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Treatment of stress incontinence by vagino-pubic urethropexy
TREATMENT OF STRESS INCONTINENCE
BY
VAGINO-PUBIC URETHROPEXY M. PACHECO-MENA,
M.D.
R. CEDENO-GOMEZ,
M.D.
From the Divisions of Obstetrics and Gynecology and Urology, Mexico Hospital, San Jose, Costa Rica
ABSTRACT - This is a preliminary report of a new surgical technique forthe treatment of stress incontinence in patients without cystocele or with a small’one. The technical aspects and results obtained in 20 cases are described.
This new technique for the surgical correction of stress incontinence has been devised to simplify well-established techniques by combining the vaginal and suprapubic routes. l-s Its purpose is to suspend the vagina on the posterior surface of the pubic symphysis, thus also lifting the urethra and bladder neck and achieving a significant elongation of the urethra. This technique is indicated for those patients with stress incontinence who favorably respond to the Bonney-Marshall maneuver and who do not have cystoceles large enough to require corrective surgery. The presence of a small cystocele is not a contraindication. Technique The usual asepsis of the vagina, perineal regions, and abdomen is done with the patient under general anesthesia and endotracheal intubation, placed in both the lithotomy and Trendelenburg position but without excessive flexion of the hip joints. An indwelling 18 F Foley catheter is inserted and all urine drained. Urethral length is determined by measuring the distance from the proximal border of the balloon at the internal meatus to a marking placed on the catheter at the level ofthe external meatus.e By pulling gently on the catheter and at the same time palpating the bladder through the vagina, the region of the bladder neck and urethra can be located easily (Fig. 1A). The neck can also be located by
536
observing the point of transition between the corrugated and smooth portions of the vaginal mucosa.‘O Once these structures are identified, 2 vaginal sutures of nonabsorable material are placed longitudinally on each side of the bladder neck through the submucosa for a distance of 2 cm. (Fig. 1B and C). A suprapubic midline incision of 3 to 4 cm. is now made. The pyramidal muscles are exposed and carefully retracted. With a straight clamp, its tendinous insertion on the pubis is dissected free and the cartilaginous posterior portion of the pubic symphysis is exposed without dissecting into Retzius space. Then one of the anterior loose ends of the paracervical stitches is threaded through a large cutting-edge needle and passed lateral of the bladder neck through the vagina from the exact point where the submucosal suture was initiated (Fig. ID). The piercing of the vagina is guided from above with the left index finger in the abdominal incision. The suture will be passed exactly underneath and behind the pubic bone. Once the tip of the needle is seen through the abdomen, it is taken with a straight Kelly clamp and pulled into the abdomen. The same is done for the other loose end of the suture and for the contralateral ones. When all the loose ends are within the abdomen, the anterior end of each suture is secured to the posterior cartilaginous surface of the pubic symphysis (Fig. 1E). The assistant then ties the suture and the surgeon can easily verify vaginally the extent of
UROLOGY
I
APRIL 1975 / VOLUME
V, NUMBER4
FIGURE 1. {A) Bladder neck and urethra are located by palpating urethra between index and middle fingers of right hand and pulling on catheter with left hand. (B) At level of bladder neck, nonabsorbable suture longitudinally placed on side of bladder neck one through 2 cm. of submucosa. (C) Both paracervical sutures in place. (0) In site where submucosal suture initiated, nonabsorable material passed through vagina underneath pubic bone with cutting-edge needle, guiding maneuver from above with help of left hand introduced through abdominal incision. (E) View of suture secured to pubic bone. (F) View of unsupported urethra. jG) View of suspended urethra after sutures tied to posterior surface of pubic syvnphysis.
UROLOGY
/ APRIL 1975 / VOLUME
V, NUMBER4
suspension given to the vagina. In such a manner, the paracervical portion of the vagina can be lifted, giving the urethra and bladder neck an excellent means of support (Fig. 1F and G).” When the abdominal incision is closed, the urethra is again measured to ascertain the extent of the elongation obtained. The catheter is left in place four or five days postoperatively.
