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Indications and operative treatment of stress urinary incontinence
.“.a
European Journal of Obstetrics & Gynecology and Reproductive Biology 55 (1994) 45-46
ELSEVIER SCIENCE IRELAND
.
.
.
.
AD”
.
.
.
OBSTETR GYNEC & ..0 . . . . me”=.,.. .,e..*.
Indications and operative treatment of stress urinary incontinence Stuart L. Stanton SI George S Hospital Medical School, Lanesbourgh
1. Introduction Failure rates for the surgical cure of stress incontinence range between 10% and 40%. To overcome this, accurate diagnosis and then the correct choice of surgical procedure matched to the clinical and urodymamic features of the patient are necessary. Diagnosis should be made on clinical and urodynamic data and where there has been failure of previous bladder neck surgery it is important to re-evaluate the patient. The indications for continence surgery are: (1) Presence of stress incontinence due to urethral sphincter incompetence, for which the patient wants surgery. (2) Failure of conservative treatment. The criteria for surgical treatment are: (1) (2) (3) (4)
Absence of voiding difficulty. Absence of detrusor instability. A physically tit patient. A mentally alert patient.
2.3. Position of the bladder neck The position of the bladder neck can initially be confirmed by clinical examination. 2.4. Other pelvic pathology In addition to incontinence, there may be either uterine disease or prolapse which needs simultaneous correction. 3. Urodynamic diagnosis Urodynamic studies should define the cause of incontinence and confirm here that it is due to urethral sphincter incompetence. If voiding difficulty or detrusor instability are present, these can be made worse by continence surgery. The position of the bladder neck can be more objectively defined using perineal or vaginal ultrasound, and this allows the comparison before and after surgery. 4. The operation
The choice of surgery is a match between the patient’s clinical features, urodynamic features and the characteristics of the operation.
2. Patient features 2.1. Physical frailty A physically tit and active patient will overcome surgery quicker but will have a higher expectation of success than a frail patient who will make less demands. 2.2. Difficult voiding Symptoms of voiding difftculty such as a slow stream, incomplete emptying or straining to void will need to be confirmed by urodynamic studies. 0028-2243/94/$07.00 0 1994 Elsevier Science Ireland SSDI 0028-2243(93)01779-S
Wing, Crammer Terrace, London S WI 7 ORE, UK
There are up to ten major types of bladder neck surgery and at least 100 variations have been described. Surgery works either by elevating the bladder neck or increasing urethral resistance or combining the two. It can be carried out via the vaginal or suprapubic route or a combination of both (Fig. 1). 4.1. Choice of surgery (Fig. 2) The anterior colporrhaphy is less popular now than operations to correct stress incontinence but it is still used to correct a cystourethrocele. Periurethral collagen injections are satisfactory when used for mild stress incontinence or as an adjunct to surgery and will produce up to a 70% subjective and objective cure at 12 months. The Marshall-Marchetti-Krantz (MMK) operation is a well established procedure but it only elevates the bladder neck and does not correct any cystocele. There is a l-5% incidence of osteitis pubis.
Ltd. All rights reserved.
S.L. Stanton / Eur. J. Obsret. Gynecol. Reprod. Biol. 55 (1994) 45-46
46
Obstruction
Elevation Vaginal route Suprapubic route
Combined route
Anterior colporrhaphy Peri-urethral collagen MMK Artificial urinary sphincter Colposuspension Sling Endoscopic bladder neck suspension
Fig. I. Classitication of surgery.
