- Email: [email protected]
Surgery for stress incontinence
STRESS INCONTINENCE
Surgery for stress incontinence Sanjay Kallat Paul Hilton
Stress urinary incontinence (SUI) is defined as the involuntary loss of urine associated with effort or exertion, or on sneezing or coughing.1 The International Continence Society defines urodynamic stress incontinence as the involuntary loss of urine with increased abdominal pressure in the absence of a detrusor muscle contraction. Stress incontinence causes anxiety, distress, embarrassment and low self-esteem, and can lead to isolation from social activity. It can have a siginificant negative impact on a woman’s quality of life. The prevalence of stress incontinence varies from 12% to 44%, with the highest rates among women in their 50s.2,3
Open colposuspension. The view is into the retropubic space, showing three suspensory sutures between the paravaginal tissues and the ileopectineal ligament on the right side. 1
probably have elements of both, with predominance of one or the other type.4
Aetiology Continence is dependent on the coordination of multiple anatomical and physiological factors involving the bladder, urethra, urethral sphincter and the pelvic floor muscles, by an intact nervous system. The pelvic floor supports the bladder and urethra, and plays a pivotal role in transmission of any increments in abdominal pressure to the urethra. It creates a positive urethral closure pressure gradient, which maintains continence. Damage to the urethral and bladder neck supports (e.g. as a result of nerve injury, childbirth, menopause) results in an alteration of the normal relationship, causing urine leakage during episodes of increased abdominal pressure.
First-line treatment Conservative treatment with pelvic floor muscle physiotherapy is recommended as first-line therapy for stress urinary incontinence. Options include: • pelvic-floor exercises (see pages 29–30) • electrical stimulation • weighted vaginal cones • biofeedback. A systematic review reported that pelvic floor exercises improved self-reported cure rates over a 3- to 6-month period (17%), compared to no treatment (2%).5 Performing pelvic floor exercises also reduced the number of leakage episodes experienced daily over the same period. No significant difference in self-reported cure or improvement rates was noted when pelvic-floor exercises were compared to weighted vaginal cones or pelvic-floor electrical stimulation at 12 months.5–7 Where conservative treatment has failed to improve symptoms and quality of life, surgery should be considered.
Types of stress incontinence Stress incontinence can be caused by hypermobility in an otherwise healthy urethra. This may be as a result of damge to pelvic floor supports to the urethra during pregnancy and childbirth, or due to age-related changes. Intrinsic urethral sphincter deficiency occurs in the weak, but normally supported urethra, and may be due to urethral muscle weakness, nerve injury, periurethral scarring or fibrosis. These conditions are not mutually exclusive and most patients
Traditional surgical techniques During 2002–2003, around 9000 operations on the female bladder outlet were performed in England.8 The choice of surgical procedure depends on many factors, including: • age of patient • medical fitness for surgery • planned treatment for co-existing benign gynaecological pathology (e.g. prolapse, previous surgery) • surgeon and patient preference.
Sanjay Kallat is a Specialist Registrar at the Royal Victoria Infirmary, Newcastle upon Tyne, UK. Paul Hilton qualified from the University of Newcastle upon Tyne in 1974 and now works as Consultant Urogynaecologist at the Royal Victoria Infirmary, Newcastle upon Tyne, UK. He has clinical and research interests in all aspects of urogynaecology.
WOMEN’S HEALTH MEDICINE 2:6
Open retro-pubic colposuspension Until recently, the most commonly performed procedure for treatment of stress urinary incontinence was the open retro-pubic 34
© 2005 The Medicine Publishing Company Ltd
STRESS INCONTINENCE
Efficacy: many studies report long-term cure rates of 80–90%. The incidences of voiding dysfunction, de novo detrusor overactivity and perioperative complications were not found to be statistically different from open colposuspension in a recent systematic review. Short- and long-term cure rates are also comparable.14 Where synthetic material is used, a risk of erosion into the vagina, urethra or bladder is recognized. There is currently a lack of data comparing different types of slings.