537
Results We used this technique on 20 patients, and the fundamental requirement in all cases was severe stress incontinence with no cystocele or a very small one. All patients responded favorably to the Bonney-Marshall maneuver prior to correction of the incontinence. To determine the necessity for complete urologic preoperative work-up, 11 patients were studied with chain urethrocystograms, cystoscopy, and cystometry, and 9 patients underwent the procedure simply on the basis of a positive response to the Bonney-Marshall maneuver. No significant difference in results was found in the two groups. The youngest patient was thirty-one years old and the eldest 72 years; 19 of the 20 patients were leading an active sexual life up to the time of the procedure. Three patients had an anterior and posterior vaginal repair previously for correction of stress incontinence, and 2 had incontinence secondary to total abdominal hysterectomy. No difficulty was encountered from a technical standpoint; rather, observers described the technique as simple and rapid. Follow-up in 14 cases has been more than three months, and in 6 cases it has been less than three months. In 5 cases concomitant surgery for other causes was performed: 3 had posterior vaginal one tracheloplasty for repair for rectocele, chronic cervicitis, and one sterilization through laparoscopy. The length of time for indwelling catheter drainage ranged from one to seven days postoperatively; however, in half the cases it was discontinued on the fourth postoperative day. On removal of the catheter, 12 patients urinated spontaneously without difficulty; 8 patients needed catheterization because of retention, two of these after they had already voided spontaneously. The elongation of the urethra obtained was significant, from 5 mm. to 23 mm. with an average of 14 mm. All patients are continent at the present time. Two patients had symptoms after leaving the hospital, one complained of dysuria that subsided after treatment, and one had pollakiuria for eight days. There was only one readmission to the hospital, a seventy-two-year-old patient with severe urinary sepsis. The others were asymptomatic after the surgical procedure. Based on the knowledge we gained from this technique, we offer the following reasons for the temporary periods ofpostoperative urinary retention that have occurred in some of our patients.
538
First, the suspension of the proximal portion of the urethra and the bladder neck has gone beyond what is necessary to correct urinary stress incontinence, resulting in a hyper-correction of the vesicourethral angle. We have noticed that in women who have had previous hysterectomy, on tying the suspension sutures there was a great elevation of the vaginal wall at the site of the vaginal stitches. The second is the development of edema at the level of the bladder neck and proximal urethra that would function as a mechanical obstacle. By endoscopic examination, in 1 patient we detected the presence of edema on both sides of the bladder neck and the portion next to the urethra, comparable to the growth of prostatic lobes in the male. This edema could be of lymphatic or venous origin from obstruction caused by the stitches that pass closely to the urethra. Finally, there is also the possibility of an emotional factor contributing to postoperative urinary retention. This is a phenomenon which has been noted also in the postoperative period when any of the other methods to correct urinary stress incontinence in the female have been used.
Conclusion This procedure significantly simplifies the treatment of stress incontinence by urethropexy in those patients without cystocele or with a very small one or in patients with recurrent or persistent incontinence after treatment with anterior vaginal repair. The technique is simple and does not need special instruments. The procedure could be easily reversed if the results are unsatisfactory by simply cutting the sutures through the vagina. Although the series of cases and follow-up time are small, we feel the results have been satisfactory. Long-term results of this series and a larger series will be given at a later date. P.O. Box 106 San Jose, Costa Rica Central America (DR. PACHECO-MENA)
References 1. CANTOR, A. J., and LEBHERZ, T. B.: Combined urethrovesical suspension and vaginourethroplasty for correction of urinary stress incontinence, Obstet. Gynec. 30: 537 (1967). 2. GOEBELL, R.: Zur operativen Beseitigung der Angelborenen Incontinez Vesicae, Z. Gynak. Urol. 2: 187 (1910).
UROLOGY /
APRIL 1975 / VOLUME V, NUMBER4
3. MARCHEITI, A. A.: The female bladder and urethra before and after correction ofstress incontinence, Am. J. Obstet. Gynec. 58: 1145 (1949). 4. MARSHALL, V. F., MARCHETTI, A. A., and KRANTZ, K. E.: The correction of stress incontinence by simple vesicourethral suspension, Surg. Gynec. Obstet. 88: 509 (1949). 5. PEREYRA, A. J.: A simplified surgical procedure for the correction ofstress incontinence in women, West. J. Surg. Gynec. 67: 233 (1959). 6. PEREYRA, A. J., and LEBHERZ, T. B.: Combined urethrovesical suspension and vaginourethroplasty for
UROLOGY
/
APRIL 1975
/
VOLUME V, NUMBER 4
correction of urinary stress incontinence, Obstet. Gynec. 30: 537 (1967). 7. STOECKEL, W.: The use of the pyramidal muscle in the surgical treatment of urinary incontinence, Zbl. Gynaek. 41: 11 (1917). 8. BONNEY, V.: On diurnal incontinence of urine in women, J. Obstet. Gynaecol. Br. Emp. 30: 358 (1923). 9. GARDINER, S. H.: Vaginal surgery for stress incontinence, Clin. Obstet. Gynec. 6: 178 (1963). 10. DUFOUR, A., and ANDRE, P.: Retention et inconti-
nence d’urine, Encyclopedic
Med. Chirurgicales,
Paris,
10: l(l966).
