Recurrent stress urinary incontinence in the female

Surgical management of recurrent stress urinary incontinence: A 12-year experience

OBJECTIVE

The goal of the study was to evaluate the surgical procedures used to manage recurrent stress urinary incontinence in a tertiary referral center, to compare the procedures with respect to efficacy and failure rates, and to identify risk factors for failure.

STUDY DESIGN

The health records of patients who underwent surgical treatment of recurrent stress urinary incontinence performed by the senior author (H.P.D.) between 1984 and 1995 were reviewed. The objective cure rate was evaluated by means of urodynamic studies and physical assessment, and the subjective cure rate was determined by means of historical report. In light of our selection criteria, the time to failure, the number of previous anti-incontinence procedures needed to give the best cure rate, and the risk factors for failure of the 3 predominantly used surgical techniques were determined. The statistical methods used were the chi(2) test with 95% confidence interval, the Cox proportional hazard model with logistic regression, and survival analysis.

RESULTS

One hundred ninety-eight female patients were surgically treated for recurrent stress urinary incontinence between January 1, 1984, and December 31, 1995. Four surgical techniques were used: (1) the combined abdominovaginal (2-team) polypropylene (Marlex; Phillips Petroleum Company, Bartlesville, Okla) sling (group 1, n = 70), (2) the modified urethral Marlex sling (group 2, n = 68), (3) Burch retropubic colpourethropexy (group 3, n = 49), and (4) suburethral Marlex sling (group 4, n = 11). The study population consisted of 118 patients. The rest of the original 198, including all the patients in group 4, were excluded. Objective and subjective cure rates of 69% and 89%, 66% and 96%, and 69% and 88% were calculated for groups 1, 2, and 3, respectively. By 6 years after the operation 100% of the failures in groups 1 and 2 had occurred, and 88% of the group 3 failure occurred within 2 years after the operation. Cure rates of 77%, 73%, and 38% (P =.320) were achieved with the 2-team sling procedure (group 1) after 1, 2, and 3 previous anti-incontinence operations, respectively, whereas cure rates of 81%, 25%, and 0% (P =.001) were obtained with the Burch procedure (group 3) after 1, 2, and 3 previous anti-incontinence operations, respectively. This indicates that the Burch procedure should be avoided after >1 previous operation, whereas the 2-team sling can be used after >/=3 previous anti-incontinence procedures. Statistical significance could not be determined for group 2 because that procedure was not used to treat any patient with 3 previous operations. Age was a marginal risk factor for failure in group 1. No statistically significant risk factors were identified for group 2. The number of previous anti-incontinence procedures was the major risk factor for failure in group 3 when age, parity, gravidity, weight, hormone replacement therapy, number of previous anti-incontinence procedures, and urethral closure pressure were covariables.

CONCLUSION

According to our data, both sling procedures and Burch retropubic colpourethropexy can be used to surgically manage recurrent stress urinary incontinence with selection criteria such as those that we used. In our opinion comparative prospective studies of different surgical techniques with similar selection criteria, long-term follow-up of >/=10 years, and the inclusion of urodynamic studies may be the most ethical way to determine the right operations for recurrent stress urinary incontinence.

Tissue reaction to expanded polytetrafluoroethylene suburethral sling for urinary incontinence: clinical and histologic study

OBJECTIVE

The use of expanded polytetrafluoroethylene suburethral sling for recurrent urinary incontinence has shown an excellent cure rate but a number of complications. This study was designed to evaluate patients who had tissue reaction or removal of the sling, to determine potential causes, clinical course, and eventual outcome.

STUDY DESIGN

A retrospective review of consecutive charts was completed for 115 patients who had suburethral sling surgery with expanded polytetrafluoroethylene. Patients having tissue reaction or removal of sling material were identified, and eight removed sling specimens were analyzed histologically with Milligan's trichrome, hematoxylin and eosin, fibrin, Brown-Brenn bacteria, and Dahl's calcium stains.

RESULTS

Twenty-four patients had reactions to the sling material, and 23 slings were eventually removed. Seventeen of 23 patients having sling removal remained continent. Histologic evaluations revealed gram-positive cocci in all expanded polytetrafluoroethylene patch interstices. Fibrous tissue, fibroblasts, and collagen were present in one half of specimens.

CONCLUSION

There is a 23% reaction or removal rate for expanded polytetrafluoroethylene suburethral sling procedures. Seventeen of 23 patients remained continent in spite of sling removal. Histologic studies showed gram-positive cocci in the patch interstices, although prophylactic antibiotic coverage did not prevent infection and cultures from the vaginal or abdominal reaction sites did not reveal a significant growth of organisms. Patients need to be aware of the high complication rate for this suburethral sling procedure, and physicians need to work further to modify sling materials and techniques to reduce complications.

Results of various operations for urinary stress incontinence

Four hundred and eleven women with urinary incontinence were studied and treated over a 12-year period. The surgical procedures undertaken included 45 colporrahies with Kelly stitches, 12 interposition operations, 49 fascial slings, 49 Zoedler slings using Mersilene, 66 slings using dura, 136 retropubic colpourethrocystopexies, and 54 other operations. Retropubic operations, such as colpourethrocystopexy, should be considered the primary operation for stress incontinence, for if correctly executed, they give the best long-term cure rate (97%).

Comparative urodynamic studies of women with prolapse and stress incontinence before and after abdomino-vaginal sling urethro-plasty

The effect of abdomino-vaginal sling urethro-plasty according to lyodura slings on the intravesical and intraurethral pressure was evaluated in 25 women with prolapse and stress incontinence. The investigations including a gynecological examination, urine and simultaneous urethro-cystometry. Prior to the operation, all incontinent women had a negative urethral closure pressure at stress. After surgery all 25 patients reported continence, which was confirmed by positive urethral closure pressures. The urethral pressure at rest was significantly decreased in all patients 2 weeks after operation but returned to the same value 1 year after surgery as before surgery. The functional and the absolute urethral lengths increased minimally after the operation.

Marlex gauze hammock sling operation with Cooper's ligament attachment in the management of recurrent urinary stress incontinence

In 1970 Morgan described an operation designed to meet the problem created by scarring and fibrosis resulting from previous operative procedures to the urethra and bladder neck. In the method, a 2 cm wide polypropylene (Marlex) mesh is placed as a broad hammock to elevate and support the urethrovesical junction with lateral attachment at Cooper's ligament. Sixty-nine women operated upon by Morgan's technique have been followed up for 6 months to 8 years. In those with unmixed stress incontinence, 90% were dry at follow-up, whereas in those with a mixture of stress incontinence and symptoms of detrusor disturbance, only 50% were benefited.

Modification of Marshall-Marchetti-Krantz operation

In a classic article published in 1949 Marshall, Marchetti, and Krantz demonstrated that stress incontinence in women without uterine prolapse could be corrected by a simple vesicourethral suspension. Beginning in 1960 one of the authors (W.E.C.) became concerned about suturing the urethra to the periosteum of the pubis. It occurred to him that use of the upper sutures only to pull up the bladder and hold its anterior wall to the back of the rectus muscles might be just as effective, and this has proved to be so.

The sloughed urethra syndrome

Sloughing of the urethra following obstetric trauma or pelvic surgery usually results in total urinary incontinence. Nine patients in a series of 2,000 investigated for incontinence presented with this syndrome. A technique of urethral reconstruction from the vaginal wall using a supporting bulbocavernosus graft and a Marlex sling is presented and results are discussed.