Incontinence, Urinary: Surgical Therapies

INTRODUCTION

Section 2 of 11

Urinary incontinence is a medical condition that has significant negative effect on the quality of life. It causes social stigma, financial hardship, and associated medical problems. Affected individuals often delay seeking treatment due to shame and embarrassment. Urinary incontinence is not a normal part of the aging process. This is a condition that has multiple etiologic factors.

Urinary incontinence may be divided into 2 broad categories.

1. Urge incontinence
2. Stress incontinence

Pharmacotherapy is the mainstay of therapy for urge incontinence. Surgery and physiotherapy are 2 primary treatment options for stress incontinence.

With recent advances in medical technology and better understanding of female anatomy and physiology, many innovative surgical methods are available for correction of stress incontinence. This chapter will review these surgical options.

History of the Procedure: Described by Kelly in 1913, the anterior vaginal repair is the oldest surgical procedure for correction of stress incontinence. Kelly believed the cause of stress incontinence was an incompetent urethra. The anterior vaginal repair was designed to correct this condition.

In 1949, the Marshall-Marchetti-Kranz (MMK) procedure was described. The suspension sutures were placed within the urethral wall and tied to the periosteum of the pubic symphysis. The original MMK procedure was complicated by urethral obstruction and erosion because the surgical sutures were placed directly into the urethral wall.

In 1961, Burch reported a modification of the MMK procedure. The modifications involved placing the surgical sutures at the bladder neck and tying them to the Cooper's ligament.

The original transvaginal bladder neck suspension was described by Peyrera in 1959. Many modifications of the Peyrera transvaginal bladder neck suspension exist today. They include Stamey (1975), Raz (1981), and Gittes (1987) bladder neck suspensions. Although initial success rates were quite promising, the long-term success rate with transvaginal bladder neck suspensions has been disappointing.

In contrast, pubovaginal slings are gaining in popularity for all types of female stress urinary incontinence. Historically, the indication for pubovaginal sling procedure was limited to women with intrinsic sphincter deficiency. However, it has been expanded to include Type II stress incontinence.

The current trend is to perform pubovaginal slings or retropubic urethropexy for correction of urethral hypermobility. The long-term success rate of pubovaginal sling is reported to be comparable to retropubic urethropexy.

Problem: Stress urinary incontinence is defined as involuntary loss of urine coincident with increased intra-abdominal pressure in the absence of uninhibited detrusor contraction.

Type I stress urinary incontinence is defined as urine loss occurring in the absence of urethral hypermobility. This is the mildest form of SUI. Patients with Type I SUI have a Valsalva Q-tip angle less than 30 degrees an abdominal leak point pressure greater than 120 cm H₂O.

Type II stress urinary incontinence is defined as stress incontinence due to urethral hypermobility. Patients with urethral hypermobility have a Valsalva Q-tip angle greater than 30 degrees and abdominal leak point pressure more than 90 cm H₂O.

Type III stress urinary incontinence is defined as stress incontinence due to intrinsic sphincteric dysfunction (ISD). Patients with ISD have Valsalva Q-tip angle less than 30 degrees and abdominal leak point pressure less than 60 cm H₂O.

Frequency:

• Urinary incontinence affects approximately 13 million people in the U.S, predominantly women.
  • This includes 10-35% of adults and 50% of the 1.5 million residents in nursing homes.
  • Up to 60% of nursing home patients are incontinent, while 30% of elderly living at home are incontinent.
• Urinary incontinence is an under-diagnosed and under-reported medical problem.
  • An estimated 50-70% of women with urinary incontinence fail to seek medical evaluation and treatment because of social stigma.
  • Only 5% of incontinent individuals in the community and 2% in nursing homes receive appropriate medical evaluation and treatment.
  • Incontinent patients often suffer with this condition for 6-9 years before seeking medical therapy.
• Stress incontinence affects between 15-60% of women.
• Stress incontinence is a disorder of the young and the old. Over one-fourth of nulliparous, young college athletes experience stress incontinence when participating in sports.

Etiology:

• The cause of stress urinary incontinence is complex. Many different factors contribute.
  • They include advancing age, multi-parity, prolonged or difficult labor, and hysterectomy.
  • Other factors that may increase the risk of developing incontinence include obesity, straining at stool as a child or young adult, heavy manual labor, chronic obstructive pulmonary disease, and smoking.

In cases of stress urinary incontinence secondary to ISD, previous pelvic surgery, radiation and sympathetic nerve dysfunction are all etiologic factors.

Pathophysiology:

• Two major types of stress incontinence exist.
  1. Urethral hypermobility
  2. Intrinsic sphincter deficiency

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• Urethral hypermobility results from weakened anatomic support of the urethra, whereas intrinsic sphincter deficiency arises from a defect within the urethra proper.
  • When there is loss of anatomic support, the proximal urethra and the bladder neck descend to rotate away and out of the pelvis at times of increased intra-abdominal pressure.
  • Because the bladder neck and proximal urethra move out of the pelvis, more pressure is transmitted to the bladder.
  • During this process, the posterior wall of the urethra shears off the anterior urethral wall to cause opening of the bladder neck.
  • The uneven pressure transmission and the opening of the bladder neck results in involuntary urine loss during periods of physical activity, called Type II stress incontinence.
• Intrinsic sphincter deficiency is a condition in which the urethral sphincter is unable to coapt and generate enough resting urethral closing pressure to retain urine in the bladder.
  • The anatomic support is normal but the urethra cannot remain closed due to lack of mucosal seal mechanism.
  • Inadequate bladder outlet resistance during times of physical activity result in involuntary urine loss, called Type III stress incontinence.