colposuspension (Figure 1), described by Burch in 1961.9 This procedure involves supporting the anterior vagina and bladder neck by elevating them towards the ileopectineal ligaments, using two to three sutures on each side. Efficacy: most published series report an objective cure rate between 80 and 90%. A recently updated systematic review suggests overall cure rates of 68–80%, and a reduction in cure rate of the order of 15–20% beyond 5 years.10 Subjective and objective cure rates averaging around 70% have been described after 8-year follow-up.11 The long-term effectiveness of this procedure has led to it being considered as the standard surgical treatment of stress urinary incontinence. When compared to traditional sling procedures, no significant difference is demonstrated in subjective or objective cure rates.12 No difference in perioperative complications, de novo detrusor overactivity or voiding difficulty was identified between the two procedures. However, a trend towards greater risk of new or recurrent prolapse has been reported in patients undergoing open colposuspension.10
Anterior vaginal repair or colporrhaphy This technique has been used in the past to treat concurrent prolapse and stress incontinence, with the plication of periurethral fascia to support the bladder neck. Efficacy: a Cochrane review concluded that anterior vaginal repair is less effective than open retro-pubic colposuspension;15 the failure rate within 5 years of anterior repair was 38%, compared to 17% for colposuspension. Of those women who underwent anterior repair, 23% had further surgery for incontinence, compared to 2% of those who underwent colposuspension.
Sub-urethral sling procedure This traditional treatment for stress urinary incontinence has been in practice for many years. Numerous methods and materials have been described, including: • porcine dermis • fascia lata • collagen • synthetic materials (e.g. Mersilene, Marlex and Gore-tex meshes). A sub-urethral sling procedure usually requires a combined abdominal and vaginal approach (Figure 2). In the Aldridge sling, first described in 1942,13 the fascia attached to a central pedicle is tunnelled through the retro-pubic space and attached under the urethra.
Recent trends and current treatment options The anatomical and pathophysiological factors implicated in causation of stress urinary incontinence have been the subject of extensive research in recent years. This has led to the development of new treatments, many of which are less invasive than the traditional techniques already discussed. Particularly noteworthy are the minimally invasive sling procedures and laparoscopic colposuspension. Laparoscopic colposuspension The technique of laparoscopic colposuspension was first described in 1991.16 Access to the retro-pubic space can be gained through
Sling procedure. The sling, fashioned from rectus sheath, is being drawn down through the retropubic space into the suburethral area. 2
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© 2005 The Medicine Publishing Company Ltd
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18-month follow-up, nor were there differences in rates of de novo detrusor overactivity, voiding dysfunction or perioperative complications. In keeping with other endoscopic procedures, patients undergoing laparoscopic colposuspension had less blood loss, lower analgesic requirements, shorter hospital stays and quicker returns to normal activity, but longer operating times than those undergoing open procedures. One study reported stress urinary incontinence on video cystometry in 43% of the laparoscopic group, compared to 10% for the open group at 5-year follow-up.18 The longevity of cure for this procedure is uncertain. Tension-free vaginal tape (TVT) An ambulatory tension-free urethropexy procedure was first described in 1996,19,20 and has since come to be known as the tension-free vaginal tape (TVT) procedure (Figure 3). The TVT procedure can be performed under local, regional or general anaesthesia. The device is comprised of a strip of polypropylene (prolene) mesh enclosed in a detachable sliding polyurethane sheath, attached to an insertion needle at both ends. With the patient positioned in lithotomy, two small suprapubic incisions and a 1 cm vertical incision at mid-urethral level are made. The needles with the tape attached are introduced vaginally in a carefully controlled manoeuvre, negotiating through the endopelvic facia, the retropubic space and the rectus sheath in sequence, to emerge through the suprapubic incisions on each side. After insertion, cystoscopy is performed to inspect the bladder and urethra for any signs of perforation. The patient is asked to cough and the tension of the tape is adjusted until only minimal leak is noted. Most procedures are performed as day-case or 24-hour admissions.
