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Urethrovesical suspension (Marshall-Marchetti-Krantz)
Urethrovesical Suspension (Marshall-Marchetti-Krantz) Experience With 204 Cases
Richard W. McDuffie, Jr., MD, FACS, Eugene, Oregon Robert B. Litin, MD, Eugene, Oregon Kenneth E. Blundon, MD, FACS, Eugene, Oregon
Urinary stress incontinence is a common condition and its cure is sometimes perplexing. In their classic article in 1949, Marshall, Marchetti and Krantz [l] explained the operating procedure for urethral suspension which pioneered this field. Since then the operation and its modifications [2-91 have been used with varying degrees of success. Each method has its proponents. There are several theories about the pathophysiology of incontinence [JO]. Possible causes include the degree of the posterior urethrovesical angle, the length of the urethra and the position of the urethra as an intraabdominal structure. It is believed that the intraabdominal position gives the urethra the ability to transmit and conduct abdominal pressures [ll131. The urethrovesical suspension we perform is similar to that described by Marshall et al [I] except that we use only four sutures. The anterior pubovesical area is mobilized and the urethra freed. Two sutures are placed along the urethra, one on each side, as low as possible, and two sutures are then placed at the urethrovesical junction. These sutures are then tied to the pubic fascia as described by others. Absorbable Dexon@ and chromic sutures have been used. One of the authors (KEB) used a urethral catheter postoperatively for approximately 5 days. The other authors use a no. 16 suprapubic tube, which is left in place for approximately 10 days. Five to 8 days postoperatively the suprapubic tube is clamped and the women are allowed to void on their own. The suprapubic tube serves as a precautionary measure in case the patient is unable to urinate. Only four patients have had prolonged retention, the longest for 2 months. All eventually voided without trouble. With the suprapubic tube, the patients do not need repeated catheterizations. There is no difference in the failure rate in the two groups of patients. Lately we have tried intermittent catheterization and early removal of the tube; however, at present we see no overall difference in the infection rates in these groups. The suprapubic tube is more From the Sacred Heart Hospital, Eugene, Oregon. Requests for reprints should be addressed to Richard W. McOuffie, MD, 677 East 12th Avenue, Suite 440, Eugene, Oregon 97401.
Volume 141. Fabruaty 1931
convenient. The women are more satisfied with the tube than with repeated catheterizations. We place the tube through a separate stab wound only because it makes a much clearer primary wound postoperatively and there is less wound drainage. Our preoperative evaluation includes intravenous pyelography, cystoscopy and stress testing in all patients. We did not perform cystometrography in early years; however, our routine cystoscopy now includes a check for residual urine, first sensation to void and bladder capacity. We believe this has been sufficient in almost all cases. At present we do not believe that preoperative cystometrography in all patients is necessary. However, we use cystometriography whenever it is deemed necessary. Of the 204 patients we have operated on, 14 (6 percent) had a previous anterior vaginal repair, 115 (56 percent) had hysterectomy (63 vaginal, 45 abdominal and 7 unknown), and 9 patients (4 percent) had a previous Marshall-Marchetti repair (one operation in 7 patients and two operations in 2 patients). Previous surgery does not appear to affect the success of our operation. We combined this procedure with other operations in 65 patients. We mobilized the urethra vaginally in 56 patients when we believed preoperatively that there was fixation from previous vaginal surgery, which we can determine with preoperative cystoscopy. We also combined the operation with two hernia repairs, two oophorectomies and five hysterectomies. The age range of the patients operated on was 28 to 86 years; the average age was 58.3 years and the median age 51 to 55 years. In 133 patients for whom the information was available, the total anesthetic time was 49 minutes for urethrovesical suspension alone and 75 minutes for multiple procedures. The average anesthetic time for all patients was 61 minutes. Of 204 patients, 12 (5.8 percent) were lost to follow-up for 1 month to 5 years, with 10 lost to followup in the first 8 months after surgery. Most of these patients are from earlier years, when the importance of follow-up was not as well appreciated as it is today. Of these 12 patients, 10 were continent and 2 were considered failures at that time. 297
McDuffie
et al
