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

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

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

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)

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

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

Stress incontinence : Weakness of the pelvic floor muscles

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

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

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

Surgical Treatment benefit risk Best long minimal term result complication

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

Retropubic Suspensions Burch’s MMK

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

Burch Colposuspension

Burch Colposuspension

Subjective Cure Rate for Burch’s Operation

Objective Cure Rate for Burch’s Operation

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

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

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

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

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

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

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

Tension-free vaginal Tape

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

Transobturator Tape (outside in)

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)

Transobturator Tape (inside out)

Imaging

TVT / TOT / TVT-O Complications 3% Voiding difficulty, hemorrhage, hematoma, bladder perforation, infection No report of rejection, erosion or fistula

Comparison of Mid-urethral sling (TVT) to various procedure Tension-Free Midurethral Slings in the Treatment of Female Stress Urinary Incontinence: A Systematic Review and Meta-analysis of Randomized Controlled Trials of Effectiveness Giacomo Novara et al. (Italy) 2007

Comparison of Mid-urethral Sling vs Colposuspension (QEH) No. of patients 222 402 Age 50.74 60.36* (p<0.001) Bladder injury (%) 0.9 4* (p=0.03) Days of bladder training (mean) 3.96 3.41 1 year subjective success (%) 82.7 89* 1 year objective success (%) 89.1 83.4 1 year DO (%) 27.7 30.2 3 years subjective success (%) 76.3 (169) 87.7 (173)* (p=0.007) 3 years objective success (%) 77.1 85.6* (p=0.04) 5 years subjective success (%) 75.8 (95) 89.2 (74)* 5 years objective success (%) 77.9 91.9* (p=0.01)

Today, mid-urethral slings not only have replaced the Burch colposuspension as the gold standard in the treatment of SUI but also are even more often performed than colposuspension Easy to perform, superior in terms of operation time, postoperative pain, and hospital stays but similar cure rates

Peri-urethral Injection Use of injectable bulk forming agents to increase the urethral closure pressure

Peri-urethral Injection Material Fat Collagen Silicone

Peri-urethral Injection Advantages Safe Disadvantages Low success rate 25 – 60% Expensive Need to be repeated every 1-2 year

Artificial Sphincter Last resort Use when all the other operation have failed

Artificial Sphincter

Conclusions 1 in 2 women in HK has urinary symptoms 1 in 3 women has SUI Much advances made in the care of female urinary incontinence Effective treatment available which can significantly improve women’s QoL

Conclusion The concept of the midurethral sling has revolutionized surgical treatment of SUI. Its minimally invasive approach and success rates have led to an increasing acceptance of the technique TVT and TOT are both comparable in cure rate The TOT approach is a potentially safer method owing to the avoidance of the retropubic space: bladder, vessels, bowel injury Pregnancy is not contraindicated and cesarean is not abolute

Long-term studies and RCTs are needed to identify the proper indications for the various types of slings and to assess efficacy and complication rates over time.