Clinical:

• Stress incontinence occurs during periods of increased intra-abdominal pressure.
  • Typically, patients complain of involuntary urine loss during coughing, laughing, and sneezing.
  • Incontinence will worsen during high-impact sports activities such as golf, tennis, or aerobics.
• In general, women with stress incontinence experience less urine loss compared to women with overactive bladder.
  • Stress incontinence occurs at predictable times.
  • Irritative voiding symptoms, such as urinary frequency, urgency, and nocturia, are typically absent.
  • Urethral hypermobility results in smaller amount of urine loss and fewer pads needed compared to intrinsic sphincteric deficiency.
• Patients with urinary incontinence should undergo a basic evaluation that includes history, physical examination, measurement of postvoid residual urine, and urinalysis.
• Additional information from a patient’s voiding diary, Q-tip test, cough stress test, cystoscopy, and urodynamics may be needed in selected patients.

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• Videourodynamics is the criterion standard in the evaluation of an incontinent patient.

INDICATIONS

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• The type of surgery required depends on the type of stress incontinence present.
  • Individuals often have more than one cause for stress incontinence.
  • They may have urethral hypermobility, intrinsic sphincter deficiency, or a combination of both.
• According to the treatment guidelines released by American Urologic Association (1997), surgery offers good long-term results as either initial or second-line treatment. Surgery may be offered as an initial form of treatment for selected women with stress urinary incontinence.
• Surgery must be individualized for each patient, and it must follow standard recommendations for appropriate surgery. The option selected depends on the surgeon’s training and expertise in a vaginal or abdominal approach.
• The most important factor in choosing a surgical procedure is the specific nature of the patient’s incontinence problem and any co-existing vaginal pathology. Patient preference, surgical complications, and co-morbid medical conditions also play a role in the decision-making process.
• The surgical management of stress incontinence can be divided into procedures designed to restore the active mechanism of continence (artificial urinary sphincter), the anatomic mechanism of continence (bladder neck suspension or pubovaginal sling), or the mucosal seal mechanism (pubovaginal sling, periurethral bulking agent, or artificial urinary sphincter).
• The surgical objective for urethral hypermobility is to improve the support of the sphincter unit (by preventing the descent of the bladder neck) without obstruction. The goal of surgery for ISD is to increase urethral coaptation and resistance.
  • Although bladder neck suspension results in both improved support and compression of the proximal urethra, it does not cure a patient with ISD.
  • Pubovaginal sling will correct both urethral hypermobility and intrinsic sphincter deficiency.

RELEVANT ANATOMY AND CONTRAINDICATIONS

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Relevant Anatomy: The female urethra is a 4-cm, elongated tube composed of an inner epithelial lining, a spongy submucosa, a middle smooth muscle layer, and outer fibroelastic connective tissue. The spongy submucosa contains a rich vascular plexus that is responsible for providing adequate urethral occlusive pressure to create the "washer effect," an important female continence mechanism. Urethral smooth muscle and fibroelastic connective tissues serve to circumferentially augment the occlusive pressure generated by the submucosa.

All parts of the female urethra are influenced by estrogen. The lack of estrogen at menopause leads to atrophy and replacement of the submucosa (vascular plexus) by fibrous tissue. Lack of estrogen is one of the risk factors for ISD; replacement of estrogen may reverse the effects of ISD. When estrogen is given to a postmenopausal woman with atrophic vaginitis, the mucosa regains its turgor with simultaneous up-regulation of alpha receptors and angiogenesis of the vascular plexus. Previous bladder neck operations, radiation, and neurogenic disease can also affect the ability to achieve a perfect seal.

• Internal sphincter

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  • Women do not have an anatomic internal sphincter like males, but women have a functional internal sphincter.
  • The female internal sphincter is composed of bladder neck and proximal urethra.
  • Under normal circumstances, the pressure of the internal sphincter is much higher than that in the bladder.
• External sphincter
  • The female external sphincter is known as the "rhabdosphincter" and is composed of 2 types of striated muscle fibers, fast and slow twitch.
  • Fast twitch fibers cause sudden stopping of the urinary stream to provide the voluntary "guarding reflex."
  • Slow twitch fibers maintain the constant tone of the external sphincter to provide involuntary passive continence called the involuntary "guarding reflex."
  • The rhabdosphincter has most prominent effect on the female urethra at the urogenital triangle. Located about 1.8 cm distal to the bladder neck, it exerts its influence for a distance of about 1.5 cm of urethral length.
• Pelvic diaphragm
  • The pelvic diaphragm lines the floor of the bony pelvis and is comprised of 4 sheets of muscles, including pubococcygeus, iliococcygeus, ischiococcygeus, and coccygeus.
  • The pelvic diaphragm is often referred to as levator ani. The levator ani musculature is attached to the inner sides of the bony pelvis by a condensation of pelvic fascia called the arcus tendineus.
  • Levator ani is the most important component of the pelvic diaphragm, and the integrity of the pelvic floor depends upon its function. When levator ani is damaged, stress urinary incontinence and/or herniation of pelvic organs through the vagina may occur.
• Supporting ligaments and fascia

