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 Best long minimal term result
complication

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%
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)

52. Imaging

53. TVT / TOT / TVT-O Complications3%
Voiding difficulty, hemorrhage, hematoma, bladder perforation, infection
No report of rejection, erosion or fistula

54. 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

55. 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)

56. 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

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

58. Peri-urethral Injection
Material
Fat
Collagen
Silicone

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

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

64. Artificial Sphincter

65. 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

66. 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

67. 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.