Laparoscopic urethral sling for treatment of intrinsic sphincter deficiency

Laparoscopic artificial urinary sphincter implantation for female genuine stress urinary incontinence: technique and 4-year experience in 25 patients

OBJECTIVE

to assess the safety, feasibility and efficacy of laparoscopic implantation of the artificial urinary sphincter (AUS) in women with genuine stress urinary incontinence (SUI).

PATIENTS AND METHODS

from April 2005 to July 2009, 25 women (mean age 66.8 years) with genuine SUI had a laparoscopic implantation of the AUS (AMS 800(TM) , American Medical Systems, Minnetonka, MN, USA). Patients had a negative Marshall test and urodynamic studies showed decreased closure pressure. All patients had a history of urogynaecological surgery. Transperitoneal laparoscopic access was created with two midline 10-mm and two lateral 5-mm trocars. One of the lateral port incisions was later extended to facilitate urethrovaginal dissection with scissors and dissector, and the insertion and assembly of the AUS. In six cases of concomitant genito-urinary prolapse, laparoscopic anterior and posterior mesh promontofixation was also performed.

RESULTS

the AUS was successfully implanted in all cases with no conversion to open surgery. There were no intra- or perioperative complications, except one vaginal perforation which was repaired during surgery. The mean operative duration was 92 min (71 min without and 123 min with simultaneous promontofixation). Five patients developed urinary retention, which was managed with re-insertion of the urethral catheter for 2 days in four and with insertion of a suprapubic catheter for 4 weeks in a patient with spina bifida. During the mean follow-up of 26.1 months, two treatment failures were diagnosed due to vaginal erosion and were managed with removal of the AUS. All the remaining 23 patients reported continence, either complete (in 19) or social (in four). However, this was not a randomized comparative study.

CONCLUSION

laparoscopic implantation of the AUS in women with genuine SUI is safe, feasible and efficient.

Laparoscopic approach for artificial urinary sphincter implantation in women with intrinsic sphincter deficiency incontinence: a single-centre preliminary experience

BACKGROUND

Implantation of an artificial urinary sphincter (AUS) is used as a last resort in women with stress urinary incontinence (SUI).

OBJECTIVE

To assess the early functional outcome after laparoscopic placement of an AUS in women.

DESIGN, SETTING, AND PARTICIPANTS

Twelve women with type 3 SUI underwent a laparoscopic AUS placement between 2006 and 2008. Eleven (92%) had previously undergone anti-incontinence procedures.

INTERVENTION

The AUS was implanted with laparoscopic access either preperitoneally or intraperitoneally. The cuff was placed around the bladder neck between the periurethral fascia and the vagina.

MEASUREMENTS

Perioperative complications were reviewed. To assess resolution of urinary incontinence, all patients were seen at 1, 3, 6, and 12 mo after the surgery and yearly thereafter.

RESULTS AND LIMITATIONS

The mean age of subjects was 56.7+/-12 yr (33-78). The mean body mass index was 24+/-2.3 (20-25). The mean preoperative closure pressure was 22+/-10.9 cmH(2)O (4-35). The mean operative time was 181+/-39 min [110-240]. Intraoperative complications occurred in three women (25%), with bladder (n=2) and vaginal (n=2) injuries. These complications required open conversion. AUS implantation was postponed in one case. The mean hospital stay was 7+/-2.3 d (3-11). The bladder catheter was removed after a mean time of 10+/-8 d (2-30). Urinary retention was observed in five cases (45%) after bladder catheter removal. AUS activation was done 4-14 wk after implantation. Mean follow-up was 12.1+/-8 mo (5.2-27). Incontinence was completely resolved in eight women (88%) who underwent complete laparoscopic procedure. The main limitation of the study was the limited length of follow-up.

CONCLUSIONS

AUS implantation can be successfully achieved by laparoscopy. It appears to be technically feasible. These results are still preliminary, and further studies of larger populations with longer follow-up are needed to make any statement regarding surgical strategy.

Laparoscopic artificial urinary sphincter in women for type III incontinence: preliminary results

PURPOSE

To evaluate the feasibility by laparoscopy of the AMS 800 (American Medical Systems, Inc., Minnetonka, Minnesota) artificial urinary sphincter in women with type III incontinence.

MATERIALS AND METHODS

Four women with genuine stress incontinence due to intrinsic sphincter deficiency were operated by laparoscopy. Primary criterion was negative Marshall test. One patient had not undergone surgery, and we performed laparoscopic promonto-fixation in the same procedure. Two of the three remaining patients had previous TVT (tension-free vaginal tape) with complications regarding the perforation and erosion of bladder mucosa and urethra. Laparoscopic explantation of TVT was performed 3 months previously. In the last case, previous urethropexy and laparoscopic promonto-fixation in association with TVT were performed 10 years and 1 year ago respectively. A modified surgical procedure was used to implant the AMS 800 through laparoscopic transperitoneal approach, with placement of the cuff around the bladder neck between the periurethral fascia and the vagina.

RESULTS

Mean age was 68.5 (50-79) years. Mean closure pressure was 24.5 (20-28) cm. Water. There was no erosion or extrusion. The only significant risk factor was previous surgery. The operative time was less than 3 hours. The hospital stay was 8 days. The mean follow-up was 6 (3-13) months. Activation was done 6 to 8 weeks after implantation. Social continence (1 pad use with moderate leakage) and improvement of quality of life was reported in one patient. In this case the balloon was changed in order to obtain more pressure in the cuff. Resolution of incontinence was achieved in 3 patients.

CONCLUSIONS

The AMS 800 can be successfully implanted by laparoscopy to treat women with genuine stress incontinence, a low urethral closure pressure and negative Marshall test indicating severe intrinsic sphincter deficiency. A long term follow-up is warranted to determine the efficacy and durability of this procedure.

Laparoscopic management of female urinary incontinence

Recent technologic developments in laparoscopic reconstructive surgery have generated an interest in the laparoscopic approach to bladder neck suspension. There have been numerous descriptions of a variety of techniques for the laparoscopic approach to bladder neck suspension. Initial reports seemed to suggest satisfactory rates of improvement in the stress urinary incontinence of these patients. Long-term follow-up has shown that although this minimally invasive approach to the management of stress urinary incontinence is associated with a short duration of urinary diversion, minimal postoperative discomfort, and a quick return to a productive life, the durability of the cure has failed the test of time. The laparoscopic bladder neck suspension in 3 and 4 years follow-up has achieved a success rate of only 30%, with a mean time to failure of 18 months. Any new surgical technique applied to the management of stress urinary incontinence must have a minimum of 2 years mean follow-up to determine its true clinical efficacy and durability.

Fascia lata sling cystourethropexy for the management of female urinary incontinence

Pubovaginal sling cystourethropexy has rapidly become one of the primary surgical treatment options for women with urinary incontinence. The procedure has evolved over time with regard to clinical indications, patient selection criteria and surgical techniques. This article reviews the historical development of pubovaginal sling cystourethropexy, including recent technical advances. The selection of graft materials is considered and the utility of fascia lata emphasized. Clinical results and potential complications of the procedure are also reviewed.