Tension-free vaginal tape. The tape is shown in place through the right side of the retropubic space, being passed through the left side to form a sling. 3
transperitoneal or extra-peritoneal approaches (no advantage of one approach over the other has been shown in available literature). Once access is gained, as with the open procedure, the paravaginal tissues and the bladder neck are attached to the ileopectineal ligaments. No consensus exists regarding material for anchoring the tissues to the ligament, and polypropylene mesh, staples and sutures have all been used.
Efficacy: a recent multicentre randomized trial compared the efficacy of the TVT procedure to open colposuspension in 344 women. Significantly shorter operation time, hospital stay and time to return to normal activity were noted in the TVT group.21 Objective cure rates of 63% in the TVT group and 51% in the colposuspension group were reported at 2-year follow-up.22 Case series report favourable long-term objective and subjective cure
Efficacy: a large MRC-funded, randomized trial awaits publication, but to date the procedure has been compared against open colposuspension in several small trials and one systematic review.17 No difference in subjective cure rates was demonstrated at 6- to
a
b
Periurethral injection therapy. The bladder neck is shown within the urethra a before and b immediately after injection. 4
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rates at 5-year follow-up. The TVT has also been shown to be cost-effective compared to colposuspension.23 The National Institute for Health and Clinical Excellence (NICE) has published guidance stating that the TVT procedure appears to have similar effectiveness to the main alternatives for surgical treatment of stress urinary incontinence and should be one of the available treatment options.24 A number of minimally invasive techniques for insertion of midurethral tapes via the retro-pubic space or the obturator foramen are currently being aggressively marketed. Good quality, robust data to support the use of these devices outside the context of well-designed randomized trials is currently lacking.
REFERENCES 1 Abrams P, Cardozo L, Fall M et al. Standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourology and Urodynamics 2002; 21: 167–78. 2 Hunskaar S, Lose G, Sykes D, Voss S. The prevalence of urinary incontinence in women in four European countries. Brit J Urol Int 2004; 93(3): 324–30. 3 Peyrat L, Haillot O, Bruyere F, Boutin J M, Bertrand P, Lanson Y. Prevalence and risk factors of urinary incontinence in young and middle-aged women. Brit J Urol Int 2002; 89(1): 61–6. 4 Blaivas J G, Olsson C A. Stress incontinence: classification and surgical approach. J Urol 1988; 139(4): 727–31. 5 Hay-Smith E, Bø K, Berghmans L, Hendriks H, de Bie R, van Waalwijk van Doorn E. Pelvic floor muscle training for urinary incontinence in women (Cochrane Review). In: The Cochrane library. Chichester, UK: John Wiley & Sons Ltd, 2004. 6 Berghmans L C, Hendriks H J, Bø K, Hay-Smith E J, de Bie R A, van Waalwijk van Doorn E. Conservative treatment of stress urinary incontinence in women: a systematic review of randomized clinical trials. Brit J Urol Int 1998; 82(2): 181–91. 7 Herbison P, Plevnik S J M. Weighted vaginal cones for urinary incontinence (Cochrane Review). In: The Cochrane library. Chichester, UK: John Wiley & Sons Ltd, 2004. 8 Department of Health. Hospital episode statistics 2002–2003. Available online at http://www.doh.gov.uk/publicationsandst atistics/hes/ 9 Burch J. Urethrovaginal fixation to Cooper’s ligament for stress incontinence, cystocele and prolapse. Am J Obstet Gynecol 1961; 81: 281–90. 10 Lapitan M, Cody D, Grant A. Open retropubic colposuspension for urinary incontinence in women (Cochrane Review). In: The Cochrane library. Chichester, UK: John Wiley & Sons Ltd, 2004. 11 Drouin J, Tessier J, Bertrand P E, Schick E. Burch colposuspension: long-term results and review of published reports. Urol 1999; 54(5): 808–14. 12 Sand P K, Winkler H, Blackhurst D W, Culligan P J. A prospective randomized study comparing modified Burch retropubic urethropexy and suburethral sling for treatment of genuine stress incontinence with low-pressure urethra. Am J Obstet Gynecol 2000; 182(1): 30–4. 13 Aldridge A. Transplantation of fascia for relief of stress incontinence. Am J Obstet Gynecol 1944; 44: 394–411. 