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Review of an 8-Year Experience with Modifications of Endoscopic Suspension of the Bladder Neck for Female Stress Urinary Incontinence
0022-534 7/90/1431-0044$02.00/0 THE JOURNAL OF UROLOGY Copyright© 1990 by AMERICAN UROLOGICAL ASSOCIATION, INC.
Vol. 143, January
Printed in U.S.A.
REVIEW OF AN 8-YEAR EXPERIENCE WITH MODIFICATIONS OF ENDOSCOPIC SUSPENSION OF THE BLADDER NECK FOR FEMALE STRESS URINARY INCONTINENCE KEVIN R. LOUGHLIN, WILLET F. WHITMORE, III, RUBEN F. GITTES AND JEROME P. RICHIE From the Department of Surgery, Division of Urology, Brigham and Women's Hospital, Harvard University Medical School, Boston, Massachusetts
ABSTRACT
Several modifications of endoscopic suspension of the bladder neck for treatment of female stress urinary incontinence have been used during an 8-year period. Of 154 patients treated 25 failures occurred, for an over-all success rate of 84%. Fifteen patients had postoperative complications for an over-all complication rate of 9.8%. Hospital stay decreased steadily throughout the review period to a current average of 2.2 days, with many patients presently undergoing an operation on an outpatient basis. (J. Ural., 143: 44-45, 1990) (part C of figure). 8 When artificial material was used to buttress the repair, small vaginal mucosal incisions were made on either side of the urethrovesical junction. When no synthetic material was used no vaginal incisions were made. All patients had 1 large suprapubic incision or 2 smaller suprapubic stab incisions to admit the passage of the Stamey needles through the lower abdominal skin. After the No. 2 polypropylene or nylon sutures had been passed their placement was evaluated cystoscopically to ensure that a suture had not been placed inadvertently into the bladder lumen. After confirming proper positioning of the sutures, a suprapubic tube was placed percutaneously. Postoperative care was straightforward. Whether the patient underwent a same-day operation or was admitted for a short hospital stay, all patients were discharged from the hospital with a suprapubic tube. The patient was instructed to clamp the tube upon arising in the morning, and to measure voided and post-voided volumes approximately 4 hours later. The remainder of the day the suprapubic tube was connected to a leg bag via gravity drainage. The patient would return to the office 7 to 10 days postoperatively with a record of the postvoid residuals. The bladder then would be filled with saline by the surgeon and the post-void residual confirmed. If the patient voided greater than 75% of the total bladder volume the suprapubic tube was removed, otherwise the suprapubic tube was left in place and the patient returned 1 to 2 weeks later to reevaluate the post-void residual. Patients were tested for leakage of urine with coughing. They were kept on a low dose of oral antibiotics while the suprapubic tube was in place; antispasmodic medication was prescribed as needed.
