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Surgical Treatment Of Stress Urinary Incontinence: Options And Surgical Pearls

UroToday.com - Until a decade ago slings were advocated for complicated cases, patients who had failed multiple procedures such as Kelly plications, needle suspensions or retropubic bladder neck suspensions and for patients with recognized intrinsic sphincter dysfunction. A number of publications in the last half of the 90’s helped to fuel the use of the sling as the main surgical procedure for stress incontinence. The AUA guidelines for the surgical treatment of female stress urinary incontinence in 1997 showed that slings were far superior to needle suspensions.1 Other papers reporting that slings could be used in virtually all stress incontinent patients. 2,3,4 New developments in sling technology, some of them now obsolete, proved to the average practicing urologist that they could easily learn to do a sling and that they could have initial good results. We now have a plethora of choices of sling materials and techniques, many of them marketed to patients, and the question is then raised; which sling for which patient?

As sling usage has increased various techniques and sling materials have been advocated. In choosing the appropriate sling technique and sling material for an individual patient it is helpful to review the history of slings.

The History of Slings

Slings despite their recent popularity are not new. The first sling procedure for incontinence was reported over 100 years ago by Giordano in 1907.5 Slings in a variety of forms has been used since then. In 1978 McGuire and Lytton reintroduced the procedure to the urologic community.6 They used a combined abdominal vaginal approach using rectus fascia. Initially the strip of rectus fascia was left attached on one end. Later a smaller detached piece of fascia, 8 - 10 cm, was used with long nylon sutures forming the remainder of the sling.

In addition to reports in the 1990s that slings could be used in all patients with stress incontinence changes in technology and marketing occurred that led many urologists to add sling procedures to their treatment armamentarium. The development of a woven polyester collagen impregnated sling (Protogen) fixed with bone anchors was seen as a quick and easy way to perform a pubovaginal sling. Aggressive marketing led many urologists to adopt the sling as their treatment of choice for stress urinary incontinence. Ultimately the Protogen sling was removed from the market due to a high rate of vaginal erosion.7 By the time Protogen slings were no longer available allograft tissues consisting of banked human fascia either abdominal or fascia lata in a freeze dried or fresh frozen form had been introduced as a sling material.8 Xenograft material was also readily available. Various bone anchoring systems, placed suprapubically or vaginally, had also been developed. 9

The next development in sling technology was the mid-urethral sling. The Tension-Free Vaginal Tape (TVT) developed by Ulmsten in 1996 uses a loosely woven polypropylene mesh (Prolene) and supports the midurethral complex without tension.10 The TVT is performed by blindly passing two trocars from below through a vaginal incision, behind the symphysis pubis and out through the suprapubic skin. The procedure is ideally performed with local or spinal anesthesia as a stress test is performed to adjust the sling’s tension. Other midurethral slings have since been developed that use needles, similar to those previously used for vaginal needle suspensions, allowing the urologist to use a more familiar antegrade passage of the needles through the space of Retzius. The TVT also can be performed with an abdominal guide that allows for creation of a pathway from above below prior to coupling the trocar to the abdominal guide. There is now five year data for the TVT. Long term data confirms that 85% of patients are cured and 11% are improved after 5 years.11 Patients with intrinsic sphincter dysfunction have a cure rate of 72% and an improved rate of 14%.12 Intraoperative complications of the TVT include bladder perforation, bowel injury and major vascular injury resulting in death. Other complications include erosion into the urinary tract and vaginal wall extrusion. A more complete listing of injuries involving synthetic mesh is available on the FDA Med-watch website. (www.fda.gov/medwatch).

Transobturator slings were developed next. These are subfascial hammocks of silicone or polypropylene mesh that avoid the retropubic space and are placed transversly underneath the urethra from one obturator foramina to the other. The advantage of these slings is that the retropubic space is avoided with low risk of bladder, bowel or major vessel injury. The transobturator slings can be placed inside out or outside in. The latest developments in synthetic slings are very small slings that are placed in a manner similar to either the retropubic or transobturator approach.

Present Options in Slings

The gold standard sling remains the pubovaginal rectus fascial sling. Popularized by McGuire the sling, which now measures approximately 2 by 6-8 cm, is harvested from the rectus fascia.6 The ends of the sling are sutured with heavy sutures which are then passed through the space of Retzuis and tied over the rectus muscle. Cure rates with this type of sling range from 80% to 92% and the results are durable. 3,13 The main concerns with this sling are postoperative voiding dysfunction and recovery from the fascial harvest which is perceived as making the operation “more difficult and painful” and limits the patient’s activities for 6 weeks postoperatively.

Synthetic mid urethral slings are ideal for the patient with anatomic stress incontinence who is looking for a surgery with minimal recovery time. In one of the few randomized surgical studies for stress incontinence the TVT has been shown to be comparable to a Burch colposuspenion at 6, 12 and 24 months.14 Large randomized trials comparing mid urethral or transobturator slings to pubovaginal slings have not been performed.