539
BY
VAGINO-PUBIC URETHROPEXY M. PACHECO-MENA,
M.D.
R. CEDENO-GOMEZ,
M.D.
From the Divisions of Obstetrics and Gynecology and Urology, Mexico Hospital, San Jose, Costa Rica
ABSTRACT - This is a preliminary report of a new surgical technique forthe treatment of stress incontinence in patients without cystocele or with a small’one. The technical aspects and results obtained in 20 cases are described.
This new technique for the surgical correction of stress incontinence has been devised to simplify well-established techniques by combining the vaginal and suprapubic routes. l-s Its purpose is to suspend the vagina on the posterior surface of the pubic symphysis, thus also lifting the urethra and bladder neck and achieving a significant elongation of the urethra. This technique is indicated for those patients with stress incontinence who favorably respond to the Bonney-Marshall maneuver and who do not have cystoceles large enough to require corrective surgery. The presence of a small cystocele is not a contraindication. Technique The usual asepsis of the vagina, perineal regions, and abdomen is done with the patient under general anesthesia and endotracheal intubation, placed in both the lithotomy and Trendelenburg position but without excessive flexion of the hip joints. An indwelling 18 F Foley catheter is inserted and all urine drained. Urethral length is determined by measuring the distance from the proximal border of the balloon at the internal meatus to a marking placed on the catheter at the level ofthe external meatus.e By pulling gently on the catheter and at the same time palpating the bladder through the vagina, the region of the bladder neck and urethra can be located easily (Fig. 1A). The neck can also be located by
536
observing the point of transition between the corrugated and smooth portions of the vaginal mucosa.‘O Once these structures are identified, 2 vaginal sutures of nonabsorable material are placed longitudinally on each side of the bladder neck through the submucosa for a distance of 2 cm. (Fig. 1B and C). A suprapubic midline incision of 3 to 4 cm. is now made. The pyramidal muscles are exposed and carefully retracted. With a straight clamp, its tendinous insertion on the pubis is dissected free and the cartilaginous posterior portion of the pubic symphysis is exposed without dissecting into Retzius space. Then one of the anterior loose ends of the paracervical stitches is threaded through a large cutting-edge needle and passed lateral of the bladder neck through the vagina from the exact point where the submucosal suture was initiated (Fig. ID). The piercing of the vagina is guided from above with the left index finger in the abdominal incision. The suture will be passed exactly underneath and behind the pubic bone. Once the tip of the needle is seen through the abdomen, it is taken with a straight Kelly clamp and pulled into the abdomen. The same is done for the other loose end of the suture and for the contralateral ones. When all the loose ends are within the abdomen, the anterior end of each suture is secured to the posterior cartilaginous surface of the pubic symphysis (Fig. 1E). The assistant then ties the suture and the surgeon can easily verify vaginally the extent of
UROLOGY
I
APRIL 1975 / VOLUME
V, NUMBER4
FIGURE 1. {A) Bladder neck and urethra are located by palpating urethra between index and middle fingers of right hand and pulling on catheter with left hand. (B) At level of bladder neck, nonabsorbable suture longitudinally placed on side of bladder neck one through 2 cm. of submucosa. (C) Both paracervical sutures in place. (0) In site where submucosal suture initiated, nonabsorable material passed through vagina underneath pubic bone with cutting-edge needle, guiding maneuver from above with help of left hand introduced through abdominal incision. (E) View of suture secured to pubic bone. (F) View of unsupported urethra. jG) View of suspended urethra after sutures tied to posterior surface of pubic syvnphysis.
UROLOGY
/ APRIL 1975 / VOLUME
V, NUMBER4
suspension given to the vagina. In such a manner, the paracervical portion of the vagina can be lifted, giving the urethra and bladder neck an excellent means of support (Fig. 1F and G).” When the abdominal incision is closed, the urethra is again measured to ascertain the extent of the elongation obtained. The catheter is left in place four or five days postoperatively.