14 Bezerra C, Bruschini H, Cody D. Suburethral sling operations for urinary incontinence in women (Cochrane Review). In: The Cochrane library. Chichester, UK: John Wiley & Sons Ltd, 2004. 15 Glazener C, Cooper K. Anterior vaginal repair for urinary incontinence in women (Cochrane Review). In: The Cochrane library. Chichester, UK: John Wiley & Sons Ltd, 2004. 16 Vancaillie T G, Schuessler W. Laparoscopic bladderneck suspension. J Laparoendosc Surg 1991; 1(3): 169–73. 17 Moehrer B, Ellis G, Carey M, Wilson P. Laparoscopic colposuspension for urinary incontinence in women (Cochrane Review). In: The Cochrane library. Chichester, UK: John Wiley & Sons Ltd, 2004. 18 Burton G. A five year prospective randomised urodynamic
Periurethral injection therapy with bulking agents Injectable agents include autologous fat, collagen and silicone microparticles. Injection is undertaken transurethrally through a cystoscope, or paraurethrally under local anaesthetic (Figure 4). Efficacy: a recent systematic review concluded that this procedure resulted in improvement of subjective and objective cure rates, although there is a significant lack of long-term follow-up data.25 Most series quote initial cure rates of 60–80%, declining to 40% at 2-year follow-up.26 Longer-term results are generally poor, with one study showing minimal cure rates by 4 years,27 hence such treatment might be considered to have only a limited place in the management of stress urinary incontinence. It may, however, have a place in offering short-term symptomatic improvement to women whose fitness for other surgical treatment is poor due to co-existing morbidity.
CONFLICT OF INTERESTS Paul Hilton has received research funding from Gynecare for support of a randomized comparative trial of TVT and colposuspension, and from GyneIdeas to support development work on devices for use in incontinence and prolapse surgery; he has no personal financial interest in these or any other companies.
Learning points • The favourable short- and medium-term efficacy of minimally invasive sling procedures has led to them replacing traditional open retro-pubic colposuspension as the preferred first surgical choice for treatment of stress urinary incontinence in many units. • In circumstances where benign pathology requiring surgery co-exists with incontinence, management should be carefully planned, with the aim of offering the best outcome, with lowest morbidity and improved quality of life. • Women should be offered careful counselling about available treatment options, their respective efficacy rates and complications, thereby allowing them an informed management choice.
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study comparing open and laparoscopic colposuspension. Neurourol Urodyn 1999; 18: 296. 19 Petros P E, Ulmsten U I. An integral theory of female urinary incontinence. Experimental and clinical considerations. Acta Obstet Gynecol Scand 1990; 153: 7–31. 20 Ulmsten U, Henriksson L, Johnson P, Varhos G. An ambulatory surgical procedure under local anesthesia for treatment of female urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 1996; 7(2): 81–6. 21 Ward K, Hilton P. Prospective multicentre randomised trial of tension-free vaginal tape and colposuspension as primary treatment for stress incontinence. Brit Med J 2002; 325(7355): 67–70. 22 Ward K L, Hilton P. A prospective multicenter randomized trial of tension-free vaginal tape and colposuspension for primary urodynamic stress incontinence: two-year follow-up. Am J Obstet Gynecol 2004; 190(2): 324–31. 23 Manca A, Sculpher M J, Ward K, Hilton P. A cost-utility analysis of tension-free vaginal tape versus colposuspension for primary urodynamic stress incontinence. Brit J Obstet Gynaecol 2003; 110(3): 255–62. 24 National Institute for Clinical Excellence. Guidance on the use of tension free vaginal tape (Gynecare TVT) for stress incontinence. Health Technology Appraisal 2003: 56. 25 Pickard R, Reaper J, Wyness L, Cody D, McClinton S, N’Dow J. Periurethral injection therapy for urinary incontinence in women (Cochrane Review). In: The Cochrane library. Chichester, UK: John Wiley & Sons Ltd, 2004. 26 Monga A K, Robinson D, Stanton S L. Periurethral collagen injections for genuine stress incontinence: a 2-year follow-up. Br J Urol 1995; 76(2): 156–60. 27 Gorton E, Stanton S, Monga A, Wiskind A K, Lentz G M, Bland D R. Periurethral collagen injection: a long-term follow-up study. Brit J Urol Int 1999; 84(9): 966–71.