The colposuspension corrects both stress incontinence and any accompanying cystourethrocele but it does require adequate vaginal capacity and mobility. There is a known risk of post-operative detrusor instability and voiding difficulty. The sling is usually used as secondary surgery and is made of either organic or inorganic material. There are a variety of different techniques. Essentially, the bladder neck is supported by the sling and usually without tension. Endoscopic bladder neck suspension operations, such as the Stamey and Modified Pereyra (Raz) procedure are carried out with a vaginal and abdominal approach. The techniques are simple but blind and therefore require cystoscopy to ensure that sutures are not passed into the bladder or urethra. Over the last 3-4 years results have shown that the operation is less satisfactory than previously thought. If a cystourethrocele is present, an anterior colporrhaphy will also be required. The artificial urinary sphincter is an infrequently performed operation at tertiary referral centres. It is used where there is a decrease in urethral resistance and this is usually where several conventional operations have already failed. It offers a 65-90% chance of success but does require follow-up for life and revisions may be
necessary. It is completely implanted and avoids the use of diversion surgery. 5. Reasons for recurrence The commonest reasons for recurrence are: (1) Incorrect diagnosis (2) Persistence of urethral sphincter incompetence when either the incorrect operation has been chosen, the operative technique has been faulty or the patient’s tissues have been inadequate for the procedure. (3) New pathology has developed: (a) detrusor instability, (b) voiding difficulty leading to retention with overflow, and (c) a urinary fistula. 6. Treatment of recurrence It will be necessary to repeat the history and clinical examination and urodynamic studies to determine whether there has been a change in the original diagnosis. If urethral sphincter incompetence is still present, it is important to decide whether further elevation of the bladder neck or an increase in urethral resistance is necessary. If detrusor instability or a voiding difficulty are found then treatment is directed to either of those. Finally it is important to note the comments by Thompson and Rock in the preface to the seventh edition of Telinde’s Operative Gynecology (1992) ‘After the right patient has been selected for operation, the right operation must be selected for the patient’. 7. Suggested reading
Reduced wag. capacity
Adeq. “ag. capacity
Urethra not aligned
Urethra aligned: Functionless
1
2 3 M.M.K. or co1po.
colpo.
Sling
? Sling
A.U.S. or Neo-urethra
4 5
Fig. 2. Choice of surgery.
Hilton P. Which operation and for which patient. In: Drife J, Hilton P, Stanton SL, eds. Micturition. London: SpringerVerlag, 1989. Mundy A.R. Urodynamic and reconstructive surgery of the lower urinary tract. Edinburgh: Churchill Livingstone, 1993. Ostergard D, Bent A. Urogynecology and urodynamics: theory and practice, 3rd edition. Baltimore: Williams and Wilkins, 1991. Raz S. Atlas of transvaginal surgery. Pennsylvania: WB Saunders, 1992. Stanton SL, Tanagho E. Surgery for female incontinence, 2nd edn. Heidelberg: Springer-Verlag, 1986.
European Journal of Obstetrics & Gynecology and Reproductive Biology 55 (1994) 45-46
ELSEVIER SCIENCE IRELAND
.
.
.
.
AD”
.
.
.
OBSTETR GYNEC & ..0 . . . . me”=.,.. .,e..*.
Indications and operative treatment of stress urinary incontinence Stuart L. Stanton SI George S Hospital Medical School, Lanesbourgh
1. Introduction Failure rates for the surgical cure of stress incontinence range between 10% and 40%. To overcome this, accurate diagnosis and then the correct choice of surgical procedure matched to the clinical and urodymamic features of the patient are necessary. Diagnosis should be made on clinical and urodynamic data and where there has been failure of previous bladder neck surgery it is important to re-evaluate the patient. The indications for continence surgery are: (1) Presence of stress incontinence due to urethral sphincter incompetence, for which the patient wants surgery. (2) Failure of conservative treatment. The criteria for surgical treatment are: (1) (2) (3) (4)
Absence of voiding difficulty. Absence of detrusor instability. A physically tit patient. A mentally alert patient.
2.3. Position of the bladder neck The position of the bladder neck can initially be confirmed by clinical examination. 2.4. Other pelvic pathology In addition to incontinence, there may be either uterine disease or prolapse which needs simultaneous correction. 3. Urodynamic diagnosis Urodynamic studies should define the cause of incontinence and confirm here that it is due to urethral sphincter incompetence. If voiding difficulty or detrusor instability are present, these can be made worse by continence surgery. The position of the bladder neck can be more objectively defined using perineal or vaginal ultrasound, and this allows the comparison before and after surgery. 4. The operation
The choice of surgery is a match between the patient’s clinical features, urodynamic features and the characteristics of the operation.
