Dr. BARTANI

Anti-incontinece surgury Retropubic Suspension Surgery for Incontinence in Women Slings

Retropubic Suspension Surgery for Incontinence in Women Marshall-Marchetti-Krantz Procedure Burch Colposuspension Paravaginal Repair Vagino-Obturator Shelf Repair

CHOICE OF SURGICAL TECHNIQUE Two types of stress incontinence have been suggested: one associated with a hypermobile but otherwise healthy urethra, a manifestation of weakened support of the proximal urethra, and one arising from a deficiency of the urethral sphincter mechanism itself, thereby compromising the ability of the urethra to act as a watertight outlet.

Surgical Procedures Retropubic surgical procedures, usually chosen as surgical therapy for patients with SUI in which there is a significant component of hypermobility

Open retropubic colposuspension is the surgical approach of lifting the tissues near the bladder neck and proximal urethra into the area of the pelvis behind the anterior pubic bones. When it is an open procedure the approach is through an incision over the lower abdomen. There are four variations of open retropubic colposuspension: Marshall-Marchetti-Krantz (MMK), Burch, vaginoobturator shelf (VOS), and paravaginal

INDICATIONS FOR RETROPUBIC REPAIR Specific Indications A retropubic approach for the correction of anatomic SUI is indicated (1) for a patient undergoing a laparotomy for concomitant abdominal surgery that cannot be performed vaginally and (2) where there is limited vaginal access.

MARSHALL-MARCHETTI-KRANTZ PROCEDURE In the original description, three pairs of sutures (taking double bites of tissue) were placed on each side of the urethra, incorporating fullthickness vaginal wall (excluding mucosa) and lateral urethral wall(excluding mucosa)

The recommendation from the ICI committee is that the MMK procedure is not advised for the treatment of SUI (grade A).

BURCH COLPOSUSPENSION approximating the periurethral fascia to the tough bands of fibrous tissue running along the superior aspect of the pubic bone (Cooper [iliopectineal] ligament) Two to four sutures are placed on each side, each suture taking a good bite of fascia and vaginal wall, with care taken not to pass through the vaginal mucosa

PARAVAGINAL REPAIR The origins of the paravaginal repair date to White (1912), who described the importance of the “white line” of the pelvis (arcus tendineus) as an integral structure supporting the proximal urethra and bladder base to the pelvic wall

VAGINO-OBTURATOR SHELF REPAIR The full thickness of the vagina and its overlying layer of endopelvic fascia are elevated by the surgeon’s finger in the vagina and are approximated to the internal obturator muscle and anchored to the bulk of this with absorbable 0 or 1 sutures

slings Sling Materials autologous, allograft, xenograft, or synthetic materials

MIDURETHRAL SLINGS Sling placement was classically described at the level of the bladder neck in an effort to correct urethral hypermobility and enhance pressure transmission invoked by intra-abdominal straining

furthered the concept of the importance of the midurethral mechanism for preservation of urinary incontinence under stress circumstances. These findings further demonstrate the fact that hypermobility is a secondary finding noted in association with incontinence but not causative of the condition of effortrelated urinary loss (SUI).

The Tension-Free Vaginal Tape ProcedureTransobturator Slings

Special Groups of Patients Elderly: there are few data evaluating the effect of advanced age on outcomes rate of de novo UUI was greater to a statistically significant degree in the older patients (18% vs. 4%). Overall, cure rates at least in older women with urethral hypermobility are comparable to those in younger women.

Obesity Whether obesity affects surgical outcome with the TVT procedure is controversial Obesity poses a greater risk for necrotizing fasciitis than diabetes in obstetric and gynecologic procedures

Concomitant Pelvic Organ Prolapse concurrent surgery does not appear to alter success of a TVT procedure, whether concurrent surgery alters the time to efficient voiding or incidence of urinary retention

USE OF INJECTABLE AGENTS IN FEMALE STRESS URINARY INCONTINENCE

The goal of injectable agents is to augment or restore urethral mucosal coaptation and its “hermetic seal effect” contribution to the continence mechanism

Patient Selection, Indications, and Contraindications Injectable agents are one of the many treatment options for SUI. Although initially it was thought that these agents would be most effective in patients with ISD alone, multiple reports have shown clinical efficacy in patients with hypermobility

Injectable agents may provide a rapid response for some patients and are an option for those who do not wish to undergo more invasive procedures. However, these patients must understand that efficacy and duration of these agents are inferior to surgery and follow-up injections may be required. Other possible indications include elderly patients, those with high anesthetic risk, or those willing to accept an improvement rather than cure of their SUI symptoms

Injection Techniques The materials can be administered under local anesthesia with cystoscopic control as an outpatient procedure. Both the periurethral and transurethral methods have been done to implant the agent within the urethral wall, preferably into the submucosa or lamina propria. It is thought that the implant should be positioned at the bladder neck or proximal urethra.

The ideal injectable agent that is biocompatible, nonantigenic, noncarcinogenic, and nonmigratory, causes little or no inflammatory reaction or fibrotic ingrowth, and retains efficacy over time has not yet been found.

Complications Treatment-related morbidity has been minimal. Common complications include transient urinary retention, which ranges from 1% to 21% and can be managed with intermittent catheterization or short-term use of a Foley catheter. Urinary tract infection occurs in 1% to 25% of patients De novo detrusor overactivity was reported In elderly women (39%) Hematuria can occur in 2% of patients

Currently Used Injectable Agents Glutaraldehyde Cross-linked Bovine Collagen (Contigen) Carbon-Coated Zirconium Beads (Durasphere) Silicone Microimplants (Macroplastique) Calcium Hydroxyapatite (Coaptite) Polyacrylamide Hydrogel (Bulkamid) Porcine Dermal Collagen Autologous Chondrocytes

Adjustable Continence Therapy (ACT)