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© 2005 The Medicine Publishing Company Ltd
Surgery for stress incontinence Sanjay Kallat Paul Hilton
Stress urinary incontinence (SUI) is defined as the involuntary loss of urine associated with effort or exertion, or on sneezing or coughing.1 The International Continence Society defines urodynamic stress incontinence as the involuntary loss of urine with increased abdominal pressure in the absence of a detrusor muscle contraction. Stress incontinence causes anxiety, distress, embarrassment and low self-esteem, and can lead to isolation from social activity. It can have a siginificant negative impact on a woman’s quality of life. The prevalence of stress incontinence varies from 12% to 44%, with the highest rates among women in their 50s.2,3
Open colposuspension. The view is into the retropubic space, showing three suspensory sutures between the paravaginal tissues and the ileopectineal ligament on the right side. 1
probably have elements of both, with predominance of one or the other type.4
Aetiology Continence is dependent on the coordination of multiple anatomical and physiological factors involving the bladder, urethra, urethral sphincter and the pelvic floor muscles, by an intact nervous system. The pelvic floor supports the bladder and urethra, and plays a pivotal role in transmission of any increments in abdominal pressure to the urethra. It creates a positive urethral closure pressure gradient, which maintains continence. Damage to the urethral and bladder neck supports (e.g. as a result of nerve injury, childbirth, menopause) results in an alteration of the normal relationship, causing urine leakage during episodes of increased abdominal pressure.
First-line treatment Conservative treatment with pelvic floor muscle physiotherapy is recommended as first-line therapy for stress urinary incontinence. Options include: • pelvic-floor exercises (see pages 29–30) • electrical stimulation • weighted vaginal cones • biofeedback. A systematic review reported that pelvic floor exercises improved self-reported cure rates over a 3- to 6-month period (17%), compared to no treatment (2%).5 Performing pelvic floor exercises also reduced the number of leakage episodes experienced daily over the same period. No significant difference in self-reported cure or improvement rates was noted when pelvic-floor exercises were compared to weighted vaginal cones or pelvic-floor electrical stimulation at 12 months.5–7 Where conservative treatment has failed to improve symptoms and quality of life, surgery should be considered.
Types of stress incontinence Stress incontinence can be caused by hypermobility in an otherwise healthy urethra. This may be as a result of damge to pelvic floor supports to the urethra during pregnancy and childbirth, or due to age-related changes. Intrinsic urethral sphincter deficiency occurs in the weak, but normally supported urethra, and may be due to urethral muscle weakness, nerve injury, periurethral scarring or fibrosis. These conditions are not mutually exclusive and most patients
Traditional surgical techniques During 2002–2003, around 9000 operations on the female bladder outlet were performed in England.8 The choice of surgical procedure depends on many factors, including: • age of patient • medical fitness for surgery • planned treatment for co-existing benign gynaecological pathology (e.g. prolapse, previous surgery) • surgeon and patient preference.
