frequently coexist. Evaluation of stress urinary incontinence Evaluation of SUI commences with a thorough history, physical examination and routine laboratory studies, including urinalysis, urine culture and renal function tests. For a precise diagnosis, SUI should be witnessed by the examiner. In 1997, the Urodynamics Society recommended minimal standards by which the efficacy of therapy for urinary incontinence should be assessed.24 According to these recommendations, which have been approved by both the American Urologic Association and the Society for Urodynamics and Female Urology, pre-treatment evaluation should consist of a structured micturition history and/or questionnaire, physical examination with full bladder, micturition diary, pad test, and urodynamics. Urodynamic evaluation should consist of at least simple uroflowmetry, cystometry, detrusor pressure/flow study, assessment of the relative contribution of urethral hypermobility, ISD and estimation of post-void residual urine by ultrasonography or catheterisation. Recently the National Institute for Health and Clinical Excellance (NICE) published guidelines.25 These guidelines are somewhat controversial as assessment does not include routine cystometry. It is only considered to be indicated prior to surgery when detrusor overactivity is clinically suspected, when there has been previous surgery for stress incontinence, anterior compartment prolapse or there are symptoms suggestive of voiding dysfunction.
Treatment options Conservative and pharmacological therapy Women with SUI are often treated with a trial of conservative therapy before surgery is offered, usually in the form of pelvic floor muscle
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Figure 2. The sling (in grey) is supported in position by bringing suture material or the sling material itself up under the pubic arch (in yellow) to a suprapubic position
training (PFMT), compression devices such as pessaries and in some cases pharmacotherapy. The rationale for a conservative approach is clear. SUI is not a progressive disease. A moderate delay in surgical therapy does not make such treatment more difficult. The impact of incontinence varies greatly from patient to patient. The patient’s feelings and goals must be taken into consideration in treatment planning. Thus, it is generally appropriate that the least invasive treatment that offers a reasonable chance for success is used first. In 1948 Kegel was the first to report pelvic floor muscle exercises to be effective in treatment of female UI.26 Since Kegel first presented his results, several randomised controlled trials have shown that PFMT with or without biofeedback is more effective than no treatment for SUI.27-29 Duloxetine, a new serotonin and noradrenaline re-uptake inhibitor, has recently become available with reported benefit in patients with stress incontinence. In particular it has been reported to have a synergistic effect when combined with PFMT.30 If these measures are not effective, surgery is indicated.
Surgical therapy Urethral bulking agents Bulking agents such as dextranomer/hyaluronic acid, glutaraldehyde crosslinked bovine collagen (GAX-collagen), polytetrafluoroethylene (PTFE), autologous fat and silicone polymers have all been used to improve urethral mucosal coaptation and increase outflow resistance. Although early studies with collagen injections suggested short- to medium-term ‘cure/improvement’ rates of 48% to 95%, long-term outcome results are much less favourable.31,32 Therefore they are not appropriate first line treatment options in the majority of cases.33 The main indications for injection therapy include high-risk patients for major surgery, elderly patients, previous surgical failures or patient preference. 368
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Colposuspension The Burch (open) colposuspension has been considered alongside rectus fascia slings as the ‘gold standard’ surgical procedure to correct SUI. The vaginal tissues near the bladder neck and proximal urethra are lifted toward the posterior pubic bones to reduce urethral motion and in turn prevent motion-related deficient urethral closure. It is suitable in patients with urethral hypermobility alone but not in patients with ISD where some degree of urethral compression must be applied. Currently this procedure is often laparoscopic with the aim of minimising perioperative morbidity. However, cure rates seem to be slightly lower when compared with the open approach.34 The cure of incontinence following colposuspension has been found to be time dependent.35,36 The longest follow-up with a maximum of 20 years and a mean of 13.8 years after colposuspension, found that cure appeared to plateau at 69% at around 10-12 years.35 Recently Albo et al. showed significantly better results with respect to stress incontinence for rectus fascia sling versus burch colposuspension at two year follow-up. However, there was a significantly greater risk of urinary tract infection in the sling group.37 Sub-urethral sling procedures The first pubovaginal sling operation for stress incontinence is credited to von Giordano in 1907. In a major operation, gracilis muscle was dissected out and used as a graft around the urethra. In 1942, Aldridge, Millin and Read described their correction of UI using fascial slings, but it is McGuire who popularised the procedure in the 1970s.38 These procedures were not minimally invasive, requiring the harvesting of fascia from the patient’s rectus fascia or tensor fascia lata. Using an idea based on the needle suspension, they developed the principle of inserting a sling with minimal dissection, hence creating a minimally invasive procedure. The principle of sling surgery is placing a sling under the urethra
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via an incision in the anterior vaginal wall. This sling is supported in position by bringing suture material or the sling material itself up under the pubic arch to a suprapubic position (Fig. 2). There are many variations of the sling procedure which can be subdivided by material, position of the sling (bladder neck or midurethra), method of placement and degree of tension. As a general guideline, an autologous fascial pubovaginal sling is appropriate and effective for both simple and complex sphincteric incontinence with documented long-term efficacy, whereas the Burch coloposuspension is most effective for those with simple sphincteric incontinence associated with urethral hypermobility.38-40 Outcomes with cure/dry rates of 83% and dry/improved rates of 87% at a minimum of 48 months have been reported.33,41 Long-term follow-up has shown that cure rates are durable with an 88% overall cure rate beyond four years.42 Thus, the pubovaginal sling procedure using autologous fascia has become the gold standard for treating intrinsic sphincter deficiency and SUI in women. In 1990 Ulmsten and Petros proposed the Integral Theory of female UI.43 According to the theory, stress and urge symptoms may both derive, for different reasons, from the same anatomical defect, a lax vagina. Altered collagen/elastin in the vaginal connective tissue and/or its ligamentous supports may cause laxity. Modern surgical therapy of female SUI is no longer focused on the proximal urethra and bladder neck, but also on providing additional support at the mid-urethra to restore continence. This has led to the introduction of mid-urethral sling techniques. The tension free vaginal tape (TVT) procedure introduced in 1996 was the pioneering procedure for placing mid-urethral mesh. This technique used a ‘bottom-up’ retropubic route of sling passage, and was soon followed by the suprapubic arch (SPARC) sling system, using a similar method but via a ‘top-down’ approach through the retropubic space towards the mid-urethra. The efficacy, simplicity and minimal invasiveness of these procedures led to other mid-urethral procedures, such as the transobturator tape (TOT) technique, and more recently the prepubic TVT with the objective of avoiding the space of Retzius (former) and the obturator space (latter) and their vessels and nerves. All of these procedures keep the same principles of mid-urethral, tensionfree placement of a synthetic sling material.44-47 However, there is a significantly increased risk of erosion and extrusion with synthetic slings virtually never seen with autologous fascia.
