Surgical treatment for stress urinary incontinence

The Use of Imaging for Synthetic Midurethral Slings

Ultrasound and magnetic resonance imaging can be used to image midurethral slings, which have may have complications such as pain. There is considerable misunderstanding regarding the utility of the different modalities. This article aims to review the current literature to identify the benefits and limitations of each imaging modality and identify the place that each should have for patients with midurethral sling complications. A literature search was performed, and all relevant articles were identified and reviewed. Different imaging modalities are complementary, but more research is required in this area.

Survey on surgery for stress urinary incontinence in an era mid-urethral slings are being questioned

INTRODUCTION

Concerns about vaginal mesh have reduced the use of mid-urethral slings (MUS) in some countries. In view of their potential withdrawal in Belgium and The Netherlands, we polled urogynaecologists on their practice for treating stress urinary incontinence (SUI) and what their experience is with alternative procedures, and we asked them how their patients perceive the risk and success rates.

METHODS

A survey among members of the pelvic floor special interest group of the Flemish Society for Obstetrics and Gynaecology, Belgian Association of Urology and Dutch Society of Obstetrics and Gynaecology.

RESULTS

Their primary procedure of choice is the MUS (99%). Sixty-five per cent performs at least 25 MUS yearly; they report high success (90%; IQR [85-92]) and low adverse outcome rates. Physicians anticipate complications as reported in the literature: 5% (IQR [410]) overactive bladder, 5% (IQR [2-10]) voiding problems, 2% (IQR [15]) exposures, 2% (IQR [1-5]) dyspareunia and 1% (IQR [1-3]) chronic pain. Eighty-five per cent of physicians report their patients express fears about having a MUS though usually they cannot precisely tell why. Reportedly they tell their physicians of concerns about pain (54%), exposure (45%), dyspareunia (25%), voiding problems (15%) or overactive bladder (8%). Only half of respondents had ever performed a colposuspension. The majority of these were older and performed colposuspension via laparotomy. Only six (4%) had performed > 20 colposuspensions yearly.

CONCLUSION

Dutch and Belgian urogynaecologists estimate success and adverse effect rates of MUS in line with the literature. Their patients most cited worries were fear of chronic pain and exposure. Only half of respondents had ever performed a colposuspension. They were older and performed the procedure via laparotomy.

Burch colposuspension

Aims

To evaluate the historic and pathophysiologic issues which led to the development of Burch colposuspension, to describe anatomic and technical aspects of the operation and to provide an update on current evidence.

Methods

We have performed a focused literature review and have searched the current available literature about historic dimension, technical descriptions, and efficacy of Burch colposuspension.

Results

Burch colposuspension, performed either by an open or a laparoscopic approach, is an effective surgical treatment for stress urinary incontinence.

Conclusions

In current recommendations, Burch colposuspension remains an option for secondary treatment. Because midurethral slings have recently become under scrutiny, it may return as a first‐line treatment procedure. Both open and laparoscopic Burch colposuspension should therefore nowadays be provided in fellowship programs worldwide.

On the Stiffness of the Mesh and Urethral Mobility: A Finite Element Analysis

Midurethral slings are used to correct urethral hypermobility in female stress urinary incontinence (SUI), defined as the complaint of involuntary urine leakage when the intra-abdominal pressure (IAP) is increased. Structural and thermal features influence their mechanical properties, which may explain postoperative complications, e.g., erosion and urethral obstruction. We studied the effect of the mesh stiffness on urethral mobility at Valsalva maneuver, under impairment of the supporting structures (levator ani and/or ligaments), by using a numerical model. For that purpose, we modeled a sling with “lower” versus “higher” stiffness and evaluated the mobility of the bladder and urethra, that of the urethrovesical junction (the α-angle), and the force exerted at the fixation of the sling. The effect of impaired levator ani or pubourethral ligaments (PUL) alone on the organs displacement and α-angle opening was similar, showing their important role together on urethral stabilization. When the levator ani and all the ligaments were simulated as impaired, the descent of the bladder and urethra went up to 25.02 mm, that of the bladder neck was 14.57 mm, and the α-angle was 129.7 deg, in the range of what was found in women with SUI. Both meshes allowed returning to normal positioning, although at the cost of higher force exerted by the mesh with higher stiffness (3.4 N against 2.3 N), which can relate to tissue erosion. This finite element analysis allowed mimicking the biomechanical response of the pelvic structures in response to changing a material property of the midurethral synthetic mesh.