Sanjay Kallat is a Specialist Registrar at the Royal Victoria Infirmary, Newcastle upon Tyne, UK. Paul Hilton qualified from the University of Newcastle upon Tyne in 1974 and now works as Consultant Urogynaecologist at the Royal Victoria Infirmary, Newcastle upon Tyne, UK. He has clinical and research interests in all aspects of urogynaecology.
WOMEN’S HEALTH MEDICINE 2:6
Open retro-pubic colposuspension Until recently, the most commonly performed procedure for treatment of stress urinary incontinence was the open retro-pubic 34
© 2005 The Medicine Publishing Company Ltd
STRESS INCONTINENCE
Efficacy: many studies report long-term cure rates of 80–90%. The incidences of voiding dysfunction, de novo detrusor overactivity and perioperative complications were not found to be statistically different from open colposuspension in a recent systematic review. Short- and long-term cure rates are also comparable.14 Where synthetic material is used, a risk of erosion into the vagina, urethra or bladder is recognized. There is currently a lack of data comparing different types of slings.
colposuspension (Figure 1), described by Burch in 1961.9 This procedure involves supporting the anterior vagina and bladder neck by elevating them towards the ileopectineal ligaments, using two to three sutures on each side. Efficacy: most published series report an objective cure rate between 80 and 90%. A recently updated systematic review suggests overall cure rates of 68–80%, and a reduction in cure rate of the order of 15–20% beyond 5 years.10 Subjective and objective cure rates averaging around 70% have been described after 8-year follow-up.11 The long-term effectiveness of this procedure has led to it being considered as the standard surgical treatment of stress urinary incontinence. When compared to traditional sling procedures, no significant difference is demonstrated in subjective or objective cure rates.12 No difference in perioperative complications, de novo detrusor overactivity or voiding difficulty was identified between the two procedures. However, a trend towards greater risk of new or recurrent prolapse has been reported in patients undergoing open colposuspension.10
Anterior vaginal repair or colporrhaphy This technique has been used in the past to treat concurrent prolapse and stress incontinence, with the plication of periurethral fascia to support the bladder neck. Efficacy: a Cochrane review concluded that anterior vaginal repair is less effective than open retro-pubic colposuspension;15 the failure rate within 5 years of anterior repair was 38%, compared to 17% for colposuspension. Of those women who underwent anterior repair, 23% had further surgery for incontinence, compared to 2% of those who underwent colposuspension.
Sub-urethral sling procedure This traditional treatment for stress urinary incontinence has been in practice for many years. Numerous methods and materials have been described, including: • porcine dermis • fascia lata • collagen • synthetic materials (e.g. Mersilene, Marlex and Gore-tex meshes). A sub-urethral sling procedure usually requires a combined abdominal and vaginal approach (Figure 2). In the Aldridge sling, first described in 1942,13 the fascia attached to a central pedicle is tunnelled through the retro-pubic space and attached under the urethra.