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  • The urethropelvic ligament is a fibrous band of connective tissue that lines the undersurface of the bladder neck and attaches laterally to the arcus tendineus. It provides the major support to the bladder neck and proximal urethra. Laxity of the urethropelvic ligament results in stress urinary incontinence.
  • The pubocervical fascia is a fibrous sheet of connective tissue that lines the base of the urinary bladder and inserts laterally to the arcus tendineus. Intact pubocervical fascia prevents the herniation of the bladder and the proximal urethra into the vagina. Damage to the pubocervical fascia may cause the bladder to herniate through the vagina, resulting in cystocele formation.
  • The cardinal ligaments arise from the arcus tendineus and anchor to the uterine cervix. The cardinal ligaments stabilize and support the uterus, vagina, and the bladder. Weakening of the cardinal ligaments may cause cystocele and uterine descensus.
  • The uterosacral ligaments originate from condensation of fibrous connective tissue overlying the sacral promontory and insert in the uterine cervix. Uterosacral ligaments stabilize the uterus in the bony pelvis. Weakening of the uterosacral ligaments may result in prolapsed uterus or vaginal vault prolapse.

Contraindications:

• Intrinsic sphincter deficiency is a contraindication for bladder neck suspension of all types (transvaginal, retropubic, and laparoscopic). Performing bladder neck suspension for intrinsic sphincteric dysfunction will lead to persistent stress incontinence.
• Performing a bladder neck suspension alone is contraindicated in the presence of moderate or severe cystocele because urethral obstruction or worsening of the cystocele may result. In this situation, bladder neck suspension must be accompanied by a formal cystocele repair at the time of surgery.
• Presence of atrophic vaginitis and intrinsic sphincter deficiency are contraindications for in-situ vaginal wall sling.
• Severe urge incontinence is a contraindication for any type of anti-incontinence surgery. Pre-operative urge symptoms should be controlled with anti-cholinergic therapy prior to anti-incontinence surgery.
• The absolute contraindications to female artificial urinary sphincter include uncontrolled detrusor overactivity and high-grade vesicoureteral reflux. Relative contraindications include the presence of urinary tract infections and the manual dexterity to manipulate the pump. Patient motivation is the foremost consideration because there is the possibility of surgical revision for mechanical problems.

WORKUP

Section 5 of 11

Lab Studies:
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• Urinalysis and urine culture: Urinary tract infection can cause irritative voiding symptoms and urge incontinence.

• Urine cytology: Carcinoma-in-situ of the urinary bladder can cause symptoms of urinary frequency and urgency. Irritative voiding symptoms disproportionate to the overall clinical picture and/or hematuria warrant urine cytology and cystoscopy.

• Chem 7 profile: Blood urea nitrogen (BUN) and creatinine (Cr) are checked if compromised renal function is suspected. These tests are helpful for patients in whom poor renal function, obstructed ureters, or urinary retention is suggested.

Other Tests:
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• Voiding diary: A voiding diary is a daily record of patient's bladder activity. It is an objective documentation of patient's voiding pattern, incontinent episodes, and inciting events associated with urinary incontinence.

• Pad test

• This is an objective test that documents the urine loss. Intravesical Methylene Blue test or oral Pyridium or Urised may be used. Methylene Blue and Urised turns the urine color blue; Pyridium turns the urine color orange.

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• Patients should resume their usual physical activities while wearing a Peri-pad. If the pads turn to orange or blue, the patient is experiencing urine loss. If the pads remain white, it most likely is a normal vaginal fluid.

• Q-tip test

• To perform a proper Q-tip test, place the patient in a dorsal lithotomy position. Make sure the examining table is parallel to the floor. Insert a sterile well-lubricated Q-tip into the urethra until the cotton swab portion is completely in the bladder. Then, gently pull back on the Q-tip until the cotton swab is snug against the bladder neck.

  Measure the angle between the Q-tip and the floor with a protractor. Women with normal pelvic anatomy should have a resting Q-tip angle of 0 degrees with respect to the floor. Ask the patient to Valsalva (strain) and cough.

  An abnormal upward deflection of the Q-tip (greater than 30 degrees) by Valsalva maneuvers is evidence of urethral hypermobility.

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• The absence of hypermobility suggests that the cause of the stress incontinence is due to intrinsic sphincter deficiency.

• Cough stress test

• A critical part of the pelvic examination is direct observation of urine using the cough stress test or Marshall test.

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• A sterile catheter is inserted into the urethra and the bladder is filled 200-250 ml with water. The catheter is removed. Observation of leakage during Valsalva or cough denotes a positive test.

• Standing pelvic examination

• A standing pelvic examination is performed if a pelvic examination fails to demonstrate urine loss or if a pelvic organ prolapse is suspected.

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• If the cough leak test is initially performed in the lithotomy position and no leakage is observed, then this test should be repeated in the standing position. Observable urine leakage in this position constitutes a positive test.

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• If there is any doubt about the pelvic organ prolapse, the patient should be examined in the standing position. The patient stands with legs apart with one foot resting on a step stool. When the patient performs the Valsalva maneuver, the force of gravity will help the pelvic organ (uterus, bladder) slide down the vagina to enhance the diagnosis. If pelvic prolapse is present, the prolapsed organ should be pushed up either with a pessary or a gauze and the cough stress test should be repeated in the standing position.

Diagnostic Procedures:
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• Postvoid residual (PVR)

• The PVR measurement is a part of the basic evaluation for urinary incontinence. To determine the postvoid residual urine, either a bladder ultrasound or urethral catheter may be used.

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• If the PVR is high, the bladder may be acontractile or the bladder outlet may be obstructed. Both of these conditions will cause urinary retention with overflow incontinence.

• Uroflow

• Uroflow is a useful screening test mainly for evaluating bladder outlet obstruction. Uroflow is volume of urine voided per unit of time.