There have been 11 deaths in the 204 patients. Only one death was surgical; it was caused by a pulmonary embolus. Nine of the 11 patients died 1 or more years after surgery, and only 1 patient died within the first year after operation. Of these 10 patients that were followed up, 7 were continent and 3 were incontinent at the time of death. The overall complication rate, including such minor problems as urinary tract infection, was only 14.7 percent. The complications included prolonged urinary retention (2 weeks) in four patients, increased pain with osteitis pubis in three patients, thrombophlebitis, bacteremia and incisional hernia in two patients each, and wound dehiscence, incarcerated Penrose drain and death from pulmonary embolus in one patient each. Thus a total of 16 patients (7.8 percent) had significant complications. We consider this an acceptable major complication rate in this age group. One of the problems with evaluating results reported in the literature is that the degree of urinary leakage is a subjective finding. Therefore, for the sake of quantitation and comparison, we chose to consider all patients with urinary leakage postoperatively as failures, even though over half the women in this age range normally have occasional urinary leakage even without an operation. Thirty-seven of our patients, or 18 percent, were in this category. However, 10 of the 37 patients had improvement postoperatively, leaving only 27 failures or 13 percent. This finding compares favorably with those in other reported series. None of our patients had deterioration of their condition after operation. Thus our 13 percent failure rate over 15 years is as good as or better than the results reported by others. At 1 month, excluding the one death from pulmonary embolus, we had 201 successes and 2 failures, or a 99 percent success rate. This indicates that the operation was done properly, since all but two pa-, tients were continent at that point. At 1 year we had 175 patients, of whom 157 were considered successes and 18 failures, for an 89.7 percent success rate. Again, not all patients’ conditions were as bad as their preoperative condition, but we chose to consider them failures for statistical purposes. At 5 years we had followed up 70 patients, 10 of whom still had some leakage and 60 of whom were continent, for a success rate of 85.7 percent. At 10 years we had 25 patients, 18 of whom were continent, for a 72 percent success rate. At 15 years we had only four patients, three of whom were continent, for a 75 percent success rate. As mentioned, we had a 99 percent success rate at 1 month, with most of the failures within the 5 to 10 years. Unfortunately, we were unable to quantitate the weight of patients preoperatively or as the years went by. This information was not available, although we believe it may be significant. Also, we have no way of analyzing how womens’ tissues behave over time. With changing estrogen levels do they become 298
more lax. As for the 37 patients considered failures, some of them have chronic obstructive pulmonary disease, several may have had a neurogenic bladder, and one patient had multiple sclerosis postoperatively. Two patients had failure after auto accidents. In summary, of 204 patients, 37 patients were not considered successes by our criteria. Ten of the 37 had improvement, for an 87 percent success rate over the 15 year period. These results are as good as those with other operations; whether they will remain so is not known. However, for most patients this operation would be very successful, and the various modifications of urethral suspension may well be reserved for unusual patients. Our short operating time, our low major complication rate and the fact that no patient’s condition was made worse by this operation, combined with the good overall success rate, lead us to recommend this operation for urinary stress incontinence for the properly selected woman. Summary The pre- and postoperative evaluation of 204 patients who underwent Marshall-Marchetti-Krantz urethrovesical suspension is analyzed. The major complication rate was 7.8 percent. In our hands, this operation has been a success. Our success rates were as follows: at 1 month 99 percent; at 1 year, 89.7 percent; at 5 years, 85.7 percent; at 10 years, 72 percent; and at 15 years, 75 percent. References 1. Marshall VD, Marchetti AA, Krantz KE. The correction of stress incontinence by simple vesicourethral suspension. Surg Gynecol Obstet 1949;88:509. 2. Pereyra AJ. Simplified surgical procedures for the correction of stress incontinence in women. West J Surg 1959;67: 223. Hutch JA. A modification of the Marshall-Marchetti-Krantz operation. J Urol 1968;99:607. Stamey TA. Endoscopic suspension of the vesical neck for urinary incontinence. Surg Gynecol Obstet 1975;136:547. Lapides J. Operative technique for stress urinary incontinence. Urology 1974;3:657. Burch JC. Urethrovaginal fixation to Coppers ligament for correction of stress incontinence, cystocele and prolapse: Am J Obstet Gynecol 1961;81:281. 7,. Burch JC. Urethrovaginal fixation to Coopers ligament for correction of stress incontinence, cystocele and prolapse. Prog Gynecol 1963;4:591. 8. Collins WE, Abele RP. Modifications of Marshall-MarchettiKrantz operation. Urology 1978:3:325-e. 9. Backer MH, Probst RE. The Pereyra procedure: favorable experience with 200 operations. Am J Obstet Gynecol 1976; 125:346-52. 10. Lapides J, et al. Pathophysiology of stress incontinence. Surg Gynecol Obstet 1960;3:224. 11. Persky L, Knute G. Complications of Marshall-Marchetti-Krantz urethropexy. Urology 1976;8:469-71. 12. Quattlebaun RB Jr. Successful management of female stress urinary incontinence. Urology 1976;7:501-3. 13. Hald T. Bates P, Bradley W, et al. The first report of the standardization of the terminology of lower urinary tract function. Br J Urol 1976:48:39.