No single operation has emerged as the most reliable method to treat female stress urinary incontinence. Various procedures, including anterior colporrhaphy (Kelly plication1 ), suprapubic vesicourethral suspension (Marshall-Marchetti-Krantz procedure2), ileopectineal ligament urethrovesical suspension (Burch procedure3 ), combined urethrovesical suspension and vaginourethroplasty (Pereyra4 and Raz5 procedures), pubovaginal slings6 and endoscopic suspension of the vesical neck (Stamey procedure 7), all have been reported as being highly successful in the treatment of female stress incontinence. Our preference has been use of a modified endoscopic suspension of the vesical neck because of patient satisfaction, ease of performance and shortened hospital stay. We review our experience with this technique. MATERIALS AND METHODS
We reviewed retrospectively 154 women with stress urinary incontinence who were treated by endoscopic suspension of the bladder neck at our institution from July 1979 to June 1987. All charts and operative notes were reviewed, and when possible phone calls were made to confirm postoperative results. Followup ranged from 1 month to 8 years, with a median of 3 years. Technique. The patients ranged from 27 to 91 years old. The chief complaint in all patients was leakage of urine. Preoperative evaluation included complete history and physical examination, and a Marshall (Bonney) test. Cystoscopy and urodynamics were eliminated in the majority of patients. Urodynamics were reserved for patients with abnormal neurological findings or those who had failed a prior incontinence operation. No patient had a symptomatic cystocele, rectocele or enterocele. Although the experience of 4 surgeons comprises the basis for this report, the operative technique was standardized. The patient was placed in the dorsal lithotomy position after local, spinal or general anesthesia had been administered. Cystoscopy was performed and the bladder was emptied. A Foley catheter was placed per urethram, and the balloon was inflated and used as a landmark for the urethrovesical junction. No. 2 polypropylene or nylon sutures were placed on either side of the urethrovesical junction with Stamey needles. The only major modification of technique that occurred during the series was a changeover from a buried synthetic buttress (telfa or polypropylene pledget, part A of figure) to the use of a full thickness vaginal suture that was incorporated as an autologous pledget
RESULTS
A total of 154 patients underwent modified endoscopic urethral suspension between July 1979 and June 1987. Of these patients 129 were cured of the incontinence postoperatively. Success was defined as a negative Marshall or Bonney test (no urinary leakage with coughing) postoperatively and a history that the patient no longer required any pads. Modifications in the procedure occurred during the 8-year period. In 71 patients a buried telfa or polypropylene pledget was used, in 24 a simple transvaginal mattress stitch was used (part B of figure), and 59 had an autologous pledget of vaginal wall. The success rates of the various modifications were 85 % (60 of 71 patients) with the telfa or polypropylene pledget, 75% (18 of 24) with no pledget and 86% (51 of 59) with the autologous pledget, for an over-all rate of 84% (129 of 154). The success rates were remarkably constant during the study except for the period when no pledget
Accepted for publication July 21, 1989.
44
ENDOSCOPIC SUSPENSION OF BLADDER NECK FOR FEJ\1lALE STRESS URINARY INCONTINENCE
45
C
Supports of endoscopic bladder neck suspension. A, polypropylene pledget buttress. B, simple transvaginal mattress suture. C, autologous pledget of vaginal wall.
was used to buttress the repair. Postoperative bladder instability was not specifically evaluated, although it appeared to occur in less than 10% of the patients and usually was well controlled with anticholinergic medication. The length of hospitalization decreased throughout the study, which undoubtedly was due to a variety of factors, including increased facility with the operative technique, motivation from hospital administration to shorten hospital stay and increased confidence on the part of the surgeons that early postoperative care could be managed at home. Average hospitalization was 6.2 days in 1980, 9 4.4 days in 1984 and 2.2 days in 1987. Analysis of the 25 failures revealed that many of them occurred in high risk patients. Three patients had neurogenic bladders, 2 had previous pelvic radiation and 5 had failed a prior incontinence operation. A total of 21 patients who had failed a prior incontinence procedure at our institution or elsewhere underwent endoscopic suspension of the bladder neck and 16 were cured, for a success rate of 76%. Complications occurred in 9.8% of the patients. One patient had a postoperative myocardial infarction but recovered completely. One patient had postoperative bleeding and required 3 units of blood. This was the only patient in the entire series who required a blood transfusion. One patient who had undergone prior pelvic radiation suffered a bowel perforation secondary to placement of a percutaneous suprapubic tube. This complication was managed conservatively without surgical exploration and convalescence was uneventful. Three patients had prolonged postoperative urinary retention (retention longer than 1 month postoperatively) but all eventually voided on their own. Three patients had suture abscesses that required removal of 1 of the suspension sutures. Of these patients 2 became incontinent after unilateral removal of a suspension suture. In 6 patients the suprapubic tube became displaced out of the bladder. All 6 patients were treated successfully by removal of the suprapubic tube and placement of a Foley urethral catheter.