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• Low uroflow rate may reflect urethral obstruction, a weak detrusor or combination of both. This test alone cannot distinguish between obstruction and acontractile detrusor. To properly diagnose bladder outlet obstruction, perform pressure-flow studies.

• Filling cystometrogram

• In 40% of patients, stress and urge incontinence coexist. In many instances stress incontinence may lead to development of urge incontinence.

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• A filling cystometrogram assesses the bladder capacity, compliance, and the presence of phasic contractions. Most commonly, liquid filling medium is used. An average adult bladder holds approximately 450-500 ml of urine. During the test, provocative maneuvers help to unveil bladder instability.

• Abdominal leak point pressure (ALPP)

• An important component of multichannel videourodynamics is the determination of the abdominal leak point pressures (ALPP). Abdominal leak point pressures allow stress incontinence (SUI) to be classified into urethral hypermobility, ISD, or both in combination. It is important to note that "normal leak point pressure" should approach infinity. In other words, patients with normal continence mechanism will generate intra-abdominal pressures (Pabd) high enough to faint but will not provoke stress incontinence.

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  Type I SUI	ALPP > 120 cm H2O
  Type II SUI	Urethral hypermobility; ALPP between 90 and 120 cm H2O
  Type II/III SUI	Urethral hypermobility and intrinsic sphincter deficiency; ALPP between 60 and 90 cm H2O
  Type III SUI	Intrinsic sphincter deficiency; ALPP between zero and 60 cm H2O

  The ALPP should be measured when the bladder is half full (eg, 250 mL), and both the Valsalva and coughing maneuvers should be performed. Initially, instruct the patient to bear down in gradients (ie, mild, moderate, severe), and then note the ALPP as the lowest intravesical pressure (Pves) at which leakage is observed. If Valsalva maneuvers fail to produce the desired response, instruct the patient to cough in gradients (ie, mild, moderate, severe) to obtain the ALPP. The lowest intravesical pressure (Pves) at which leakage is seen is the ALPP. The ALPP obtained with Valsalva maneuver is more accurate than the cough-induced ALPP. Both techniques should be employed , however, if Valsalva maneuvers fail to manifest SUI.

  Alternatively, both Valsalva and cough-induced ALPP may be repeated by increasing the bladder volume in 100 mL gradients beyond 250 mL. Increasing the bladder volume reportedly increases the sensitivity of detecting ALPP.

• Voiding cystometrogram (pressure-flow study)

• A pressure-flow study simultaneously records the voiding detrusor pressure and the rate of urinary flow. This is the only test able to assess bladder contractility and the extent of a bladder outlet obstruction.

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• Pressure-flow studies can be combined with voiding cystogram and videourodynamic study for complicated cases of incontinence.

• Cystogram

• A static cystogram (AP and lateral) helps to confirm the presence of stress incontinence, the degree of urethral motion, and presence of cystocele. Intrinsic sphincter deficiency will be evident by an open bladder neck. Presence of a vesicovaginal fistula may also be noted.

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• A voiding cystogram can assess bladder neck and urethral function (internal and external sphincter) during filling and voiding phases. A voiding cystogram can identify a urethral diverticulum, urethral obstruction, and vesicoureteral reflux.

• Electromyography (EMG): EMG helps to ascertain the presence of coordinated or discoordinated voiding. Failure of urethral relaxation during bladder contraction results in discoordinated voiding (detrusor sphincter dyssynergia).

• Cystoscopy

• The precise role of cystoscopy in the evaluation of female urinary incontinence is controversial. Less than 2% of bladder tumors have been identified by routinely performing cystoscopy in incontinent women.

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• However, cystoscopy allows discovery of bladder lesions, such as stitch in the bladder, bladder cancer, and bladder stone, which would remain undiagnosed by urodynamics alone. A visual inspection of the urethra helps to establish the presence of urethral stricture or gross evidence of poor urethral closure.

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• There is general agreement that cystoscopy is indicated for patients complaining of persistent irritative voiding symptoms or hematuria. Obvious causes of bladder overactivity such as cystitis, stone, and tumor can be easily diagnosed. This information is important in determining the etiology of the incontinence and may influence treatment decisions.

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• This author also performs urethroscopy to assess the structure and function of the urethral sphincter mechanism.

• Dynamic retrograde urethroscopy

• The cystoscope is introduced into the bladder. The bladder is filled to 250 ml with irrigant. The flow of the irrigant is turned off. The cystoscope is withdrawn to midurethra. The activity of the urethral sphincter mechanism is observed at rest and with Valsalva maneuvers.

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• Patients with Type II incontinence have a closed bladder neck at rest and have an intact voluntary guarding reflex. Patients with Type III incontinence have an open bladder neck at rest and have an impaired voluntary guarding reflex.

• Videourodynamics

• Videourodynamics is the gold standard for evaluation of an incontinent patient. Videourodynamics combines the radiographic findings of VCUG and multichannel urodynamics. Videourodynamics is the most sophisticated diagnostic test for an incontinent patient.

  Performing urodynamics:

  Instruct the patient to arrive at the urodynamic laboratory with a full bladder. Perform a noninvasive uroflow and PVR. Place the patient in the dorsolithotomy position. Prepare her genitalia, and drape using sterile technique.

  Perform flexible cystoscopy. Survey the entire bladder urothelium and then retroflex the cystoscope to examine the bladder neck. Fill the bladder to 250 mL of water (see below).