The American Journal 01 Surgery
Richard W. McDuffie, Jr., MD, FACS, Eugene, Oregon Robert B. Litin, MD, Eugene, Oregon Kenneth E. Blundon, MD, FACS, Eugene, Oregon
Urinary stress incontinence is a common condition and its cure is sometimes perplexing. In their classic article in 1949, Marshall, Marchetti and Krantz [l] explained the operating procedure for urethral suspension which pioneered this field. Since then the operation and its modifications [2-91 have been used with varying degrees of success. Each method has its proponents. There are several theories about the pathophysiology of incontinence [JO]. Possible causes include the degree of the posterior urethrovesical angle, the length of the urethra and the position of the urethra as an intraabdominal structure. It is believed that the intraabdominal position gives the urethra the ability to transmit and conduct abdominal pressures [ll131. The urethrovesical suspension we perform is similar to that described by Marshall et al [I] except that we use only four sutures. The anterior pubovesical area is mobilized and the urethra freed. Two sutures are placed along the urethra, one on each side, as low as possible, and two sutures are then placed at the urethrovesical junction. These sutures are then tied to the pubic fascia as described by others. Absorbable Dexon@ and chromic sutures have been used. One of the authors (KEB) used a urethral catheter postoperatively for approximately 5 days. The other authors use a no. 16 suprapubic tube, which is left in place for approximately 10 days. Five to 8 days postoperatively the suprapubic tube is clamped and the women are allowed to void on their own. The suprapubic tube serves as a precautionary measure in case the patient is unable to urinate. Only four patients have had prolonged retention, the longest for 2 months. All eventually voided without trouble. With the suprapubic tube, the patients do not need repeated catheterizations. There is no difference in the failure rate in the two groups of patients. Lately we have tried intermittent catheterization and early removal of the tube; however, at present we see no overall difference in the infection rates in these groups. The suprapubic tube is more From the Sacred Heart Hospital, Eugene, Oregon. Requests for reprints should be addressed to Richard W. McOuffie, MD, 677 East 12th Avenue, Suite 440, Eugene, Oregon 97401.
Volume 141. Fabruaty 1931
convenient. The women are more satisfied with the tube than with repeated catheterizations. We place the tube through a separate stab wound only because it makes a much clearer primary wound postoperatively and there is less wound drainage. Our preoperative evaluation includes intravenous pyelography, cystoscopy and stress testing in all patients. We did not perform cystometrography in early years; however, our routine cystoscopy now includes a check for residual urine, first sensation to void and bladder capacity. We believe this has been sufficient in almost all cases. At present we do not believe that preoperative cystometrography in all patients is necessary. However, we use cystometriography whenever it is deemed necessary. Of the 204 patients we have operated on, 14 (6 percent) had a previous anterior vaginal repair, 115 (56 percent) had hysterectomy (63 vaginal, 45 abdominal and 7 unknown), and 9 patients (4 percent) had a previous Marshall-Marchetti repair (one operation in 7 patients and two operations in 2 patients). Previous surgery does not appear to affect the success of our operation. We combined this procedure with other operations in 65 patients. We mobilized the urethra vaginally in 56 patients when we believed preoperatively that there was fixation from previous vaginal surgery, which we can determine with preoperative cystoscopy. We also combined the operation with two hernia repairs, two oophorectomies and five hysterectomies. The age range of the patients operated on was 28 to 86 years; the average age was 58.3 years and the median age 51 to 55 years. In 133 patients for whom the information was available, the total anesthetic time was 49 minutes for urethrovesical suspension alone and 75 minutes for multiple procedures. The average anesthetic time for all patients was 61 minutes. Of 204 patients, 12 (5.8 percent) were lost to follow-up for 1 month to 5 years, with 10 lost to followup in the first 8 months after surgery. Most of these patients are from earlier years, when the importance of follow-up was not as well appreciated as it is today. Of these 12 patients, 10 were continent and 2 were considered failures at that time. 297
McDuffie
et al