In conclusion, we present the 8-year experience at our institution with a modified technique for endoscopic suspension of the bladder neck. The technique is reliable, with an over-all 84% success rate and a complication rate of only 9.8%. The technique is simple, can be performed with the use of local anesthesia in selected patients 10 and results in shortened hospital stay. REFERENCES
1. Kelly, H. A. and Dumm, W. M.: Urinary incontinence in women,
2.
3.
4.
5. 6. 7.
8. 9.
10.
without manifest injury to the bladder: a report of cases. Surg., Gynec. & Obst., 18: 444, 1914. Marshall, V. F., Marchetti, A. A. and Krantz, K. E.: The correction of stress incontinence by simple vesicourethral suspension. Surg., Gynec. & Obst., 88: 590, 1949. Burch, J. C.: Urethrovaginal fixation to Cooper's ligament for correction of stress incontinence, cystocele, and prolapse. Amer. J. Obst. Gynec., 81: 281, 1961. Pereyra, A. J. and Lebherz, T. B.: Combined urethrovesical suspension and vaginourethroplasty for correction of urinary stress incontinence. Obst. Gynec., 30: 537, 1967. Raz, S.: Modified bladder neck suspension for female stress incontinence. Urology, 17: 82, 1981. McGuire, E. J. and Lytton, B.: Pubovaginal sling procedure for stress incontinence. J. Urol., 1 HI: 82, 1978. Stamey, T. A.: Endoscopic suspension of the vesical neck for urinary incontinence. Surg., Gynec. & Obst., 136: 547, 1973. Gittes, R. F. and Loughlin, K. R.: No-incision pubovaginal suspension for stress incontinence. J. Urol., 138: 568, 1987. Loughlin, K. R., Gittes, R. F., Klein, L.A. and Whitmore, W. F., HI: The comparative medical costs of 2 major procedures available for the treatment of stress urinary incontinence. J. Urol., 127: 436, 1982. Gittes, R. F. and Loughlin, K. R.: No incision urethropexy for stress incontinence under local anesthesia. J. Urol., part 2, 139: 270A, abstract 429, 1988.
Vol. 143, January
Printed in U.S.A.
REVIEW OF AN 8-YEAR EXPERIENCE WITH MODIFICATIONS OF ENDOSCOPIC SUSPENSION OF THE BLADDER NECK FOR FEMALE STRESS URINARY INCONTINENCE KEVIN R. LOUGHLIN, WILLET F. WHITMORE, III, RUBEN F. GITTES AND JEROME P. RICHIE From the Department of Surgery, Division of Urology, Brigham and Women's Hospital, Harvard University Medical School, Boston, Massachusetts
ABSTRACT
Several modifications of endoscopic suspension of the bladder neck for treatment of female stress urinary incontinence have been used during an 8-year period. Of 154 patients treated 25 failures occurred, for an over-all success rate of 84%. Fifteen patients had postoperative complications for an over-all complication rate of 9.8%. Hospital stay decreased steadily throughout the review period to a current average of 2.2 days, with many patients presently undergoing an operation on an outpatient basis. (J. Ural., 143: 44-45, 1990) (part C of figure). 8 When artificial material was used to buttress the repair, small vaginal mucosal incisions were made on either side of the urethrovesical junction. When no synthetic material was used no vaginal incisions were made. All patients had 1 large suprapubic incision or 2 smaller suprapubic stab incisions to admit the passage of the Stamey needles through the lower abdominal skin. After the No. 2 polypropylene or nylon sutures had been passed their placement was evaluated cystoscopically to ensure that a suture had not been placed inadvertently into the bladder lumen. After confirming proper positioning of the sutures, a suprapubic tube was placed percutaneously. Postoperative care was straightforward. Whether the patient underwent a same-day operation or was admitted for a short hospital stay, all patients were discharged from the hospital with a suprapubic tube. The patient was instructed to clamp the tube upon arising in the morning, and to measure voided and post-voided volumes approximately 4 hours later. The remainder of the day the suprapubic tube was connected to a leg bag via gravity drainage. The patient would return to the office 7 to 10 days postoperatively with a record of the postvoid residuals. The bladder then would be filled with saline by the surgeon and the post-void residual confirmed. If the patient voided greater than 75% of the total bladder volume the suprapubic tube was removed, otherwise the suprapubic tube was left in place and the patient returned 1 to 2 weeks later to reevaluate the post-void residual. Patients were tested for leakage of urine with coughing. They were kept on a low dose of oral antibiotics while the suprapubic tube was in place; antispasmodic medication was prescribed as needed.
