Surgical Treatment of Stress Urinary Incontinence

1. Surgical Treatment of Stress Urinary Incontinence Dr Cecilia Cheon Consultant, Department of Obs. & Gyn. Queen Elizabeth Hospital, Hong Kong, China President, HK Urgynaecology Association

2. Definition of Urinary Incontinence Urinary incontinence is the complaint of any involuntary leakage of urine. Abram P et al. Neuro Urodyn 02

3. Terminology - Symptoms • Stress urinary incontinence (SUI) - Involuntary leakage on effort or exertion, or on sneezing or coughing

4. Urodynamic Terminology • Urodynamic stress incontinence (USI) - Involuntary leakage of urine during increased abdominal pressure, in the absence of a detrusor contraction - Old term: Genuine stress incontinence (GSI)

5. Impact on Quality of Life • Embarrassment • Reduced Self esteem • Impaired emotional & psychological well-being • Poorer sexual relationships • Impaired social activities and relationships

6. Economic Issues • USA – estimated to be $8.1 billion (Hu, 1984) • Active evaluation and treatment of nursing home residents resulted in considerable cost savings • Indirect benefit : improve QOL of sufferers, difficult to quantify

7. Stress incontinence :Weakness of the pelvic floor muscles

8. Treatment Strategy in women with USI / SUI Conservative treatment is the first line of treatment for women with SI International Consultation on Incontinence 01, Paris

9. Treatment for SUI 1. General measures 2. Pelvic floor exercises, PFEs 3. Biofeedback - perineometer, vaginal cones 4. Electrical stimulation treatment 5. Mechanical devices 6. Pharmacological treatment 7. Surgery

10. Surgical Treatment • Paravaginal repair • Bladder neck suspensions • Bladder Neck Slings / Midurethral slings • Periurethral injections • Artificial sphincter

11. Surgical Treatment benefit risk minimal complication Best long term result

12. Bladder Neck Suspensions To use the anterior vagina as a hammock to elevate the bladder neck • Needle suspensions • Retropubic suspensions - abdominal - laparoscopic

13. Retropubic Suspensions • Burch’s • MMK

14. Burch’s Colposuspension Suspension of anterior vagina to the iliopectineal ligament（Cooper’s ligament） • Abdominal  Laparoscopic

15. Burch Colposuspension

16. Burch Colposuspension

18. Subjective Cure Rate for Burch’s Operation

19. Objective Cure Rate for Burch’s Operation

20. Burch’s Success rate • 39 trials, 3,301 women • 1st year 85 – 90% • 5 year 70% • No significant difference between open and laparoscopic approach Lapitan et al, Cochrane Database Systematic Reviews 2008

21. Burch’s Colposuspension Complications • Detrusor overactivity 5 – 10% • Voiding difficulty 10 – 15% • Apical / posterior 5 – 17% compartment prolapse

22. Slings Sling under the bladder neck or mid-urethra • Correct hypermobility • Increase sphincter closure pressure

23. Midurethral-slings • To date, three major slings available - Tension-free vaginal tape (retropubic approach) – TVT - Tension-free vaginal tape (transobturator approach) – TOT / TVT-O - Minisling

24. The Integral Theory of Continence • Pelvic organ prolapse mainly caused by connective tissue laxity in the vagina or its supporting ligaments • Stress urinary incontinence is essentially due to pelvic floor muscle weakness

25. The pictorial diagnostic algorithm summarizes the relationships between structural damage in the three zones and urinary and fecal symptoms. Arrows represent directional muscle forces. Anterior zone: external urethral meatus to bladder neck; middle zone: bladder neck to cervix; posterior zone: vaginal apex, posterior vaginal wall, and perineal body. PRM = m.puborectalis; PCM = pubococcygeus; PUL = pubourethral ligament; ATFP = arcus tendineus fascia pelvis; N = bladder base stretch receptors

26. Tension-free Vaginal Tape (TVT) • Ulmsten et al in 1996 • Treats stress incontinence by positioning a polypropylene mesh tape underneath the urethra • Monofilament, macroporous, >75 microns • Free passage of marophages • In growth of fibroblast • Minimize erosion / infection

27. Tension-free vaginal Tape

36. Transobturator Tape (TOT) • Delorme1 in 2001 described the transobturator (outside-in : TOT) procedure • Insert mesh tape under the urethra through small incisions in the groin area • eliminates retropubic needle passage

37. Transobturator Tape (outside in)

49. Transobturator Tape (TOT-O) • A variation of the technique has been described in 2003 by de Leval termed the TOT vaginal tape ‘‘inside-out’’ technique (TVT-O)

50. Transobturator Tape (inside out)