2. Patient features 2.1. Physical frailty A physically tit and active patient will overcome surgery quicker but will have a higher expectation of success than a frail patient who will make less demands. 2.2. Difficult voiding Symptoms of voiding difftculty such as a slow stream, incomplete emptying or straining to void will need to be confirmed by urodynamic studies. 0028-2243/94/$07.00 0 1994 Elsevier Science Ireland SSDI 0028-2243(93)01779-S
Wing, Crammer Terrace, London S WI 7 ORE, UK
There are up to ten major types of bladder neck surgery and at least 100 variations have been described. Surgery works either by elevating the bladder neck or increasing urethral resistance or combining the two. It can be carried out via the vaginal or suprapubic route or a combination of both (Fig. 1). 4.1. Choice of surgery (Fig. 2) The anterior colporrhaphy is less popular now than operations to correct stress incontinence but it is still used to correct a cystourethrocele. Periurethral collagen injections are satisfactory when used for mild stress incontinence or as an adjunct to surgery and will produce up to a 70% subjective and objective cure at 12 months. The Marshall-Marchetti-Krantz (MMK) operation is a well established procedure but it only elevates the bladder neck and does not correct any cystocele. There is a l-5% incidence of osteitis pubis.
Ltd. All rights reserved.
S.L. Stanton / Eur. J. Obsret. Gynecol. Reprod. Biol. 55 (1994) 45-46
46
Obstruction
Elevation Vaginal route Suprapubic route
Combined route
Anterior colporrhaphy Peri-urethral collagen MMK Artificial urinary sphincter Colposuspension Sling Endoscopic bladder neck suspension
Fig. I. Classitication of surgery.
The colposuspension corrects both stress incontinence and any accompanying cystourethrocele but it does require adequate vaginal capacity and mobility. There is a known risk of post-operative detrusor instability and voiding difficulty. The sling is usually used as secondary surgery and is made of either organic or inorganic material. There are a variety of different techniques. Essentially, the bladder neck is supported by the sling and usually without tension. Endoscopic bladder neck suspension operations, such as the Stamey and Modified Pereyra (Raz) procedure are carried out with a vaginal and abdominal approach. The techniques are simple but blind and therefore require cystoscopy to ensure that sutures are not passed into the bladder or urethra. Over the last 3-4 years results have shown that the operation is less satisfactory than previously thought. If a cystourethrocele is present, an anterior colporrhaphy will also be required. The artificial urinary sphincter is an infrequently performed operation at tertiary referral centres. It is used where there is a decrease in urethral resistance and this is usually where several conventional operations have already failed. It offers a 65-90% chance of success but does require follow-up for life and revisions may be
necessary. It is completely implanted and avoids the use of diversion surgery. 5. Reasons for recurrence The commonest reasons for recurrence are: (1) Incorrect diagnosis (2) Persistence of urethral sphincter incompetence when either the incorrect operation has been chosen, the operative technique has been faulty or the patient’s tissues have been inadequate for the procedure. (3) New pathology has developed: (a) detrusor instability, (b) voiding difficulty leading to retention with overflow, and (c) a urinary fistula. 6. Treatment of recurrence It will be necessary to repeat the history and clinical examination and urodynamic studies to determine whether there has been a change in the original diagnosis. If urethral sphincter incompetence is still present, it is important to decide whether further elevation of the bladder neck or an increase in urethral resistance is necessary. If detrusor instability or a voiding difficulty are found then treatment is directed to either of those. Finally it is important to note the comments by Thompson and Rock in the preface to the seventh edition of Telinde’s Operative Gynecology (1992) ‘After the right patient has been selected for operation, the right operation must be selected for the patient’. 7. Suggested reading
Reduced wag. capacity
Adeq. “ag. capacity
Urethra not aligned
Urethra aligned: Functionless
1
2 3 M.M.K. or co1po.
colpo.
Sling
? Sling
A.U.S. or Neo-urethra
4 5
Fig. 2. Choice of surgery.
Hilton P. Which operation and for which patient. In: Drife J, Hilton P, Stanton SL, eds. Micturition. London: SpringerVerlag, 1989. Mundy A.R. Urodynamic and reconstructive surgery of the lower urinary tract. Edinburgh: Churchill Livingstone, 1993. Ostergard D, Bent A. Urogynecology and urodynamics: theory and practice, 3rd edition. Baltimore: Williams and Wilkins, 1991. Raz S. Atlas of transvaginal surgery. Pennsylvania: WB Saunders, 1992. Stanton SL, Tanagho E. Surgery for female incontinence, 2nd edn. Heidelberg: Springer-Verlag, 1986.