No single operation has emerged as the most reliable method to treat female stress urinary incontinence. Various procedures, including anterior colporrhaphy (Kelly plication1 ), suprapubic vesicourethral suspension (Marshall-Marchetti-Krantz procedure2), ileopectineal ligament urethrovesical suspension (Burch procedure3 ), combined urethrovesical suspension and vaginourethroplasty (Pereyra4 and Raz5 procedures), pubovaginal slings6 and endoscopic suspension of the vesical neck (Stamey procedure 7), all have been reported as being highly successful in the treatment of female stress incontinence. Our preference has been use of a modified endoscopic suspension of the vesical neck because of patient satisfaction, ease of performance and shortened hospital stay. We review our experience with this technique. MATERIALS AND METHODS
We reviewed retrospectively 154 women with stress urinary incontinence who were treated by endoscopic suspension of the bladder neck at our institution from July 1979 to June 1987. All charts and operative notes were reviewed, and when possible phone calls were made to confirm postoperative results. Followup ranged from 1 month to 8 years, with a median of 3 years. Technique. The patients ranged from 27 to 91 years old. The chief complaint in all patients was leakage of urine. Preoperative evaluation included complete history and physical examination, and a Marshall (Bonney) test. Cystoscopy and urodynamics were eliminated in the majority of patients. Urodynamics were reserved for patients with abnormal neurological findings or those who had failed a prior incontinence operation. No patient had a symptomatic cystocele, rectocele or enterocele. Although the experience of 4 surgeons comprises the basis for this report, the operative technique was standardized. The patient was placed in the dorsal lithotomy position after local, spinal or general anesthesia had been administered. Cystoscopy was performed and the bladder was emptied. A Foley catheter was placed per urethram, and the balloon was inflated and used as a landmark for the urethrovesical junction. No. 2 polypropylene or nylon sutures were placed on either side of the urethrovesical junction with Stamey needles. The only major modification of technique that occurred during the series was a changeover from a buried synthetic buttress (telfa or polypropylene pledget, part A of figure) to the use of a full thickness vaginal suture that was incorporated as an autologous pledget
RESULTS
A total of 154 patients underwent modified endoscopic urethral suspension between July 1979 and June 1987. Of these patients 129 were cured of the incontinence postoperatively. Success was defined as a negative Marshall or Bonney test (no urinary leakage with coughing) postoperatively and a history that the patient no longer required any pads. Modifications in the procedure occurred during the 8-year period. In 71 patients a buried telfa or polypropylene pledget was used, in 24 a simple transvaginal mattress stitch was used (part B of figure), and 59 had an autologous pledget of vaginal wall. The success rates of the various modifications were 85 % (60 of 71 patients) with the telfa or polypropylene pledget, 75% (18 of 24) with no pledget and 86% (51 of 59) with the autologous pledget, for an over-all rate of 84% (129 of 154). The success rates were remarkably constant during the study except for the period when no pledget
Accepted for publication July 21, 1989.