  Next, perform the CST and Q-tip test as described previously. Perform a detailed speculum examination with one half of the gynecology speculum pointing at the anterior, posterior, and vaginal apex for a view of pelvic organ prolapse. During the pelvic examination, assess the functional integrity of the pelvic floor muscles by examining the perineal body and checking the rectal tone. The presence of levator ani muscle dysfunction or tenderness may be elicited by gentle palpation of the levator ani musculature in the paravaginal fornices.

  Perform a standing CST and/or pelvic examination as needed (see above).

  Drain the bladder. Place a urodynamic urethral catheter (ie, 7 Fr. Cook dual-lumen pigtailed catheter), rectal tube, and EMG electrodes.

  Rotate the patient to a sitting position and equalize transducers. Commence bladder filling using room temperature contrast (Conray). Cold water may evoke false positive detrusor contractions (phasic contractions). Fill the bladder at medium rate (eg, 60 mL/min). Assess the first sensation of filling fullness, and assess urge are assessed Note bladder compliance and mark the presence of uninhibited detrusor contractions are marked.

  When the bladder fills to 250 mL, measure the ALPP. Instruct the patient to perform the Valsalva in gradients (ie, mild, moderate, severe) followed by cough (ie, mild, moderate, severe). Observe the urine leakage fluoroscopically and by direct inspection. At this point, note the activity of the bladder neck, urethral mobility, and the presence of cystocele using fluoroscopy (static cystogram).

  Upon completion of ALPP, finish the filling CMG to completion. When the patient has a strong desire to void, perform a voiding CMG (pressure-flow). At this point, note urodynamic parameters,, such as maximal flow rate (Qmax) and detrusor pressure at maximal flow rate (PdetQmax).

  During the voiding CMG, note the activity of the EMG electrodes and voiding cystogram (VCUG) are noted for possible detrusor sphincter dyssynergia (DSD). Confirm the presence of DSD is confirmed by increases in EMG activity during detrusor contraction or closure of the external sphincter on VCUG during voiding.

  After the patient voids to completion, the video-urodynamic study is complete. The patient is informed on the findings on urodynamic studies and is sent home on with an oral antibiotic.

Surgical procedures for urethral hypermobility reposition the bladder neck into a normal anatomic position at rest and during physical exertion. When the bladder neck is in the correct anatomic position, it stays closed during periods of increased abdominal pressure. The 3 main types of procedures used for correction of urethral hypermobility are retropubic bladder neck suspension, transvaginal suspension, and pubovaginal sling.

Retropubic or transvaginal needle suspension is recommended over anterior vaginal repair for hypermobility. Retropubic and transvaginal suspension procedures are superior to anterior repair in “curing?stress incontinence.

For hypermobility with coexisting ISD, the surgical procedure should stabilize the anatomic support and compress the urethra, which means using one of the sling procedures. Pubovaginal slings produce better long-term outcomes than transvaginal bladder neck suspensions for correction of urethral hypermobility.

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Preoperative details:

• All patients should be informed of potential complications of anti-incontinence surgery during the informed consent process. Complications common to any anti-incontinence surgery include urethral obstruction and de novo or worsening obstructive voiding symptoms.

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• Patients with pre-existing urge incontinence should be treated with anticholinergic therapy preoperatively.

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• Patients undergoing sling surgery should be counseled on the possibility of performing self-catheterization in the event urinary retention occurs post-operatively. For patients receiving synthetic slings, possibility of urethral or vaginal erosion should be discussed.

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• Patients receiving artificial urinary sphincter should be informed of potential mechanical malfunction that may require revisionary surgery.

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• Eligible candidates for periurethral collagen injection should be skin tested for possible allergic reaction 28 days before the scheduled injection therapy.

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• Pre-operatively, all patients should be cleared of any pre-existing urinary tract infections. Intravenous broad-spectrum antibiotics are given on the morning of surgery, ideally 1 hour before starting the operation. Compressive pneumatic devices are placed on the lower extremities prior to induction of anesthesia to prevent deep venous thrombosis.

Intraoperative details:

• Marshall-Marchetti-Krantz urethropexy

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  • All patients are given intravenous ampicillin and gentamicin preoperatively. For patients with penicillin allergy, vancomycin is used. The patient is placed in a modified lithotomy position or in a supine position with the lower extremities in a frog-leg position.

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  • Abdomen and genitalia are prepared and draped in sterile fashion. A Foley catheter is placed.

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  • Transverse suprapubic incision is made. Anterior rectus fascia is incised.

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  • The bladder and the bladder neck are identified. The bladder neck is identified by palpation of the Foley balloon. Placement of a hand in the vagina facilitates the identification of the bladder neck.

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  • The prevesical fat is dissected off the bladder and the bladder neck. Two or three non-absorbable suspension sutures, such as No. 1 Prolene, are placed lateral to the bladder neck. The ends of the suspension sutures are affixed to the periosteum of the pubic symphysis and then tied securely.

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  • The bladder neck is suspended by the sutures anchored to the undersurface of the pubic bone. The suspension sutures prevent the bladder neck's descent during periods of physical activity, but it does not "pull up" the bladder neck high behind the pubic symphysis. Care should be taken not to tie the bladder neck against the pubic symphysis. Overzealous pulling up of the bladder neck will cause iatrogenic urethral obstruction.

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• Burch urethropexy

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  • Broad-spectrum intravenous antibiotics are administered as described above. The patient is placed in a modified lithotomy position or in a supine position with the lower extremities in a frog-leg position.