Figure 3. Urethrovaginal stula following mid-urethral tape procedure
Morbidity of surgery Immediate complications The perivesical/periurethral venous plexus can be a source of substantial haemorrhage during surgery for stress incontinence. The mean blood loss following Burch colposuspension has been reported as 200ml.49 Retropubic haematomas are common after sling procedures. Up to 25% incidence of retropubic haematoma has been reported by a recent study using MRI. Although most haematomas are asymptomatic, large haematomas may affect post-operative bladder emptying.50 Short-term complications Wound infection appears to be uncommon or unrecognised following vaginal surgery. There is no direct evidence that wound infection influences the cure rate for stress incontinence surgery, although infection in the presence of synthetic support materials may lead to removal. © 2008 Surgeon 6; 6: 366-72
Figure 4. TVT material which has eroded into the vagina and become calcied
Urinary tract infection is not uncommon following surgery for stress incontinence. Its frequency will increase with the duration of catheterisation at a rate of 6 – 7.5% per day.48 Urogenital fistulae most commonly follow gynaecological surgery in the developed world. Fistulae are rare but may also develop following surgery for stress incontinence (Fig 3).
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Visceral injures are more common following the TVT procedure. In a randomised trial comparing open colposuspension with the TVT procedure an average of 9% bladder perforation was reported in the TVT group compared to 2% in the open colposuspension group.51 It is advisable to perform cystoscopy following the passage of the trocar or needle during a sling procedure. If the bladder has been perforated the trocar can be removed and usually re-passed safely. Long-term complications Erosion rates varying from 0.3% to 23% have been reported for sling procedures (Fig. 4).52 Traditionally, such erosions are treated by the removal of the synthetic tape with or without a simultaneous repeat sling procedure.53 Successful endoscopic removal of intravesical TVT using holmium laser with resultant cure of symptoms of erosion has also been reported.54 Domingo et al. treated vaginal erosion by complete removal of the TOT mesh. However, in their series, two out of nine patients developed recurrent SUI.55 Recently primary reclosure of vaginal mucosa over eroded tape has also been described as a safe and effective first-line treatment option of vaginal erosion after the TVT procedure.56 Granuloma and abscess formation have been reported following peri-urethral injection. Osteitis pubis has been reported after needle suspension.58 Dyspareunia is seldom mentioned in reports on surgery for stress incontinence. It may be produced by the vaginal wound itself through scarring or vaginal narrowing. Erosion of synthetic material may also lead to dysparuenia in either partner. Dyspareunia has been reported in up to 40% of women after colposuspension.59 Post-surgical bladder outlet obstruction The exact incidence of bladder outlet obstruction (BOO) and associated voiding dysfunction after anti-incontinence surgical procedures is not known but has been estimated to be between 2.5% and 27%. The development of denovo involuntary detrusor contractions has been observed in patients with urodynamic evidence of BOO, and a greater incidence of denovo involuntary detrusor contractions may be associated with increasing degrees of BOO.60,61 According to Raz et al. three distinct groups of patients with BOO symptoms after previous anti-incontinence procedures exist.62 These groups are: 1) obstructed only: the patients who produce detrusor pressures >35 cm H2O without urinary flow, this group will benefit only from urethrolysis, 2) poor detrusor function: the patients who would continue to have problems post urethrolysis and 3) obstructed and incontinent: the patient in whom an additional resuspension procedure seems appropriate. Many surgeons reserve urethrolysis for patients in whom clean intermittent self-catheterisation (CISC) is an unacceptable alternative. The use of CISC avoids the risk of return of the stress incontinence which can occur after urethrolysis.
Conclusion SUI is the most common type of incontinence in women; it can have a considerable impact on their quality of life and may lead to social embarrassment and isolation. Thorough assessment and careful counselling should allow all women a choice of safe and effective treatment for SUI. Conservative options should be adopted first; however, definitive surgery offers good outcomes and is most appropriate for younger active women.
