SURGERY FOR FEMALE STRESS URINARY INCONTINANCE

 General considerations

1.   Diversity on choice of surgical procedure. Burch colposuspensions/ fascial slings/ MUS/Injectables

2.  Indication should be significant loss of urine creating social or hygienic problem 

3. Most procedures aim to repositioning of bladder neck and urethra in a supported retropubic position. Others aim to provide increased urethral resistance by improving urethral coaptation.

 Preoperative considerations

1.   History taking, physical examination, laboratory testing and imaging. 

2. Thorough evaluation of all pelvic floor organs should be done preoperatively, In some cases full Urodynaemics studies may be indicated.

3.   Perioperative antibiotic treatment in the operating room.

4. General, regional, or local anaesthesia according to the procedure performed and patient condition

5.  Dorsal lithotomy positioning, prepping and draping the abdomen and vagina in a sterile fashion.

6.    Draining the bladder with a Foley catheter at the beginning of the procedures.

 Operative and postoperative general considerations when performing vaginal surgery

1.  Cystourethroscopy performed at the end of the procedure is recommended to verify that the bladder is intact, that no sutures are traversing the urethra or bladder, and that ureters are patent.

2. The vagina may need to be packed at the end of the procedure to facilitate hemostasis in some cases. Packing can be removed postoperative few hours to the next day.

3. Indwelling catheter or suprapubic catheter is left in the bladder in come cases and as when is needed.

 SUBURETHRAL SLING PROCEDURES (MUS)

1. Suburethral sling is a strip of material that is tunneled underneath the bladder neck and/or proximal urethra or midurethra and then attached to above structure such as rectus facia or pelvic sidewall to create a posterior support, or hammock effect to the bladder neck and proximal urethra.
2. Slings are used for all kinds of stress urinary incontinence including anatomical urinary stress incontinence(urethral hypermobility) and can be  completely transvaginally, or with combination of transvaginal and abdominal approach.
3. Sling materials include:
1. Autologous sling such as fascia lata or rectus abdominis, harvested at the time of surgery
2. Homologous material such as cadaveric fascia lata
3. Synthetic slings: Applied retropubically or transobtoratorly.
4. Minimally invasive sling procedures have been introduced including the tension free vaginal tape using polypropene tapes.

 Suburethral slings

• Transvaginal tape (TVT) is becoming popular choice as effective minimally invasive anti-incontinence surgery.
• Long term results of up to 17 years showed comparable objective and subjective cure rate as to Burch colposuspension.
• The Tension free vaginal Tape (TVT) is the only sling but that is put at the mid-urethra level. Hence, the name Transvaginal Tape (keeping the TVT abbreviation) was suggested.
• To reduce such complications, The transobturator approach (TOT). Initial results were comparable with TVT with minimal complications.

 Operative technique of TVT (Tension-free vaginal tape) & Transobturator apparoach (TOT)

• Positioning and preparation as in preoperative consideration for vaginal surgery.
• Local, regional, or general anesthesia can be used.
• Two 5mm long abdominal incisions are made 5cm apart just above the superior rim of the pubic bone (TVT). Small stab incision is made at the ischiopubic angle at the same level as the clitoris (TOT).
• A 1.5cm long vaginal wall incision is made over the midurethra, 1cm proximal to the external urethral meatus.
• Bilateral paraurethral dissection of vaginal wall is performed.
• A prolene tape attached on both ends to trocars/needles and covered by a plastic sheath is used. One of the trocars/needles is introduced and advanced through the vaginal incision, the urogenital diaphragm, and the retropubic space in close contact to the posterior aspect of the pubic bone until its tip is brought out to the abdominal incision. TOT has similar approach but the needles are introduced either through inside out as in TVTo or from out side in as other TOT’s.
• Using the trocar/ needles at the other end of the sling, this step is then repeated, on the contralateral side.
• Cystoscopy is performed to rule out bladder or urethral damage.
• Once bladder and urethral integrity have been verified, the trocars/needles on both sides removed and hence the tape is pulled all the way through the abdominal incision. The tape tension is further adjusted under the urethra.
• The plastic sheath covering of the tape is removed. The friction between the tape and the tissue canal created by the trocars serves to hold the sling in place with no need for additional suture fixation of the sling.
• Abdominal and vaginal incisions are closed.   

 Complications:

• Bladder perforation ( 5% with TVT, almost nil with TOT)
• Bowel Injuries ( 0.7/1000)
• vascular injuries ( 0.7/1000)
• Bleeding
• Voiding dysfunction (2.8% or 23/1000- 79/1000)
• Overactive bladder.
• Tape erosion/exposure ( <1%)

 

References

1. Transobturator tape for Stress Incontinence: North Queensland Experience NAidu A, Lim YN, Barry C et al . Aust N Z J Obstet Gynaecol. 2005 Oct;45(5):446-9

2. Does the MORNAC Transobturator sling cause post-operative voiding dysfunction? A prospective study. Barry C, Naidu A, Lim YN et al. Int Urogynecol J Pelvic Floor Dysfunct. 2006 Jan;17(1):30-4

3. Transobturator sub-urethral suspension, an approach worth changing to?.Malaysian Journal of O & G: 2005 ( Suppl)

4.  Transobturator Tape(TOT) procedure: The Ipoh Experience JUMMEC 2011;14(1)

http://jummec.um.edu.my/filebank/published_article/2967/JuMMEC%202011%2014(1)%2010-20.pdf

 5. Seventeen years' follw-up of the tension-free vaginal tape procedure for stress incontinence. Nilsson CG et al . Int Urogynaecol J 24(8)