Some considerations in advising patients as to which sling may be best for them include the patient’s size and age. The obese patient who historically has more problems with wound healing from a fascial harvest may do well with a synthetic sling. However in the very obese there can be some difficulty in palpating a trocar or needle as it is being passed. In these patients a subfascial hammock may be a viable option. The age of the patient must also be considered. A synthetic mid-urethral sling or an allograft or xenograft pubovaginal sling may be ideal for the frail octogenarian who may not be looking for a very durable procedure. The 25 year old patient needs to be told that we do not know what the long term results of synthetics are. A synthetic mid urethral sling is an appealing operation to a 25 year old in terms of recovery but will it be just as appealing if she recurs every 10 to 15 years? How much synthetic can we use in patients?

Synthetics are avoided in any patients where sling tension might be beneficial for example the patient with myelodyplasia and a wide open bladder neck. Synthetics are also avoided where there is a higher risk of infection because of contamination. Examples of this would include the sling placed in a neurogenic patient who is having a concomitant bladder augmentation with bowel or the patient who is having a sling placed concomitantly with excision of a periurethral abscess or repair of a urethral diverticulum.

The surgeon performing slings should be able to offer their patient a variety of procedures. A surgeon needs to know not just how to do a procedure but needs to be able to deal with complications unique to each type of procedure. If a surgeon isn’t comfortable dealing with a vaginal extrusion of a sling or can’t do an urethrolyis of what ever sling they have placed one could argue that they shouldn’t be doing the procedure. Surgeons who use bone anchors need to know how to deal with bone pain and should know how to remove a bone anchor. One has to also inform the patient of the risks and benefits of the various procedures. It is disheartening to see a patient who has failed an allograft sling and realize that she doesn’t have a clue of what material was used or how that material was obtained. A well informed patient who has decided to have a procedure for stress incontinence should be given enough information to decide between a pubovaginal sling with autologous, allogenic or xenogenic material or a synthetic sling placed at the mid urethra or via the transobturator approach.

What slings or slings should you do? You should offer your patients a choice of procedures. You should be comfortable doing the procedure and dealing with the complications. If you presently only do one type of sling you should at least tell your patients that there are alternatives so that they may decide to seek another opinion.

Future Sling Surgery

Sling surgery continues to offer patients definitive treatment with decreasing morbidity. New sling materials and techniques will continue to evolve. Ideally randomized clinical trials with objective and subjective outcomes and adequate follow-up are necessary to insure that new techniques are as good as or better than techniques that have stood the test of time.

Bibliography:

1. Leach GE, Dmochowski RR, Appell RA, et al. J.Urol, Female Stress Urinary Incontinence Clinical Guidelines Panel summary report on surgical management of female stress urinary incontinence. The American Urological Association. J Urol 158: 1997, 875.
2. Zaragosa MR. J. Urol, Expanded indications for the pubovaginal sling: treatment of type 2 or 3 stress incontinence. 156: 1996, 1620.
3. Chaikin DC, Rosenthal J, Blaivas JG. J. Urol, Pubovaginal fascial sling for all types of stress urinary incontinence: long-term analysis. 160: 1998, 1312.
4. Loughlin KR. J. Urol, Slings - an idea whose time has come. 163: 2000, 1843.
5. Giordano, D: Twentieth Congress, Franc. De Chir. 506, 1907.
6. McGuire EJ, Lytton B: J. Urol, Pubovaginal sling procedures for stress incontinence. 119: 1978, 82.
7. Kobashi DK, Dmochowski R, Mee SL. et. al: J.Urol, Erosion of woven polyester pubovaginal sling. 162: 1999, 2070.
8. Handa VL, Jensen JK, Germain MM, Ostergard DR: Obstet Gynec, Banked human fascia lata for the suburethral sling procedures: A preliminary report. 88: 1996, 1045.
9. Kovac SR, Cruikshank SH: Obstet Gynec, Pubic bone suburethral stabilization sling for recurrent urinary incontinence. 89: 1997, 624.
10. Ulmsten U, Henriksson L, Johnson P. et al: Int Urogynecol J Pelvic Floor Dysfunct, An ambulatory surgical procedure under local anesthesia for treatment of female urinary incontinence. 7: 1996, 81.
11. Nilsson C, Kuuva N, Falconer C, et al: Int Urogynecol J Pelvic Floor Dysfunct, Long-term results of the tension-free vaginal tape (TVT) procedure for surgical treatment of female stress urinary incontinence. 12 (supple 2): 2001 S5-S8.
12. Rezapour M, Falconer C and Ulmsten U: Int Urogynecol J Pelvic Floor Dysfunct, Tension - free vaginal tape (TVT) in stress incontinent women with intrinsic sphincter deficiency: a long term follow up. 12 (supple 2): 2001, S9 - S11.
13. Morgan TO. Westney OL, McGuire EJ: J. Urol. Pubovaginal sling: 4-year outcome analysis and quality of life assessment. 163: 2000, 1845-8.
14. Ward KL, Hilton P: Int Urogynecol J Pelvic Floor Dysfunct, A randomized trial of colpsuspension and tension-free vaginal tape (TVT) for primary genuine stress incontinence: 2 year follow-up: 12 (supple 2), 2001, S7-8.

Presented by: E. Ann Gormley, MD, FACS, at the Masters in Urology Meeting - July 31, 2008 - August 2, 2008, Elbow Beach Resort, Bermuda

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