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18. Thom DH, van den Eeden SK, Brown JS. Evaluation of parturition and other reproductive variables as risk factors for urinary incontinence in later life. Obstet Gynecol 1997;90(6):983-89 19. Daneshgari F, Moore C, Frinjari H et al. Patient related risk factors for recurrent stress urinary incontinence surgery in women treated at a tertiary care center. J Urol 2006;176(4 Pt 1):1493-99 20. Abrams PH, J.G. B, Stanton SL et al. Standardisation of lower urinary tract function. Neurourol Urodynam 1988(7):403 -26 21. Chaliha C, Stanton SL. Complications of surgery for genuine stress incontinence. Br J Obstet Gynaecol 1999;106(12):1238-45 22. McGuire EJ, Herlihy E. The inuence of urethral position on urinary continence. Invest Urol 1977;15(3):205-07 23. McGuire EJ, Fitzpatrick CC, Wan J, et al Clinical assessment of urethral sphincter function. J Urol 1993;150(5 Pt 1):1452-54 24. Blaivas JG, Appell RA, Fantl JA, et al Standards of efcacy for evaluation of treatment outcomes in urinary incontinence: recommendations of the Urodynamic Society. Neurourol Urodyn 1997;16(3):145-47 25. Woodford H, George J. NICE guidelines on urinary incontinence in women. Age Ageing 2007;36(3):349-50 26. Kegel AH. Progressive resistance exercise in the functional restoration of the perineal muscles. Am J Obstet Gynecol 1948(56):238-49 27. Hay-Smith EJC, Dumoulin C. Pelvic oor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane review. The Cochrane Library 2006 28. Bo K, Talseth T, Holme I. Single blind, randomised controlled trial of pelvic oor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women. BMJ 1999;20(318):487-93 29. Lagro-Janssen TLM, Debruyne FMJ, Smits AJA et al. Controlled trial of pelvic exercises in the treatment of urinary stress incontinence in general practice. Br J Gen Pract 1991(41):445-49 30. Ghoniem GM, Van Leeuwen JS, Elser DM et al A randomized controlled trial of duloxetine alone, pelvic oor muscle training alone, combined treatment and no active treatment in women with stress urinary incontinence. J Urol 2005;173(5):1647-53 31. Su TH, Hsu CY, Chen JC. Injection therapy for stress incontinence in women. Int Urogynecol J Pelvic Floor Dysfunct 1999;10(3):200-06 32. Gorton E, Stanton S, Monga A et al. Periurethral collagen injection: a long-term follow-up study. BJU Int 1999;84(9):966-71 33. Leach GE, Dmochowski RR, Appell RA, et al Female Stress Urinary Incontinence Clinical Guidelines Panel summary report on surgical management of female stress urinary incontinence. The American Urological Association. J Urol 1997;158(3 Pt 1):875-80 34. Moehrer B, Carey M, Wilson D. Laparoscopic colposuspension: a systematic review. Br J Obstet Gynaecol 2003;110(3):230-35 35. Alcalay M, Monga A, Stanton SL. Burch colposuspension: a 10-20 year follow up. Br J Obstet Gynaecol 1995;102(9):740-45
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36. Dietz HP, Wilson PD. Colposuspension success and failure: a long-term objective follow-up study. Int Urogynecol J Pelvic Floor Dysfunct 2000;11(6):346-51 37. Albo ME, Richter HE, Brubaker L et al. Burch colposuspension versus fascial sling to reduce urinary stress incontinence. N Engl J Med 2007;24(21):2143-55 38. McGuire EJ, Lytton B. Pubovaginal sling procedure for stress incontinence. J Urol 1978;119(1):82-84 39. McGuire EJ, Bennett CJ, Konnak JA et l. Experience with pubovaginal slings for urinary incontinence at the University of Michigan. J Urol 1987;138(3):525-26 40. Raz S. Modied bladder neck suspension for female stress incontinence. Urology 1981;17(1):82-85 41. Jarvis GJ. Surgery for genuine stress incontinence. Br J Obstet Gynaecol 1994;101(5):371-74 42. Morgan TO, Jr., Westney OL, McGuire EJ. Pubovaginal sling: 4-year outcome analysis and quality of life assessment. J Urol 2000;163(6):1845-48 43. Petros PE, Ulmsten UI. An integral theory of female urinary incontinence. Experimental and clinical considerations. Acta Obstet Gynecol Scand Suppl 1990;153:7-31 44. Shindel AW, Ruiz AC, Klutke CG. Transobturator approach to suburethral sling placement in the treatment of stress urinary incontinence in women. Expert Rev Med Devices 2005;2(5):613-22 45. Costa P, Grise P, Droupy S et al Surgical treatment of female stress urinary incontinence with a trans-obturator-tape (T.O.T.) Uratape: short term results of a prospective multicentric study. Eur Urol 2004;46(1):102-6; discussion 106-07 46. Delorme E, Droupy S, de Tayrac R, Delmas V. Transobturator tape (Uratape): a new minimally-invasive procedure to treat female urinary incontinence. Eur Urol 2004;45(2):203-07 47. Daher N, Boulanger JC, Ulmsten U. Pre-pubic TVT: an alternative to classic TVT in selected patients with urinary stress incontinence. Eur J Obstet Gynecol Reprod Biol 2003;107(2):205-07 48. Foucher JE, Marhsal lV. Nosocomial catheter associated urinary tract infections. Infect Surg 1983(2):43 49. van Geelen JM, Theeuwes AG, Eskes TK et al. The clinical and urodynamic effects of anterior vaginal repair and Burch colposuspension. Am J Obstet Gynecol 1988;159(1):137-44 50. Giri SK, Wallis F, Drumm J, Saunders JA, Flood HD. A magnetic resonance imaging-based study of retropubic haematoma after sling procedures: preliminary ndings. BJU Int 2005;96(7):1067-71 51. Ward KL, Hilton P, Browning J. A randomised trial of colposuspension amd tension free vaginal tape for primary genuine stress incontinence. Neuro-urology and Urodynamics 2000(19):386-88 52. Clemens JQ, DeLancey JO, Faerber GJ et al. Urinary tract erosions after synthetic pubovaginal slings: diagnosis and management strategy. Urology 2000;56(4):589-94 53. Volkmer BG, Nesslauer T, Rinnab L et al. Surgical intervention for complications of tension-free vaginal tape procedure. J Urol 2003;169(2):570-74 54. Giri SK, Drumm J, Flood HD. Endoscopic holmium laser excision of intravesical tension-free vaginal tape and polypropylene suture after anti-incontinence procedures. J Urol 2005;174(4 Pt 1):1306-07