Laparoscopic implantation of artificial urinary sphincter in women with intrinsic sphincter deficiency: Mid-term outcomes

OBJECTIVES

To analyze the safety and the mid-term continence rates of laparoscopic implantation of artificial urinary sphincter in women.

METHODS

A total of 52 women with intrinsic sphincter deficiency underwent a laparoscopic artificial urinary sphincter implantation from 2005 to 2015 at Surgical Clinic Du Pré, Le Mans, France. The artificial urinary sphincter was implanted around the bladder neck by a transperitoneal laparoscopic approach to the Retzius space. Urodynamic assessment was carried out. Postoperative functional outcome was defined as success (no leaking, no pad use), improvement (>50% decrease in number of leakages, >50% decrease in number of pads used or use of light protection) or failure (<50% improvement, persistent or increased leaking). Outcome measures also included perioperative and long-term complications.

RESULTS

The mean age of the patients was 69.1 years (range 64-82 years). After a mean follow up of 37.5 months (median 24 months; range 1-125 months), 38 (77.6%) patients were considered to be continent (no leakage, no pads), and eight (16.3%) improved their grade of incontinence. Three patients abandoned the follow-up schedule and were excluded. There was no perioperative severe complication. Artificial urinary sphincter revision was needed in 11 (22.4%) patients, requiring a total of seven redo procedures and four permanent sphincter removals. The main reasons for redo procedures were six (11.2%) mechanical problems and one vaginal erosion (2%).

CONCLUSIONS

Herein we report one of the largest series with the longest follow up evaluating the outcomes of laparoscopic artificial urinary sphincter implantation in female patients. This approach seems to be a safe and effective treatment option for patients with intrinsic sphincter deficiency.

Transvaginal retropubic sling systems: efficacy and patient acceptability

Stress urinary incontinence is a common, disabling, and costly medical problem that affects approximately 50% of women with urinary incontinence. Suburethral retropubic slings have been developed as a minimally invasive and effective surgical option, and they have been used as a first-line treatment for stress urinary incontinence since 1995. However, complications including vaginal extrusion, erosion, pain, bleeding, infections, lower urinary tract symptoms, urinary retention, and incontinence have been reported with use of the slings. Several companies manufacture sling kits, and the sling kits vary with regard to the composition of the mesh and introducer needle. The aim of this review was to determine which sling kit was most effective for patients, had minimal reported side effects, and was best accepted by patients and surgeons. In a review of the literature, it was found that a total of 38 studies were published between 1995 and 2014 that reported on eight tension-free retropubic sling kits: SPARC, RetroArc, Align, Advantage, Lynx, Desara, Supris, and Gynecare TVT. The Gynecare TVT was the most cited sling kit; the second most cited was the SPARC. This review provides a summary of the studies that have examined positive and negative outcomes of the retropubic tension-free suburethral sling procedure using various sling kits. Overall, the results of the literature review indicated that data from comparisons of the available sling kits are insufficient to make an evidenced-based recommendation. Therefore, the decision regarding which sling kit is appropriate to use in surgery is determined by the medical provider’s preference, training, and past experience, and not by the patient.

Intraoperative Crede maneuver for tape adjustment during transobturator sling placement: does it improve continence?

OBJECTIVE

This study evaluated the efficacy of intraoperative extrinsic manual compression on the bladder, or Crede maneuver (CM) for tape adjustment during transobturator tape (TOT) sling procedure versus the traditional method where tension-free tape is adjusted the same for all patients.

METHODS

All patients undergoing TOT sling procedure for stress urinary incontinence (SUI) between May 2008 and June 2011 by the first author were assessed. Tape adjustment was either performed in a traditional manner, leaving a tonsil clamp-size space between the sling and posterior urethra, or by using CM after filling the bladder to 300 ml capacity. Patients were considered cured at postoperative visits if they had no SUI symptoms and negative Cough Stress Test (CST) result, improved if they had some SUI symptoms and negative CST result, and failed if symptomatic and had positive CST result. The Fisher exact test and the Wilcoxon rank sum test were used to evaluate the baseline differences between the 2 groups, along with multiple logistic regression to evaluate independent predictors of cure.

RESULTS

The continence rate was 77.67% in the traditional group (87/112) and 79.65% (137/172) in the CM group (P = 0.76). Older patients and smokers were less likely to be continent (odds ratio, 0.95; P = 0.015; and odds ratio, 0.22; P = 0.003, respectively). Five (4.5%) of the 112 patients in the traditional group and 12 (6.9%) of the 172 patients in the CM group had adverse outcomes including transient urinary retention, mesh erosion, or dysuria (P = 0.45).