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  • Abdomen and genitalia are prepared and draped in sterile fashion. A Foley catheter is placed.

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  • Transverse suprapubic incision is made. Anterior rectus fascia is incised.

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  • The bladder and the bladder neck are identified. The bladder neck is identified by palpation of the Foley balloon. Placement of a hand in the vagina will facilitate identification of the bladder neck.

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  • The prevesical fat is dissected off the bladder and the bladder neck. Two or three non-absorbable suspension sutures, such as No. 1 Prolene, are placed lateral to the bladder neck. The ends of the suspension sutures are affixed to the Cooper's ligament and then tied securely.

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  • The bladder neck is suspended by the sutures anchored to the Cooper's ligament. The suspension sutures prevent the bladder neck's descent during periods of physical activity, but they do not "pull up" the bladder neck high behind the pubic symphysis.

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  • Overzealous pulling up of the bladder neck will cause iatrogenic urethral obstruction. There should be enough space behind the suspension suture and the Cooper's ligament to readily admit 2 fingers.

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  • This new position allows even disposition of external pressures on all surfaces of the bladder and the proximal urethra.

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• Transvaginal urethropexy

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  • Administer broad-spectrum intravenous antibiotics. The patient is placed in the lithotomy position. The vagina, perineum, and suprapubic area are prepared and sterilely draped. A Foley catheter and self-retaining vaginal retractor is placed.

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  • The bladder neck is identified. An inverted "U" incision is made over the vaginal mucosa at the level of the bladder neck.

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  • The anterior vaginal wall is dissected off the periurethral and pubocervical fascia toward the inferior ramus of the pubic bone. The urethropelvic ligament is punctured through with Metzenbaum scissors, creating a small space to facilitate the passage of suspension sutures.

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  • Three helical bites of the urethropelvic ligament, the pubocervical fascia, and the vaginal wall excluding the epithelium are obtained using No. 1 Prolene suspension suture.

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  • The suspending sutures are transferred to the suprapubic incision using a double-prong ligature carrier under digital guidance. The suspension sutures are tied ipsilaterally and over the abdominal wall loosely. The suspension sutures support the bladder neck in proper position and prevent its descent during periods of physical activity. The vaginal and suprapubic incisions are closed.

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  • One ampule of indigo carmine is given intravenously. Cystoscopy is performed to exclude any suture intrusion into the urinary bladder or the urethra. Clear efflux of blue urine from both ureteral orifices indicates ureters have not been injured.

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  • Povidone-iodine soaked vaginal packing is placed. A urethral catheter is inserted. Some surgeons may also place a percutaneous suprapubic tube as well as a urethral catheter.

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• Anterior repair and Kelly plication

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  • Broad-spectrum intravenous antibiotics are administered. The patient is placed in lithotomy position. Vaginal and perineal area are prepared and draped in sterile fashion. A Foley catheter is placed. Normal saline is injected into the vaginal mucosa to facilitate hydrodissection. An inverted "U" or midline vaginal incision is made.

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  • Anterior vaginal wall is dissected off the pubocervical fascia. Pubocervical fascia is plicated at the midline with absorbable sutures in an interrupted fashion.

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  • For Kelly plication, the periurethral fascia is plicated to increase the intraurethral pressures. Redundant anterior vaginal wall is trimmed. Anterior vaginal wall is closed.

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• Rectus fascia pubovaginal sling

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  • All patients are given intravenous antibiotics preoperatively. The patient is placed in the lithotomy position. A combined abdominal-vaginal approach is used for the operation. A full 5-minute, povidone-iodine vaginal and abdominal surgical scrub is performed. The vagina, perineum, and abdomen are prepared and sterilely draped.

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  • A transverse incision is made over the suprapubic area. The incision is carried down to the rectus fascia. Scarpa fascia overlying the rectus fascia is dissected off. A 2 x 13 cm rectus fascia is harvested. The rectus fascia is stored in antibiotic saline solution until ready for use.

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  • The abdominal fascia is closed using non-absorbable sutures. An antibiotic soaked gauze is placed into the abdominal incision.

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  • A self-retaining vaginal retractor and a 16 Fr. Foley catheter is placed. The bladder neck is identified by visual inspection of the anterior vaginal wall and digital palpation of the Foley catheter.

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  • A single vertical midline incision or inverted "U" incision is made at the level of the bladder neck. The anterior vaginal wall is dissected off the pubocervical fascia. The urethropelvic ligament is punctured through to create a small opening to allow passage of suspension sutures.

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  • The rectus pubovaginal sling is constructed at the back table with No. 1 Prolene suspension sutures. The pubovaginal sling is brought to the operating table. The sling is centered at the bladder neck and affixed at 6 points with 4.0 Vicryl sutures. The suspension sutures are transferred suprapubically.

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  • The vaginal wound is irrigated with bacitracin solution. The vaginal incision is closed with 2.0 Vicryl suture in a continuous locking fashion.

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  • The suspension sutures are tied ipsilaterally and then across the midline loosely. At the author's institution, the weight-adjusted spacing nomogram is used to tie the suspension sutures.

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  • The subcutaneous tissues are approximated and the skin is closed with running subcuticular suture. For obese patients who are at risk for seroma formation, we place a small closed suction drain in the suprapubic area prior to skin closure.

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  • One ampule of indigo carmine is given intravenously. Cystoscopy is performed to exclude any suture intrusion into the urinary bladder or the urethra. Clear efflux of blue urine from both ureteral orifices indicates ureters have not been injured.