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55. Domingo S, Alama P, Ruiz N et al. Diagnosis, management and prognosis of vaginal erosion after transobturator suburethral tape procedure using a nonwoven thermally bonded polypropylene mesh. J Urol 2005;173(5):1627-30 56. Giri SK, Sil D, Narasimhulu G et al. Management of vaginal extrusion after tension-free vaginal tape procedure for urodynamic stress incontinence. Urology 2007;69(6):1077-80 57. Lotenfoe R, O’Kelly JK, Helal M et al. Periurethral polytetrauoroethylene paste injection in incontinent female subjects: surgical indications and improved surgical technique. J Urol 1993;149(2):279-82 58. Green DF, McGuire EJ, Lytton B. A comparison of endoscopic suspension of the vesical neck versus anterior urethropexy for the treatment of stress urinary incontinence. J Urol 1986;136(6):1205-07 59. Eriksen BC, Hagen B, Eik-Nes SH et al. Long-term effectiveness of the Burch colposuspension in female urinary stress incontinence. Acta Obstet Gynecol Scand 1990;69(1):45-50 60. Pope AJ, Shaw PJR, Coptcoat MJ. Changes in bladder function following a surgical alteration in outow resistance. Neurourol Urodyn 1990;9:503–08 61. Bump RC, Hurt WG, Elser DM. Understandinglower urinary tract function in women soon after bladder neck surgery. Neurourol Urodyn 1999;18:629–37 62. Raz S, Stothers L, Young GP et al Vaginal wall sling for anatomical incontinence and intrinsic sphincter dysfunction: efcacy and outcome analysis. J Urol 1996;156(1):166-70
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SMALL RESEARCH SUPPORT GRANTS Applications are invited for research grants (formally known as General Research Pump Priming Grants) for up to £7,000, from surgical trainees and recently appointed consultants who are Fellows/Members of the College in good standing. The closing date for applications is Friday 12 June 2009
KING JAMES IV PROFESSORSHIPS Applications are invited from practitioners of surgery or dental surgery who have made a significant contribution to the clinical and/or scientific basis of surgery. The courtesy title of Professor will be accorded to the individuals for the duration of the College year in which their lectures are delivered. Applicants must be Fellows/ Members of the College, in good standing. The closing date for applications is Friday 12 June 2009
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R. M. Long S. K. Giri H. D. Flood Dept. of Urology, Mid Western Regional Hospital, Dooradoyle, Ireland Correspondence to: Ronan Long, 5 Threadneedle Road, Salthill, Galway, Ireland Tel: +353(0)877817504 email: ronanlong@hotmail. com
CURRENT CONCEPTS IN FEMALE STRESS URINARY INCONTINENCE Urinary incontinence is a social burden for up to one-third of the adult female population. Careful assessment, a methodical approach and appropriate treatment can lead to long-term success in the management of these patients. This article gives an outline of current concepts in the evaluation and treatment of stress urinary incontinence. keywords: sling, stress incontinence, periurethral Surgeon, 1 December 2008, pp.366-72
Introduction Stress urinary incontinence (SUI) is a common problem with an overall prevalence of 10% to 30% in females between the ages of 15 and 64 years.1 It has a significant psychosocial impact on individuals and families and is frequently suffered in silence with low consultation and treatment rates.2,3 SUI is defined by the International Continence Society as involuntary leakage of urine on effort or exertion, or on sneezing or coughing.3 The clinical finding of SUI is generally confirmed with a urodynamic study demonstrating stress leak in the absence of a detrusor contraction. Pathogenesis The pathogenesis of SUI is multifactorial and is thought to relate to a general weakening of the pelvic musculature and the collagen-dependent tissues involved in pelvic support as a result of pregnancy and parturition. Other important factors relate to bladder neck position, the intrinsic closing ability, or coaption, of the urethra, the reflex contraction of the pelvic floor musculature at the time of cough and strain, and miscellaneous factors such as the neurological and hormonal milieu within the pelvis. While loss of only one of these factors might not upset the normal balance, it appears that when enough components are dysfunctional, leakage ensues. SUI can affect any age group, but is most often a disease of older, parous women. Risk factors for urinary incontinence in women Urinary incontinence (UI) is very common among older women and is often regarded as a normal and inevitable part of the ageing process. Most studies indicate that UI is indeed correlated with age.4,5 Some studies have found that age was a significant risk factor for urge incontinence, but not for stress incontinence.6,7 366
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UI in women is often assumed to be attributable to the effects of pregnancy and childbirth. The literature shows that UI is a more common occurrence among pregnant women compared with other groups of women. Prevalence of 31% and 60% have been reported.8 Viktrup et al. found a prevalence of 28% for SUI during pregnancy, and 16% of these women became free of symptoms in the puerperium.9 Iosif and Ingemarsson found a prevalence of 9% of persisting SUI after caesarean deliveries.10 Viktrup et al compared continent women having delivered vaginally with women who underwent a caesarean section and found a difference in favour of cesarean section.9 However, three months after delivery, the difference became statistically insignificant. It is becoming clear that both pregnancy and vaginal delivery are risk factors for UI. Recently, Rortveit et al reported the results of the Norwegian EPINCONT study on urinary incontinence after vaginal delivery or caesarean section.11 The risk of urinary incontinence was higher among women who had caesarean sections than among nulliparous women and was even higher among women who have had vaginal deliveries. Obesity is well established as a factor for UI that may contribute to the severity of the condition. Data from several studies indicate that UI in women is associated with higher BMI and greater weight.6,12 Clinically, it has long been assumed that urinary symptoms are an integral part of the transition from the pre-menopausal to the post-menopausal state. Rekers et al. compared pre-menopausal women with post-menopausal and found no significant difference in the prevalence of UI between the two groups.1 Other studies have found no significant differences between post-menopausal © 2008 Surgeon 6; 6: 366-72