Recent trends and current treatment options The anatomical and pathophysiological factors implicated in causation of stress urinary incontinence have been the subject of extensive research in recent years. This has led to the development of new treatments, many of which are less invasive than the traditional techniques already discussed. Particularly noteworthy are the minimally invasive sling procedures and laparoscopic colposuspension. Laparoscopic colposuspension The technique of laparoscopic colposuspension was first described in 1991.16 Access to the retro-pubic space can be gained through
Sling procedure. The sling, fashioned from rectus sheath, is being drawn down through the retropubic space into the suburethral area. 2
WOMEN’S HEALTH MEDICINE 2:6
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© 2005 The Medicine Publishing Company Ltd
STRESS INCONTINENCE
18-month follow-up, nor were there differences in rates of de novo detrusor overactivity, voiding dysfunction or perioperative complications. In keeping with other endoscopic procedures, patients undergoing laparoscopic colposuspension had less blood loss, lower analgesic requirements, shorter hospital stays and quicker returns to normal activity, but longer operating times than those undergoing open procedures. One study reported stress urinary incontinence on video cystometry in 43% of the laparoscopic group, compared to 10% for the open group at 5-year follow-up.18 The longevity of cure for this procedure is uncertain. Tension-free vaginal tape (TVT) An ambulatory tension-free urethropexy procedure was first described in 1996,19,20 and has since come to be known as the tension-free vaginal tape (TVT) procedure (Figure 3). The TVT procedure can be performed under local, regional or general anaesthesia. The device is comprised of a strip of polypropylene (prolene) mesh enclosed in a detachable sliding polyurethane sheath, attached to an insertion needle at both ends. With the patient positioned in lithotomy, two small suprapubic incisions and a 1 cm vertical incision at mid-urethral level are made. The needles with the tape attached are introduced vaginally in a carefully controlled manoeuvre, negotiating through the endopelvic facia, the retropubic space and the rectus sheath in sequence, to emerge through the suprapubic incisions on each side. After insertion, cystoscopy is performed to inspect the bladder and urethra for any signs of perforation. The patient is asked to cough and the tension of the tape is adjusted until only minimal leak is noted. Most procedures are performed as day-case or 24-hour admissions.
Tension-free vaginal tape. The tape is shown in place through the right side of the retropubic space, being passed through the left side to form a sling. 3
transperitoneal or extra-peritoneal approaches (no advantage of one approach over the other has been shown in available literature). Once access is gained, as with the open procedure, the paravaginal tissues and the bladder neck are attached to the ileopectineal ligaments. No consensus exists regarding material for anchoring the tissues to the ligament, and polypropylene mesh, staples and sutures have all been used.
Efficacy: a recent multicentre randomized trial compared the efficacy of the TVT procedure to open colposuspension in 344 women. Significantly shorter operation time, hospital stay and time to return to normal activity were noted in the TVT group.21 Objective cure rates of 63% in the TVT group and 51% in the colposuspension group were reported at 2-year follow-up.22 Case series report favourable long-term objective and subjective cure
Efficacy: a large MRC-funded, randomized trial awaits publication, but to date the procedure has been compared against open colposuspension in several small trials and one systematic review.17 No difference in subjective cure rates was demonstrated at 6- to
a
b
Periurethral injection therapy. The bladder neck is shown within the urethra a before and b immediately after injection. 4
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rates at 5-year follow-up. The TVT has also been shown to be cost-effective compared to colposuspension.23 The National Institute for Health and Clinical Excellence (NICE) has published guidance stating that the TVT procedure appears to have similar effectiveness to the main alternatives for surgical treatment of stress urinary incontinence and should be one of the available treatment options.24 A number of minimally invasive techniques for insertion of midurethral tapes via the retro-pubic space or the obturator foramen are currently being aggressively marketed. Good quality, robust data to support the use of these devices outside the context of well-designed randomized trials is currently lacking.