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  • Povidone-iodine soaked vaginal packing is inserted. Foley catheter and/or suprapubic tube is placed.

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• Fascia lata pubovaginal sling

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  • All patients are given intravenous antibiotics preoperatively. A combined thigh-abdominal-vaginal approach is used for the operation. The patient is placed in supine position with the inner leg stretched out and the outer leg in a slightly bent position. All pressure points are adequately padded to prevent pressure necrosis.

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  • The outer thigh is prepared with povidone-iodine solution and sterilely draped. A skin incision is made on the outer thigh. A 2 x 13 cm fascia lata is harvested. A special fascial stripper may be used for the harvest.

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  • A small Penrose drain is placed and the thigh incision is closed. A compressive dressing is applied.

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  • The patient is re-positioned in a lithotomy position. A full 5-minute povidone-iodine vaginal and abdominal surgical scrub is performed. The vagina, perineum, and abdomen are prepared and sterilely draped.

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  • A transverse suprapubic incision is made. Incision is carried down to the rectus fascia. Scarpa's fascia is dissected off the rectus fascia. Antibiotic-soaked gauze is placed into the wound.

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  • A 16 Fr. Foley catheter and self-retaining vaginal retractor is placed. The bladder neck is identified. A vertical midline incision or an inverted "U" incision is made at the level of the bladder neck.

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  • The anterior vaginal wall is dissected off the pubocervical fascia. The urethropelvic ligament is punctured through to create a small opening to allow passage of suspension sutures.

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  • The fascia lata sling is constructed at the back table with No. 1 Prolene suspension sutures. The pubovaginal sling is brought to the operating table. The sling is centered at the bladder neck and affixed at 6 points with 4.0 Vicryl sutures. The suspension sutures are transferred suprapubically.

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  • The suspension sutures are tied ipsilaterally and then across the midline loosely. Alternatively, the ends of the sling may be sewn to the rectus fascia. At the author's institution, the weight-adjusted spacing nomogram is used to tie the suspension sutures.

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  • The subcutaneous tissues are approximated and the skin is closed with running subcuticular suture. For obese patients who are at risk of seroma formation, we place a small closed suction drain in the suprapubic area prior to skin closure.

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  • One ampule of indigo carmine is given intravenously. Cystoscopy is performed to exclude any suture intrusion into the urinary bladder or the urethra. Clear efflux of blue urine from both ureteral orifices indicates ureters have not been injured.

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  • The vaginal wound is irrigated with bacitracin solution. The vaginal incision is closed with 2.0 Vicryl suture in a continuous locking fashion. Povidone-iodine soaked vaginal packing is inserted. Foley catheter and/or suprapubic tube is placed.

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• Tension-free vaginal tape

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  • Recently introduced, the tension-free vaginal tape (TVT) is a polypropylene meshed tape that is placed at the mid-urethra. The TVT device consists of a polypropylene mesh tape (1.1 X 40 cm) covered by a plastic sheath and held by 2 stainless steel needles on both ends.

    Broad-spectrum intravenous antibiotics are administered. Perform the operation through the vagina with 2 small lower abdominal incisions above the pubic bone. The procedure may be performed with either local or general anesthetic.

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  • Place the patient in the dorsal lithotomy position. Prepare and drape the vagina, perineum, and suprapubic area using sterile technique. Place an 18-Fr. Foley catheter in the bladder.

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  • Apply local anesthetic to the skin just above the pubic tubercle on both sides of the midline. Continue the application of the anesthetic on each side through the rectus fascia, the rectus abdominis muscles, and into the space of Retzius.

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  • Apply local anesthetic to the anterior vaginal wall. Make a small vertical incision on the anterior vaginal wall at the midurethra. Tease the vaginal wall tissue off the urethra to expose the midurethra and dissect paraurethrally toward the endopelvic fascia.

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  • Insert the rigid catheter guide (included with the device) into the Foley catheter. Have an assistant pivot the handle of the guide to the surgeon's left side to expose the patient's left endopelvic fascia. Puncture the patient's left endopelvic fascia with the TVT needle, and advance the needle through the space of Retzius and to the anterior abdominal wall. The needle must hug the posterior wall of pubic symphysis during this maneuver. Tent up the abdominal skin with the needle. Incise the skin over the needle, and allow the needle to emerge.

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  • Fill the bladder with 250 mL saline. Perform cystoscopy with the needle in situ to rule out bladder and urethral injury. Empty the bladder. Advance the needle and the tape above the abdominal wall. Leave the needle on the abdomen.

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  • Repeat the same procedure on the contralateral side. Make sure the tape does not twist during the insertion. Cut the tape at both abdominal ends and remove the needles; however, leave the plastic sheath in place. The manufacturer recommends performing the tension test by filling the bladder with 250 mL of saline and having the patient cough. The tape should be pulled upward on both sides until only a few drops leak out when the patient coughs.

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  • Note that the success of this operation is predicated upon performing a proper tension test. Although this device is marketed as tension-free, the surgeon must make sure that it is tension-free by performing a proper tension test.

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  • Remove the plastic sheath from the tape, and close the vaginal and abdominal incisions.

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    • In situ vaginal wall sling

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    • All patients are given intravenous antibiotics preoperatively. The patient is placed in the lithotomy position. A combined abdominal-vaginal approach is used for the operation. A full 5-minute povidone-iodine vaginal and abdominal surgical scrub is performed. The vagina, perineum, and abdomen are prepared and sterilely draped.