Figure 1. (a) Demonstrates urethral hypermobility and descent of the bladder with increased abdominal pressure which causes opening of the urethra and leakage of urine. (b) Demonstrates leakage of urine with low abdominal pressures due to an intrinsic sphincter malfunction
and pre-menopausal women in the prevalence or the frequency of incontinence.14,15 Further, recent studies of risk factors have found that incontinence is not associated with the number of years since menopause, nor age at menopause.6,12 While one might expect lower rates of incontinence in women taking hormone replacement therapy, three studies have reported a two to three times increased risk of incontinence in older women taking oestrogen.16-18 Smoking along with concomitant rectocele repair, diabetes mellitus and pelvic organ prolapse are associated with an increased risk of recurrent SUI following incontinence surgery.19 Types (classication) of stress incontinence Micturition is a complex series of finely tuned and integrated neuromuscular events that involve anatomical and neurological mechanisms. Alterations in any of these components may result in dysfunctional voiding and/or urinary incontinence. The unique properties of the bladder and sphincter that are responsible for continence are detrusor accommodation, sphincteric mechanism and anatomical support. The International Continence Society (ICS) originally defined urinary incontinence as ‘involuntary loss of urine that is objectively demonstrable and a social or hygienic problem’.20 The ICS has recently redefined UI as ‘complaint of any involuntary leakage of urine’. In the assessment of female UI there are three primary types of incontinence that concern us: stress, urge and mixed incontinence. The symptom of SUI is the complaint of involuntary loss of urine during coughing, sneezing, or physical exertion such as sporting activities and sudden changes of position. The symptom of urge UI is the complaint of involuntary leakage accompanied by or immediately preceded by a sudden, strong desire to void (urgency). Mixed incontinence is where both stress and urge incontinence coexist. It is important to distinguish which type of incontinence a patient has and if mixed which is the predominant symptom. Patients with predominant urge incontinence do poorly following surgery for SUI.21 There are two generic types of stress incontinence: urethral hypermobility and intrinsic sphincter deficiency (ISD) as demonstrated in Figure 1.22,23 In urethral hypermobility, the basic abnormality is a weakness of pelvic floor support. Because of this weakness, there is rotational descent of the bladder neck and proximal urethra during © 2008 Surgeon 6; 6: 366-72
increases in abdominal pressure. If the urethra opens concomitantly, SUI ensues. The abdominal pressure can be estimated during urodynamics by recording the abdominal leak point pressure (ALPP), i.e. the increase in abdominal pressure required to produce leakage of urine. Urethral hypermobility is generally related to pressures above 60cm of H2O. ISD denotes an intrinsic malfunction of the urethral sphincter itself and is generally associated with minimal urethral mobility and ALPPs below 60cm of H2O. Hypermobility and ISD frequently coexist. Evaluation of stress urinary incontinence Evaluation of SUI commences with a thorough history, physical examination and routine laboratory studies, including urinalysis, urine culture and renal function tests. For a precise diagnosis, SUI should be witnessed by the examiner. In 1997, the Urodynamics Society recommended minimal standards by which the efficacy of therapy for urinary incontinence should be assessed.24 According to these recommendations, which have been approved by both the American Urologic Association and the Society for Urodynamics and Female Urology, pre-treatment evaluation should consist of a structured micturition history and/or questionnaire, physical examination with full bladder, micturition diary, pad test, and urodynamics. Urodynamic evaluation should consist of at least simple uroflowmetry, cystometry, detrusor pressure/flow study, assessment of the relative contribution of urethral hypermobility, ISD and estimation of post-void residual urine by ultrasonography or catheterisation. Recently the National Institute for Health and Clinical Excellance (NICE) published guidelines.25 These guidelines are somewhat controversial as assessment does not include routine cystometry. It is only considered to be indicated prior to surgery when detrusor overactivity is clinically suspected, when there has been previous surgery for stress incontinence, anterior compartment prolapse or there are symptoms suggestive of voiding dysfunction.
Treatment options Conservative and pharmacological therapy Women with SUI are often treated with a trial of conservative therapy before surgery is offered, usually in the form of pelvic floor muscle
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Figure 2. The sling (in grey) is supported in position by bringing suture material or the sling material itself up under the pubic arch (in yellow) to a suprapubic position
training (PFMT), compression devices such as pessaries and in some cases pharmacotherapy. The rationale for a conservative approach is clear. SUI is not a progressive disease. A moderate delay in surgical therapy does not make such treatment more difficult. The impact of incontinence varies greatly from patient to patient. The patient’s feelings and goals must be taken into consideration in treatment planning. Thus, it is generally appropriate that the least invasive treatment that offers a reasonable chance for success is used first. In 1948 Kegel was the first to report pelvic floor muscle exercises to be effective in treatment of female UI.26 Since Kegel first presented his results, several randomised controlled trials have shown that PFMT with or without biofeedback is more effective than no treatment for SUI.27-29 Duloxetine, a new serotonin and noradrenaline re-uptake inhibitor, has recently become available with reported benefit in patients with stress incontinence. In particular it has been reported to have a synergistic effect when combined with PFMT.30 If these measures are not effective, surgery is indicated.