There have been 11 deaths in the 204 patients. Only one death was surgical; it was caused by a pulmonary embolus. Nine of the 11 patients died 1 or more years after surgery, and only 1 patient died within the first year after operation. Of these 10 patients that were followed up, 7 were continent and 3 were incontinent at the time of death. The overall complication rate, including such minor problems as urinary tract infection, was only 14.7 percent. The complications included prolonged urinary retention (2 weeks) in four patients, increased pain with osteitis pubis in three patients, thrombophlebitis, bacteremia and incisional hernia in two patients each, and wound dehiscence, incarcerated Penrose drain and death from pulmonary embolus in one patient each. Thus a total of 16 patients (7.8 percent) had significant complications. We consider this an acceptable major complication rate in this age group. One of the problems with evaluating results reported in the literature is that the degree of urinary leakage is a subjective finding. Therefore, for the sake of quantitation and comparison, we chose to consider all patients with urinary leakage postoperatively as failures, even though over half the women in this age range normally have occasional urinary leakage even without an operation. Thirty-seven of our patients, or 18 percent, were in this category. However, 10 of the 37 patients had improvement postoperatively, leaving only 27 failures or 13 percent. This finding compares favorably with those in other reported series. None of our patients had deterioration of their condition after operation. Thus our 13 percent failure rate over 15 years is as good as or better than the results reported by others. At 1 month, excluding the one death from pulmonary embolus, we had 201 successes and 2 failures, or a 99 percent success rate. This indicates that the operation was done properly, since all but two pa-, tients were continent at that point. At 1 year we had 175 patients, of whom 157 were considered successes and 18 failures, for an 89.7 percent success rate. Again, not all patients’ conditions were as bad as their preoperative condition, but we chose to consider them failures for statistical purposes. At 5 years we had followed up 70 patients, 10 of whom still had some leakage and 60 of whom were continent, for a success rate of 85.7 percent. At 10 years we had 25 patients, 18 of whom were continent, for a 72 percent success rate. At 15 years we had only four patients, three of whom were continent, for a 75 percent success rate. As mentioned, we had a 99 percent success rate at 1 month, with most of the failures within the 5 to 10 years. Unfortunately, we were unable to quantitate the weight of patients preoperatively or as the years went by. This information was not available, although we believe it may be significant. Also, we have no way of analyzing how womens’ tissues behave over time. With changing estrogen levels do they become 298
more lax. As for the 37 patients considered failures, some of them have chronic obstructive pulmonary disease, several may have had a neurogenic bladder, and one patient had multiple sclerosis postoperatively. Two patients had failure after auto accidents. In summary, of 204 patients, 37 patients were not considered successes by our criteria. Ten of the 37 had improvement, for an 87 percent success rate over the 15 year period. These results are as good as those with other operations; whether they will remain so is not known. However, for most patients this operation would be very successful, and the various modifications of urethral suspension may well be reserved for unusual patients. Our short operating time, our low major complication rate and the fact that no patient’s condition was made worse by this operation, combined with the good overall success rate, lead us to recommend this operation for urinary stress incontinence for the properly selected woman. Summary The pre- and postoperative evaluation of 204 patients who underwent Marshall-Marchetti-Krantz urethrovesical suspension is analyzed. The major complication rate was 7.8 percent. In our hands, this operation has been a success. Our success rates were as follows: at 1 month 99 percent; at 1 year, 89.7 percent; at 5 years, 85.7 percent; at 10 years, 72 percent; and at 15 years, 75 percent. References 1. Marshall VD, Marchetti AA, Krantz KE. The correction of stress incontinence by simple vesicourethral suspension. Surg Gynecol Obstet 1949;88:509. 2. Pereyra AJ. Simplified surgical procedures for the correction of stress incontinence in women. West J Surg 1959;67: 223. Hutch JA. A modification of the Marshall-Marchetti-Krantz operation. J Urol 1968;99:607. Stamey TA. Endoscopic suspension of the vesical neck for urinary incontinence. Surg Gynecol Obstet 1975;136:547. Lapides J. Operative technique for stress urinary incontinence. Urology 1974;3:657. Burch JC. Urethrovaginal fixation to Coppers ligament for correction of stress incontinence, cystocele and prolapse: Am J Obstet Gynecol 1961;81:281. 7,. Burch JC. Urethrovaginal fixation to Coopers ligament for correction of stress incontinence, cystocele and prolapse. Prog Gynecol 1963;4:591. 8. Collins WE, Abele RP. Modifications of Marshall-MarchettiKrantz operation. Urology 1978:3:325-e. 9. Backer MH, Probst RE. The Pereyra procedure: favorable experience with 200 operations. Am J Obstet Gynecol 1976; 125:346-52. 10. Lapides J, et al. Pathophysiology of stress incontinence. Surg Gynecol Obstet 1960;3:224. 11. Persky L, Knute G. Complications of Marshall-Marchetti-Krantz urethropexy. Urology 1976;8:469-71. 12. Quattlebaun RB Jr. Successful management of female stress urinary incontinence. Urology 1976;7:501-3. 13. Hald T. Bates P, Bradley W, et al. The first report of the standardization of the terminology of lower urinary tract function. Br J Urol 1976:48:39.
The American Journal 01 Surgery