REFERENCES 1 Abrams P, Cardozo L, Fall M et al. Standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourology and Urodynamics 2002; 21: 167–78. 2 Hunskaar S, Lose G, Sykes D, Voss S. The prevalence of urinary incontinence in women in four European countries. Brit J Urol Int 2004; 93(3): 324–30. 3 Peyrat L, Haillot O, Bruyere F, Boutin J M, Bertrand P, Lanson Y. Prevalence and risk factors of urinary incontinence in young and middle-aged women. Brit J Urol Int 2002; 89(1): 61–6. 4 Blaivas J G, Olsson C A. Stress incontinence: classification and surgical approach. J Urol 1988; 139(4): 727–31. 5 Hay-Smith E, Bø K, Berghmans L, Hendriks H, de Bie R, van Waalwijk van Doorn E. Pelvic floor muscle training for urinary incontinence in women (Cochrane Review). In: The Cochrane library. Chichester, UK: John Wiley & Sons Ltd, 2004. 6 Berghmans L C, Hendriks H J, Bø K, Hay-Smith E J, de Bie R A, van Waalwijk van Doorn E. Conservative treatment of stress urinary incontinence in women: a systematic review of randomized clinical trials. Brit J Urol Int 1998; 82(2): 181–91. 7 Herbison P, Plevnik S J M. Weighted vaginal cones for urinary incontinence (Cochrane Review). In: The Cochrane library. Chichester, UK: John Wiley & Sons Ltd, 2004. 8 Department of Health. Hospital episode statistics 2002–2003. Available online at http://www.doh.gov.uk/publicationsandst atistics/hes/ 9 Burch J. Urethrovaginal fixation to Cooper’s ligament for stress incontinence, cystocele and prolapse. Am J Obstet Gynecol 1961; 81: 281–90. 10 Lapitan M, Cody D, Grant A. Open retropubic colposuspension for urinary incontinence in women (Cochrane Review). In: The Cochrane library. Chichester, UK: John Wiley & Sons Ltd, 2004. 11 Drouin J, Tessier J, Bertrand P E, Schick E. Burch colposuspension: long-term results and review of published reports. Urol 1999; 54(5): 808–14. 12 Sand P K, Winkler H, Blackhurst D W, Culligan P J. A prospective randomized study comparing modified Burch retropubic urethropexy and suburethral sling for treatment of genuine stress incontinence with low-pressure urethra. Am J Obstet Gynecol 2000; 182(1): 30–4. 13 Aldridge A. Transplantation of fascia for relief of stress incontinence. Am J Obstet Gynecol 1944; 44: 394–411. 14 Bezerra C, Bruschini H, Cody D. Suburethral sling operations for urinary incontinence in women (Cochrane Review). In: The Cochrane library. Chichester, UK: John Wiley & Sons Ltd, 2004. 15 Glazener C, Cooper K. Anterior vaginal repair for urinary incontinence in women (Cochrane Review). In: The Cochrane library. Chichester, UK: John Wiley & Sons Ltd, 2004. 16 Vancaillie T G, Schuessler W. Laparoscopic bladderneck suspension. J Laparoendosc Surg 1991; 1(3): 169–73. 17 Moehrer B, Ellis G, Carey M, Wilson P. Laparoscopic colposuspension for urinary incontinence in women (Cochrane Review). In: The Cochrane library. Chichester, UK: John Wiley & Sons Ltd, 2004. 18 Burton G. A five year prospective randomised urodynamic
Periurethral injection therapy with bulking agents Injectable agents include autologous fat, collagen and silicone microparticles. Injection is undertaken transurethrally through a cystoscope, or paraurethrally under local anaesthetic (Figure 4). Efficacy: a recent systematic review concluded that this procedure resulted in improvement of subjective and objective cure rates, although there is a significant lack of long-term follow-up data.25 Most series quote initial cure rates of 60–80%, declining to 40% at 2-year follow-up.26 Longer-term results are generally poor, with one study showing minimal cure rates by 4 years,27 hence such treatment might be considered to have only a limited place in the management of stress urinary incontinence. It may, however, have a place in offering short-term symptomatic improvement to women whose fitness for other surgical treatment is poor due to co-existing morbidity.
CONFLICT OF INTERESTS Paul Hilton has received research funding from Gynecare for support of a randomized comparative trial of TVT and colposuspension, and from GyneIdeas to support development work on devices for use in incontinence and prolapse surgery; he has no personal financial interest in these or any other companies.
Learning points • The favourable short- and medium-term efficacy of minimally invasive sling procedures has led to them replacing traditional open retro-pubic colposuspension as the preferred first surgical choice for treatment of stress urinary incontinence in many units. • In circumstances where benign pathology requiring surgery co-exists with incontinence, management should be carefully planned, with the aim of offering the best outcome, with lowest morbidity and improved quality of life. • Women should be offered careful counselling about available treatment options, their respective efficacy rates and complications, thereby allowing them an informed management choice.
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