Surgical therapy Urethral bulking agents Bulking agents such as dextranomer/hyaluronic acid, glutaraldehyde crosslinked bovine collagen (GAX-collagen), polytetrafluoroethylene (PTFE), autologous fat and silicone polymers have all been used to improve urethral mucosal coaptation and increase outflow resistance. Although early studies with collagen injections suggested short- to medium-term ‘cure/improvement’ rates of 48% to 95%, long-term outcome results are much less favourable.31,32 Therefore they are not appropriate first line treatment options in the majority of cases.33 The main indications for injection therapy include high-risk patients for major surgery, elderly patients, previous surgical failures or patient preference. 368
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Colposuspension The Burch (open) colposuspension has been considered alongside rectus fascia slings as the ‘gold standard’ surgical procedure to correct SUI. The vaginal tissues near the bladder neck and proximal urethra are lifted toward the posterior pubic bones to reduce urethral motion and in turn prevent motion-related deficient urethral closure. It is suitable in patients with urethral hypermobility alone but not in patients with ISD where some degree of urethral compression must be applied. Currently this procedure is often laparoscopic with the aim of minimising perioperative morbidity. However, cure rates seem to be slightly lower when compared with the open approach.34 The cure of incontinence following colposuspension has been found to be time dependent.35,36 The longest follow-up with a maximum of 20 years and a mean of 13.8 years after colposuspension, found that cure appeared to plateau at 69% at around 10-12 years.35 Recently Albo et al. showed significantly better results with respect to stress incontinence for rectus fascia sling versus burch colposuspension at two year follow-up. However, there was a significantly greater risk of urinary tract infection in the sling group.37 Sub-urethral sling procedures The first pubovaginal sling operation for stress incontinence is credited to von Giordano in 1907. In a major operation, gracilis muscle was dissected out and used as a graft around the urethra. In 1942, Aldridge, Millin and Read described their correction of UI using fascial slings, but it is McGuire who popularised the procedure in the 1970s.38 These procedures were not minimally invasive, requiring the harvesting of fascia from the patient’s rectus fascia or tensor fascia lata. Using an idea based on the needle suspension, they developed the principle of inserting a sling with minimal dissection, hence creating a minimally invasive procedure. The principle of sling surgery is placing a sling under the urethra
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via an incision in the anterior vaginal wall. This sling is supported in position by bringing suture material or the sling material itself up under the pubic arch to a suprapubic position (Fig. 2). There are many variations of the sling procedure which can be subdivided by material, position of the sling (bladder neck or midurethra), method of placement and degree of tension. As a general guideline, an autologous fascial pubovaginal sling is appropriate and effective for both simple and complex sphincteric incontinence with documented long-term efficacy, whereas the Burch coloposuspension is most effective for those with simple sphincteric incontinence associated with urethral hypermobility.38-40 Outcomes with cure/dry rates of 83% and dry/improved rates of 87% at a minimum of 48 months have been reported.33,41 Long-term follow-up has shown that cure rates are durable with an 88% overall cure rate beyond four years.42 Thus, the pubovaginal sling procedure using autologous fascia has become the gold standard for treating intrinsic sphincter deficiency and SUI in women. In 1990 Ulmsten and Petros proposed the Integral Theory of female UI.43 According to the theory, stress and urge symptoms may both derive, for different reasons, from the same anatomical defect, a lax vagina. Altered collagen/elastin in the vaginal connective tissue and/or its ligamentous supports may cause laxity. Modern surgical therapy of female SUI is no longer focused on the proximal urethra and bladder neck, but also on providing additional support at the mid-urethra to restore continence. This has led to the introduction of mid-urethral sling techniques. The tension free vaginal tape (TVT) procedure introduced in 1996 was the pioneering procedure for placing mid-urethral mesh. This technique used a ‘bottom-up’ retropubic route of sling passage, and was soon followed by the suprapubic arch (SPARC) sling system, using a similar method but via a ‘top-down’ approach through the retropubic space towards the mid-urethra. The efficacy, simplicity and minimal invasiveness of these procedures led to other mid-urethral procedures, such as the transobturator tape (TOT) technique, and more recently the prepubic TVT with the objective of avoiding the space of Retzius (former) and the obturator space (latter) and their vessels and nerves. All of these procedures keep the same principles of mid-urethral, tensionfree placement of a synthetic sling material.44-47 However, there is a significantly increased risk of erosion and extrusion with synthetic slings virtually never seen with autologous fascia.
Figure 3. Urethrovaginal stula following mid-urethral tape procedure
Morbidity of surgery Immediate complications The perivesical/periurethral venous plexus can be a source of substantial haemorrhage during surgery for stress incontinence. The mean blood loss following Burch colposuspension has been reported as 200ml.49 Retropubic haematomas are common after sling procedures. Up to 25% incidence of retropubic haematoma has been reported by a recent study using MRI. Although most haematomas are asymptomatic, large haematomas may affect post-operative bladder emptying.50 Short-term complications Wound infection appears to be uncommon or unrecognised following vaginal surgery. There is no direct evidence that wound infection influences the cure rate for stress incontinence surgery, although infection in the presence of synthetic support materials may lead to removal. © 2008 Surgeon 6; 6: 366-72
Figure 4. TVT material which has eroded into the vagina and become calcied
Urinary tract infection is not uncommon following surgery for stress incontinence. Its frequency will increase with the duration of catheterisation at a rate of 6 – 7.5% per day.48 Urogenital fistulae most commonly follow gynaecological surgery in the developed world. Fistulae are rare but may also develop following surgery for stress incontinence (Fig 3).
