Surgical Treatment for Stress Incontinence
Marshall Marchetti Krantz (MMK)
This procedure requires an abdominal incision. The bladder neck and urethra are separated from the back surface of the pubic bone. Sutures are placed on either side of the urethra and bladder neck, which are elevated to a higher position. The free ends of the stitches are anchored to surrounding cartilage and pubic bone. MMK is no longer a favored technique because there is potential for the development of obstructive adhesions and the incision limits the physician's ability to correct herniation of the bladder into the vagina.
This vaginal suspension procedure often is performed when the abdomen is open for another purpose, such as abdominal hysterectomy.
The bladder neck and urethra are separated from the back surface of the pubic bone. The bladder neck then is elevated by lateral (sideways) sutures that pass through the vagina and pubic ligaments. (Lateral sutures prevent urethral obstruction and allow the repair of small cystoceles, or hernias.) The vaginal wall and ligament are brought together, and the sutures are tied.
Several needle suspension procedures have been developed, each named after its creator (e.g., Stamey, Raz, Gittes); however, the basic technique is the same. Essentially, sutures are placed through the pubic skin or a vaginal incision into the anchoring tissues on each side of the bladder neck and tied to the fibrous tissue or pubic bone.
The Stamey technique is performed vaginally or through a small incision above the pubic bone. A nylon suture is used to suspend the urethra on each side and cystoscopy ensures that the urethra and bladder are not injured during the procedure.
The Raz procedure corrects urethral and bladder neck hypermobility when there is minimal or no herniation of the bladder into the vagina. An inverted U-shaped incision is made in the vaginal wall and bands of fibrous tissue around the bladder neck and urethra are released. A needle is passed through the incision, and the suspending sutures are pulled, lifting the front of the vagina and urethra.
In the Gittes procedure, a small puncture is made above the pubic fat pad. A suture is transferred by a needle through the muscle of the pubic crest to the vaginal wall, where it is looped and drawn back through the puncture. A second suture is made through the puncture to create a strong suspension support. The process is repeated through another puncture made 1.5 to 2 cm from the first site. Both suspending sutures are tied at their puncture sites.
Patients with severe stress incontinence and intrinsic sphincter deficiency may be candidates for a sling procedure. The goal of this treatment is to create sufficient urethral compression to achieve bladder control.
There are two techniques:
- percutaneous, which requires a small abdominal incision, and
- transvaginal, which is performed through the vagina.
The pubovaginal sling is made of a strip of tissue from the patient's abdominal fascia (fibrous tissue). A synthetic sling may be used, but urethral tissue erosion commonly occurs.
An incision is made above the pubic bone, and a strip of abdominal fascia (the sling) is removed. Another incision is made in the vaginal wall, through which the sling is grasped and adjusted around the bladder neck. The sling is secured by two sutures loosely tied to each other above the pubic bone incision, providing a hammock to support the bladder neck.
After this procedure, patients generally regain bladder control for more than 10 years. Possible complications include accidental bladder injury, infection, and prolonged urinary retention, which may require chronic intermittent self-catheterization.
Precision Tack® Transvaginal Anchor System is a device that restores urinary function by returning the urinary anatomy to its proper position in a minimally invasive procedure.
No abdominal incision is required and a small incision is made in the vaginal wall. Two small tacks are placed in the pubic bone and a sling is inserted into the vagina and attached to the tacks with sutures. The sling supports the bladder, bladder neck, urethra, and urethral sphincter so urine can flow and be held properly.
Gynecare TVT® (tension-free vaginal tape) is a synthetic mesh tape that prevents urine leakage during sudden movement (e.g., laughing, coughing, sneezing) and while exercising by reinforcing the ligaments and tissues that support the urethra. This minimally invasive procedure is used to correct stress incontinence and combined stress and urge incontinence in women.
The tape is placed beneath the middle of the urethra in an outpatient surgical procedure that takes 30 to 50 minutes to perform. The procedure is performed under local, regional, or general anesthesia and does not require a urinary catheter. If local or regional anesthesia is used, adjustments can be made during the procedure to ensure that adequate support is provided. Cystoscopy is performed to make sure there has been no injury to the bladder during the procedure. Gynecare TVT does not require anchors or sutures and produces minimal scarring.
Recovery from the procedure takes 3 to 4 weeks. Heavy lifting and sexual intercourse should be avoided for 4 to 6 weeks. Normal daily activity can resume within 1 to 2 weeks. Recent studies have shown that tension-free vaginal tape (TVT) may be up to 90% effective over time.
Complications are rare and include bleeding; blood vessel, bladder, and bowel injury; and urinary retention. If painful urination (dysuria), bleeding, or other concerns arise, the patient should contact her physician immediately.
Newer procedures such as the Monarc subfascial hammock and transobturator tape (TOT) also can be used to correct stress incontinence and combined stress and urge incontinence in women. These techniques may result in fewer complications (e.g., blood vessel, bladder, and bowel injury) than other transvaginal procedures.
In October 2008, the U.S. Food and Drug Administration (FDA) issued a warning to physicians about possible complications resulting from surgical mesh devices (e.g., slings) used to treat stress incontinence. These complications, which include infection, pain, and mesh erosion (i.e., wearing away of the material), can significantly decrease the quality of life for affected patients and may require additional surgery. Patients who have additional health problems, patients who undergo an accompanying surgical procedure (e.g., hysterectomy), and women who are postmenopausal may be at increased risk for complications from mesh devices.
An artificial urethral sphincter may help patients who are incontinent after surgery for prostate cancer or stress incontinence, trauma victims, and patients with birth defects in the urinary tract.
The device has three components: a pump, a balloon reservoir, and a cuff that encircles and closes the urethra. All three components are filled with fluid (e.g., saline). The cuff is connected to the pump, which is surgically implanted in the scrotum (in men) or the labia (in women). The pump is activated by squeezing or pressing a button. The fluid in the cuff empties into the reservoir, the urethra opens, and the bladder empties. Fluid from the reservoir returns to the cuff, which again closes the urethra.
Possible complications include infection, tissue breakdown, and mechanical failure.