CONCLUSION

Using CM for intraoperative tape adjustment does not improve continence rates compared to the traditional method of TOT sling placement.

Recent status of the treatment of stress urinary incontinence

The therapeutic options for management of stress urinary incontinence can be conservative, pharmacological or surgical. The treatment of patients with stress urinary incontinence should be tailored to the individual to optimize care. A multitude of surgical techniques have emerged to treat this condition in recent years. The objective of the present review was to present an overview of current practice in the management of stress urinary incontinence while considering the evidence supporting the clinical effectiveness of these procedures.

Adipose-derived stromal cell transplantation for treatment of stress urinary incontinence

We aimed to investigate the application of adipose-derived stromal cells in the treatment of stress urinary incontinence (SUI). Animal models of stress urinary incontinence were established with Sprague-Dawley female rats by complete cutting of the pudendal nerve. Rat adipose-derived stromal cells were isolated, cultured and successfully transplanted into animal models. Effects of stem cell transplantation were evaluated through urodynamic testing and morphologic changes of the urethra and surrounding tissues before and after transplantation. Main urodynamic outcome measures were measured. Intra-bladder pressure and leak point pressure were measured during filling phase. Morphologic examinations were performed. Transplantation of adipose-derived stem cells significantly strengthened local urethral muscle layers and significantly improved the morphology and function of sphincters. Urodynamic testing showed significant improvements in maximum bladder capacity, abdominal leak point pressure, maximum urethral closure pressure, and functional urethral length. Morphologic changes and significant improvement in urination control were consistent over time. It was concluded that periurethral injection of adipose-derived stromal cells improves function of the striated urethral sphincter, resulting in therapeutic effects on SUI. Reconstruction of the pelvic floor through transplantation of adipose-derived cells is a minimally invasive and effective treatment for SUI.

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.

Autologous bone-marrow-derived mesenchymal stem cell transplantation into injured rat urethral sphincter

OBJECTIVES

To evaluate the functional and histological recovery by autologous bone-marrow-derived mesenchymal stem cell (BMSC) transplantation into injured rat urethral sphincters.

METHODS

BMSC were harvested from female Sprague-Dawley retired breeder rats for later transplantation. The cells were cultured, and transfected with the green fluorescence protein gene. The urethral sphincters were injured by combined urethrolysis and cardiotoxin injection. One week after injury, the cultured BMSC were injected autologously into the periurethral tissues. Controls included sham-operated rats and injured rats injected with cell-free medium (CFM). Abdominal leak point pressures (LPP) were measured before and after surgery during the following 13 weeks. The urethras were then retrieved for histological evaluation. The presence of green-fluorescence-protein-labeled cells and the regeneration of skeletal muscles, smooth muscles, and peripheral nerves were evaluated by immunohistochemical staining.

RESULTS

LPP was significantly reduced in the injured rats. It increased gradually after transplantation, but there was no significant difference between the BMSC and CFM groups. In the BMSC group, transplanted cells survived and differentiated into striated muscle cells and peripheral nerve cells. The proportions of skeletal muscle cells and peripheral nerves in the urethra were significantly greater in the BMSC group compared to the CFM group.

CONCLUSIONS

Despite a clear trend towards recovery of LPP in BMSC-transplanted urethras, no significant effect was detected. Further study is required for clinical applications for the treatment of stress urinary incontinence.

Neuromodulation for the treatment of urinary incontinence

Neuromodulation has been reported to be effective for the treatment of stress and urgency urinary incontinence. The cure and improvement rates of pelvic floor neuromodulation in urinary incontinence are 30-50% and 60-90%, respectively. In clinical practice, vaginal, anal and surface electrodes are used for external, short-term stimulation, and sacral nerve stimulation for internal, chronic (long-term) stimulation. The effectiveness of neuromodulation has been verified in a randomized, placebo-controlled study. However, the superiority to other conservative treatments, such as pelvic floor muscle training has not been confirmed. A long-term effect has also been reported. In conclusion, pelvic floor exercise with adjunctive neuromodulation is the mainstay of conservative management for the treatment of stress incontinence. For urgency and mixed stress plus urgency incontinence, neuromodulation may therefore be the treatment of choice as an alternative to drug therapy.