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Visceral injures are more common following the TVT procedure. In a randomised trial comparing open colposuspension with the TVT procedure an average of 9% bladder perforation was reported in the TVT group compared to 2% in the open colposuspension group.51 It is advisable to perform cystoscopy following the passage of the trocar or needle during a sling procedure. If the bladder has been perforated the trocar can be removed and usually re-passed safely. Long-term complications Erosion rates varying from 0.3% to 23% have been reported for sling procedures (Fig. 4).52 Traditionally, such erosions are treated by the removal of the synthetic tape with or without a simultaneous repeat sling procedure.53 Successful endoscopic removal of intravesical TVT using holmium laser with resultant cure of symptoms of erosion has also been reported.54 Domingo et al. treated vaginal erosion by complete removal of the TOT mesh. However, in their series, two out of nine patients developed recurrent SUI.55 Recently primary reclosure of vaginal mucosa over eroded tape has also been described as a safe and effective first-line treatment option of vaginal erosion after the TVT procedure.56 Granuloma and abscess formation have been reported following peri-urethral injection. Osteitis pubis has been reported after needle suspension.58 Dyspareunia is seldom mentioned in reports on surgery for stress incontinence. It may be produced by the vaginal wound itself through scarring or vaginal narrowing. Erosion of synthetic material may also lead to dysparuenia in either partner. Dyspareunia has been reported in up to 40% of women after colposuspension.59 Post-surgical bladder outlet obstruction The exact incidence of bladder outlet obstruction (BOO) and associated voiding dysfunction after anti-incontinence surgical procedures is not known but has been estimated to be between 2.5% and 27%. The development of denovo involuntary detrusor contractions has been observed in patients with urodynamic evidence of BOO, and a greater incidence of denovo involuntary detrusor contractions may be associated with increasing degrees of BOO.60,61 According to Raz et al. three distinct groups of patients with BOO symptoms after previous anti-incontinence procedures exist.62 These groups are: 1) obstructed only: the patients who produce detrusor pressures >35 cm H2O without urinary flow, this group will benefit only from urethrolysis, 2) poor detrusor function: the patients who would continue to have problems post urethrolysis and 3) obstructed and incontinent: the patient in whom an additional resuspension procedure seems appropriate. Many surgeons reserve urethrolysis for patients in whom clean intermittent self-catheterisation (CISC) is an unacceptable alternative. The use of CISC avoids the risk of return of the stress incontinence which can occur after urethrolysis.
Conclusion SUI is the most common type of incontinence in women; it can have a considerable impact on their quality of life and may lead to social embarrassment and isolation. Thorough assessment and careful counselling should allow all women a choice of safe and effective treatment for SUI. Conservative options should be adopted first; however, definitive surgery offers good outcomes and is most appropriate for younger active women.
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18. Thom DH, van den Eeden SK, Brown JS. Evaluation of parturition and other reproductive variables as risk factors for urinary incontinence in later life. Obstet Gynecol 1997;90(6):983-89 19. Daneshgari F, Moore C, Frinjari H et al. Patient related risk factors for recurrent stress urinary incontinence surgery in women treated at a tertiary care center. J Urol 2006;176(4 Pt 1):1493-99 20. Abrams PH, J.G. B, Stanton SL et al. Standardisation of lower urinary tract function. Neurourol Urodynam 1988(7):403 -26 21. Chaliha C, Stanton SL. Complications of surgery for genuine stress incontinence. Br J Obstet Gynaecol 1999;106(12):1238-45 22. McGuire EJ, Herlihy E. The inuence of urethral position on urinary continence. Invest Urol 1977;15(3):205-07 23. McGuire EJ, Fitzpatrick CC, Wan J, et al Clinical assessment of urethral sphincter function. J Urol 1993;150(5 Pt 1):1452-54 24. Blaivas JG, Appell RA, Fantl JA, et al Standards of efcacy for evaluation of treatment outcomes in urinary incontinence: recommendations of the Urodynamic Society. Neurourol Urodyn 1997;16(3):145-47 25. Woodford H, George J. NICE guidelines on urinary incontinence in women. Age Ageing 2007;36(3):349-50 26. Kegel AH. Progressive resistance exercise in the functional restoration of the perineal muscles. Am J Obstet Gynecol 1948(56):238-49 27. Hay-Smith EJC, Dumoulin C. Pelvic oor muscle training versus no treatment, or inactive control treatments, for urinary incontinence in women. Cochrane review. The Cochrane Library 2006 28. Bo K, Talseth T, Holme I. Single blind, randomised controlled trial of pelvic oor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women. BMJ 1999;20(318):487-93 29. Lagro-Janssen TLM, Debruyne FMJ, Smits AJA et al. Controlled trial of pelvic exercises in the treatment of urinary stress incontinence in general practice. Br J Gen Pract 1991(41):445-49 30. Ghoniem GM, Van Leeuwen JS, Elser DM et al A randomized controlled trial of duloxetine alone, pelvic oor muscle training alone, combined treatment and no active treatment in women with stress urinary incontinence. J Urol 2005;173(5):1647-53 31. Su TH, Hsu CY, Chen JC. Injection therapy for stress incontinence in women. Int Urogynecol J Pelvic Floor Dysfunct 1999;10(3):200-06 32. Gorton E, Stanton S, Monga A et al. Periurethral collagen injection: a long-term follow-up study. BJU Int 1999;84(9):966-71 33. Leach GE, Dmochowski RR, Appell RA, et al Female Stress Urinary Incontinence Clinical Guidelines Panel summary report on surgical management of female stress urinary incontinence. The American Urological Association. J Urol 1997;158(3 Pt 1):875-80 34. Moehrer B, Carey M, Wilson D. Laparoscopic colposuspension: a systematic review. Br J Obstet Gynaecol 2003;110(3):230-35 35. Alcalay M, Monga A, Stanton SL. Burch colposuspension: a 10-20 year follow up. Br J Obstet Gynaecol 1995;102(9):740-45