537
Results We used this technique on 20 patients, and the fundamental requirement in all cases was severe stress incontinence with no cystocele or a very small one. All patients responded favorably to the Bonney-Marshall maneuver prior to correction of the incontinence. To determine the necessity for complete urologic preoperative work-up, 11 patients were studied with chain urethrocystograms, cystoscopy, and cystometry, and 9 patients underwent the procedure simply on the basis of a positive response to the Bonney-Marshall maneuver. No significant difference in results was found in the two groups. The youngest patient was thirty-one years old and the eldest 72 years; 19 of the 20 patients were leading an active sexual life up to the time of the procedure. Three patients had an anterior and posterior vaginal repair previously for correction of stress incontinence, and 2 had incontinence secondary to total abdominal hysterectomy. No difficulty was encountered from a technical standpoint; rather, observers described the technique as simple and rapid. Follow-up in 14 cases has been more than three months, and in 6 cases it has been less than three months. In 5 cases concomitant surgery for other causes was performed: 3 had posterior vaginal one tracheloplasty for repair for rectocele, chronic cervicitis, and one sterilization through laparoscopy. The length of time for indwelling catheter drainage ranged from one to seven days postoperatively; however, in half the cases it was discontinued on the fourth postoperative day. On removal of the catheter, 12 patients urinated spontaneously without difficulty; 8 patients needed catheterization because of retention, two of these after they had already voided spontaneously. The elongation of the urethra obtained was significant, from 5 mm. to 23 mm. with an average of 14 mm. All patients are continent at the present time. Two patients had symptoms after leaving the hospital, one complained of dysuria that subsided after treatment, and one had pollakiuria for eight days. There was only one readmission to the hospital, a seventy-two-year-old patient with severe urinary sepsis. The others were asymptomatic after the surgical procedure. Based on the knowledge we gained from this technique, we offer the following reasons for the temporary periods ofpostoperative urinary retention that have occurred in some of our patients.
538
First, the suspension of the proximal portion of the urethra and the bladder neck has gone beyond what is necessary to correct urinary stress incontinence, resulting in a hyper-correction of the vesicourethral angle. We have noticed that in women who have had previous hysterectomy, on tying the suspension sutures there was a great elevation of the vaginal wall at the site of the vaginal stitches. The second is the development of edema at the level of the bladder neck and proximal urethra that would function as a mechanical obstacle. By endoscopic examination, in 1 patient we detected the presence of edema on both sides of the bladder neck and the portion next to the urethra, comparable to the growth of prostatic lobes in the male. This edema could be of lymphatic or venous origin from obstruction caused by the stitches that pass closely to the urethra. Finally, there is also the possibility of an emotional factor contributing to postoperative urinary retention. This is a phenomenon which has been noted also in the postoperative period when any of the other methods to correct urinary stress incontinence in the female have been used.
Conclusion This procedure significantly simplifies the treatment of stress incontinence by urethropexy in those patients without cystocele or with a very small one or in patients with recurrent or persistent incontinence after treatment with anterior vaginal repair. The technique is simple and does not need special instruments. The procedure could be easily reversed if the results are unsatisfactory by simply cutting the sutures through the vagina. Although the series of cases and follow-up time are small, we feel the results have been satisfactory. Long-term results of this series and a larger series will be given at a later date. P.O. Box 106 San Jose, Costa Rica Central America (DR. PACHECO-MENA)
References 1. CANTOR, A. J., and LEBHERZ, T. B.: Combined urethrovesical suspension and vaginourethroplasty for correction of urinary stress incontinence, Obstet. Gynec. 30: 537 (1967). 2. GOEBELL, R.: Zur operativen Beseitigung der Angelborenen Incontinez Vesicae, Z. Gynak. Urol. 2: 187 (1910).
UROLOGY /
APRIL 1975 / VOLUME V, NUMBER4
3. MARCHEITI, A. A.: The female bladder and urethra before and after correction ofstress incontinence, Am. J. Obstet. Gynec. 58: 1145 (1949). 4. MARSHALL, V. F., MARCHETTI, A. A., and KRANTZ, K. E.: The correction of stress incontinence by simple vesicourethral suspension, Surg. Gynec. Obstet. 88: 509 (1949). 5. PEREYRA, A. J.: A simplified surgical procedure for the correction ofstress incontinence in women, West. J. Surg. Gynec. 67: 233 (1959). 6. PEREYRA, A. J., and LEBHERZ, T. B.: Combined urethrovesical suspension and vaginourethroplasty for
UROLOGY
/
APRIL 1975
/
VOLUME V, NUMBER 4
correction of urinary stress incontinence, Obstet. Gynec. 30: 537 (1967). 7. STOECKEL, W.: The use of the pyramidal muscle in the surgical treatment of urinary incontinence, Zbl. Gynaek. 41: 11 (1917). 8. BONNEY, V.: On diurnal incontinence of urine in women, J. Obstet. Gynaecol. Br. Emp. 30: 358 (1923). 9. GARDINER, S. H.: Vaginal surgery for stress incontinence, Clin. Obstet. Gynec. 6: 178 (1963). 10. DUFOUR, A., and ANDRE, P.: Retention et inconti-
nence d’urine, Encyclopedic
Med. Chirurgicales,
Paris,
10: l(l966).
539