44
ENDOSCOPIC SUSPENSION OF BLADDER NECK FOR FEJ\1lALE STRESS URINARY INCONTINENCE
45
C
Supports of endoscopic bladder neck suspension. A, polypropylene pledget buttress. B, simple transvaginal mattress suture. C, autologous pledget of vaginal wall.
was used to buttress the repair. Postoperative bladder instability was not specifically evaluated, although it appeared to occur in less than 10% of the patients and usually was well controlled with anticholinergic medication. The length of hospitalization decreased throughout the study, which undoubtedly was due to a variety of factors, including increased facility with the operative technique, motivation from hospital administration to shorten hospital stay and increased confidence on the part of the surgeons that early postoperative care could be managed at home. Average hospitalization was 6.2 days in 1980, 9 4.4 days in 1984 and 2.2 days in 1987. Analysis of the 25 failures revealed that many of them occurred in high risk patients. Three patients had neurogenic bladders, 2 had previous pelvic radiation and 5 had failed a prior incontinence operation. A total of 21 patients who had failed a prior incontinence procedure at our institution or elsewhere underwent endoscopic suspension of the bladder neck and 16 were cured, for a success rate of 76%. Complications occurred in 9.8% of the patients. One patient had a postoperative myocardial infarction but recovered completely. One patient had postoperative bleeding and required 3 units of blood. This was the only patient in the entire series who required a blood transfusion. One patient who had undergone prior pelvic radiation suffered a bowel perforation secondary to placement of a percutaneous suprapubic tube. This complication was managed conservatively without surgical exploration and convalescence was uneventful. Three patients had prolonged postoperative urinary retention (retention longer than 1 month postoperatively) but all eventually voided on their own. Three patients had suture abscesses that required removal of 1 of the suspension sutures. Of these patients 2 became incontinent after unilateral removal of a suspension suture. In 6 patients the suprapubic tube became displaced out of the bladder. All 6 patients were treated successfully by removal of the suprapubic tube and placement of a Foley urethral catheter.
In conclusion, we present the 8-year experience at our institution with a modified technique for endoscopic suspension of the bladder neck. The technique is reliable, with an over-all 84% success rate and a complication rate of only 9.8%. The technique is simple, can be performed with the use of local anesthesia in selected patients 10 and results in shortened hospital stay. REFERENCES
1. Kelly, H. A. and Dumm, W. M.: Urinary incontinence in women,
2.
3.
4.
5. 6. 7.
8. 9.
10.
without manifest injury to the bladder: a report of cases. Surg., Gynec. & Obst., 18: 444, 1914. Marshall, V. F., Marchetti, A. A. and Krantz, K. E.: The correction of stress incontinence by simple vesicourethral suspension. Surg., Gynec. & Obst., 88: 590, 1949. Burch, J. C.: Urethrovaginal fixation to Cooper's ligament for correction of stress incontinence, cystocele, and prolapse. Amer. J. Obst. Gynec., 81: 281, 1961. Pereyra, A. J. and Lebherz, T. B.: Combined urethrovesical suspension and vaginourethroplasty for correction of urinary stress incontinence. Obst. Gynec., 30: 537, 1967. Raz, S.: Modified bladder neck suspension for female stress incontinence. Urology, 17: 82, 1981. McGuire, E. J. and Lytton, B.: Pubovaginal sling procedure for stress incontinence. J. Urol., 1 HI: 82, 1978. Stamey, T. A.: Endoscopic suspension of the vesical neck for urinary incontinence. Surg., Gynec. & Obst., 136: 547, 1973. Gittes, R. F. and Loughlin, K. R.: No-incision pubovaginal suspension for stress incontinence. J. Urol., 138: 568, 1987. Loughlin, K. R., Gittes, R. F., Klein, L.A. and Whitmore, W. F., HI: The comparative medical costs of 2 major procedures available for the treatment of stress urinary incontinence. J. Urol., 127: 436, 1982. Gittes, R. F. and Loughlin, K. R.: No incision urethropexy for stress incontinence under local anesthesia. J. Urol., part 2, 139: 270A, abstract 429, 1988.