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36. Dietz HP, Wilson PD. Colposuspension success and failure: a long-term objective follow-up study. Int Urogynecol J Pelvic Floor Dysfunct 2000;11(6):346-51 37. Albo ME, Richter HE, Brubaker L et al. Burch colposuspension versus fascial sling to reduce urinary stress incontinence. N Engl J Med 2007;24(21):2143-55 38. McGuire EJ, Lytton B. Pubovaginal sling procedure for stress incontinence. J Urol 1978;119(1):82-84 39. McGuire EJ, Bennett CJ, Konnak JA et l. Experience with pubovaginal slings for urinary incontinence at the University of Michigan. J Urol 1987;138(3):525-26 40. Raz S. Modied bladder neck suspension for female stress incontinence. Urology 1981;17(1):82-85 41. Jarvis GJ. Surgery for genuine stress incontinence. Br J Obstet Gynaecol 1994;101(5):371-74 42. Morgan TO, Jr., Westney OL, McGuire EJ. Pubovaginal sling: 4-year outcome analysis and quality of life assessment. J Urol 2000;163(6):1845-48 43. Petros PE, Ulmsten UI. An integral theory of female urinary incontinence. Experimental and clinical considerations. Acta Obstet Gynecol Scand Suppl 1990;153:7-31 44. Shindel AW, Ruiz AC, Klutke CG. Transobturator approach to suburethral sling placement in the treatment of stress urinary incontinence in women. Expert Rev Med Devices 2005;2(5):613-22 45. Costa P, Grise P, Droupy S et al Surgical treatment of female stress urinary incontinence with a trans-obturator-tape (T.O.T.) Uratape: short term results of a prospective multicentric study. Eur Urol 2004;46(1):102-6; discussion 106-07 46. Delorme E, Droupy S, de Tayrac R, Delmas V. Transobturator tape (Uratape): a new minimally-invasive procedure to treat female urinary incontinence. Eur Urol 2004;45(2):203-07 47. Daher N, Boulanger JC, Ulmsten U. Pre-pubic TVT: an alternative to classic TVT in selected patients with urinary stress incontinence. Eur J Obstet Gynecol Reprod Biol 2003;107(2):205-07 48. Foucher JE, Marhsal lV. Nosocomial catheter associated urinary tract infections. Infect Surg 1983(2):43 49. van Geelen JM, Theeuwes AG, Eskes TK et al. The clinical and urodynamic effects of anterior vaginal repair and Burch colposuspension. Am J Obstet Gynecol 1988;159(1):137-44 50. Giri SK, Wallis F, Drumm J, Saunders JA, Flood HD. A magnetic resonance imaging-based study of retropubic haematoma after sling procedures: preliminary ndings. BJU Int 2005;96(7):1067-71 51. Ward KL, Hilton P, Browning J. A randomised trial of colposuspension amd tension free vaginal tape for primary genuine stress incontinence. Neuro-urology and Urodynamics 2000(19):386-88 52. Clemens JQ, DeLancey JO, Faerber GJ et al. Urinary tract erosions after synthetic pubovaginal slings: diagnosis and management strategy. Urology 2000;56(4):589-94 53. Volkmer BG, Nesslauer T, Rinnab L et al. Surgical intervention for complications of tension-free vaginal tape procedure. J Urol 2003;169(2):570-74 54. Giri SK, Drumm J, Flood HD. Endoscopic holmium laser excision of intravesical tension-free vaginal tape and polypropylene suture after anti-incontinence procedures. J Urol 2005;174(4 Pt 1):1306-07
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55. Domingo S, Alama P, Ruiz N et al. Diagnosis, management and prognosis of vaginal erosion after transobturator suburethral tape procedure using a nonwoven thermally bonded polypropylene mesh. J Urol 2005;173(5):1627-30 56. Giri SK, Sil D, Narasimhulu G et al. Management of vaginal extrusion after tension-free vaginal tape procedure for urodynamic stress incontinence. Urology 2007;69(6):1077-80 57. Lotenfoe R, O’Kelly JK, Helal M et al. Periurethral polytetrauoroethylene paste injection in incontinent female subjects: surgical indications and improved surgical technique. J Urol 1993;149(2):279-82 58. Green DF, McGuire EJ, Lytton B. A comparison of endoscopic suspension of the vesical neck versus anterior urethropexy for the treatment of stress urinary incontinence. J Urol 1986;136(6):1205-07 59. Eriksen BC, Hagen B, Eik-Nes SH et al. Long-term effectiveness of the Burch colposuspension in female urinary stress incontinence. Acta Obstet Gynecol Scand 1990;69(1):45-50 60. Pope AJ, Shaw PJR, Coptcoat MJ. Changes in bladder function following a surgical alteration in outow resistance. Neurourol Urodyn 1990;9:503–08 61. Bump RC, Hurt WG, Elser DM. Understandinglower urinary tract function in women soon after bladder neck surgery. Neurourol Urodyn 1999;18:629–37 62. Raz S, Stothers L, Young GP et al Vaginal wall sling for anatomical incontinence and intrinsic sphincter dysfunction: efcacy and outcome analysis. J Urol 1996;156(1):166-70
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SMALL RESEARCH SUPPORT GRANTS Applications are invited for research grants (formally known as General Research Pump Priming Grants) for up to £7,000, from surgical trainees and recently appointed consultants who are Fellows/Members of the College in good standing. The closing date for applications is Friday 12 June 2009
KING JAMES IV PROFESSORSHIPS Applications are invited from practitioners of surgery or dental surgery who have made a significant contribution to the clinical and/or scientific basis of surgery. The courtesy title of Professor will be accorded to the individuals for the duration of the College year in which their lectures are delivered. Applicants must be Fellows/ Members of the College, in good standing. The closing date for applications is Friday 12 June 2009
TRAVELLING FELLOWSHIPS • •
The Cutner Travelling Fellowship in Orthopaedics The John Steyn Travelling Fellowship in Urology
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