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    • A Foley catheter and a self-retaining vaginal retractor are placed. The bladder neck is identified. An "A" shaped incision is made over the anterior vaginal wall. A rectangular island of vaginal tissue is dissected out. The size of the island is tailored to the length and width of the urethra. The urethropelvic ligament is punctured through with Metzenbaum scissors.

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    • The 4 corners of the rectangular island of vaginal wall are secured with individual sutures of No. 1 Prolene. A 6-cm suprapubic incision is made above the pubic symphysis. The suspension sutures are passed from the vaginal to the suprapubic incision using a double-pronged ligature carrier.

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    • The proximal vaginal wall flap is advanced over the in-situ vaginal sling and closed with absorbable sutures. The suspending sutures are tied ipsilaterally and across the midline loosely. The suprapubic incision is closed.

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  • Periurethral injection therapy

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    • The patient is placed in a lithotomy position. Vaginal and periurethral areas are sterilely prepared and draped. A 2% lidocaine jelly is injected into the urethra for local analgesia.

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    • A short-beaked female cystoscope with either 30 degree or zero degree lens is inserted into the urethra. The stopcock for the irrigant is turned on halfway. The incompetent bladder neck is identified. The cystoscope is withdrawn to the midurethra.

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    • The injectable needle is advanced into the submucosal plane approximately 2 cm from the bladder neck. Care is taken not to advance the needle too proximally as it may exit the urethra and enter the bladder.

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    • A 3 cc syringe containing collagen is affixed to the working port of the injectable needle. Collagen is slowly injected until complete mucosal coaptation is seen.

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    • Depending on the adequacy of bladder neck closure, collagen may be injected at 12, 3, 6, and 9 o'clock positions. The amount of collagen required to achieve complete bladder neck coaptation may vary from 1-5 syringes.

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  • Artificial urinary sphincter

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    • All patients are given intravenous antibiotics preoperatively. The patient is placed in a lithotomy position. The abdomen and genitalia are prepared with povidone-iodine solution and sterilely draped. A Foley catheter is placed. A transverse lower abdominal incision is made. The space of Retzius is entered and the bladder neck is dissected circumferentially from the surrounding tissues and vagina.

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    • An appropriate size cuff is placed circumferentially around the bladder neck. Following placement of the cuff, the pressure-regulating balloon is implanted into the preperitoneal space and the control pump is placed through the inguinal ring into the labia majora.

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    • Temporary connections are made and the sphincter is cycled. The pressure-reservoir is filled with final volume of 20 cc of filling solution. Excess tubing is trimmed. Final connections are made in the subcutaneous space of the abdomen. The sphincter is cycled again and the cuff is left in a locked open position.

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    • Some authors advocate placing a small Jackson-Pratt drain percutaneously. This is optional in our view. One must weigh the potential benefit of preventing wound seroma in obese patients vs the potential risk of introducing drain infection. We do not employ drains at our institution. Abdominal wound is closed in layers. A Foley catheter is left indwelling.

Postoperative details:

• Retropubic urethropexy

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  • Intravenous antibiotics are given for 48 hours, followed by an oral cephalosporin. On the morning after surgery, the urethral catheter and intravenous lines are discontinued.

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  • Patients are discharged on the second or third day after surgery. They may perform normal physical activities after 4-6 weeks.

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• Transvaginal urethropexy

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  • Intravenous antibiotics are given for 24 hours, followed by an oral cephalosporin. The Foley catheter, vaginal packing, and intravenous lines are discontinued on the morning after surgery.

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  • Patients are discharged on the first or second day after surgery. They may perform light physical activities immediately. Sexual intercourse is avoided for 6-8 weeks.

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  • If suprapubic tube has been placed, it is capped and the patient starts to check the residual urine every 4 hours or as required. The suprapubic catheter is removed as soon as the residual urine is less than 60 ml.

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• Pubovaginal sling

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  • Intravenous antibiotics are given for 24 hours, followed by oral antibiotics for several days. The Foley catheter and the vaginal packing are removed on the morning following operation.

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  • The suprapubic catheter is plugged and the patient unplugs it every 4 hours to measure postvoid residuals. When the postvoid residuals become minimal, the suprapubic tube is removed. If the patient still experiences retention after 3 weeks, the suprapubic tube is removed and the patient is taught self-intermittent catheterization.

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• Periurethral bulking injections: Oral antibiotics are given for several days. If stress urinary incontinence recurs or persists, repeat injection or pubovaginal sling may be necessary.

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• Artificial urinary sphincter: Intravenous antibiotics are given for 24 hours and oral cephalosporins are continued for several days. The sphincter is left deactivated for 6 weeks. The device is activated, and the patient is instructed on its use after 6 weeks of healing.

COMPLICATIONS

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Serious complications from operations that correct stress incontinence occur very infrequently. Complications common to bladder neck suspensions and pubovaginal slings include the following: urinary retention, de novo or worsening obstructive voiding symptoms, urinary tract infection, suture abscess, wound infection, retropubic bleeding, vaginal granuloma, vesicocutaneous fistula, de novo pelvic prolapse, bladder perforation, prolonged suprapubic pain, and ilioinguinal nerve entrapment.

The current incidence of urethral obstruction ranges from 5-10% for anti-incontinence operations. Urinary retention is temporary in most cases, but it may last a month or more. While the condition lasts, clean intermittent catheterization should be performed. Less serious complications, such as wound infection, occur more frequently but are easily treated with antibiotics. The likelihood of needing a blood transfusion is less than 5% for all procedures.

• Retropubic bladder neck suspension

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• Abdominal wound infection, urinary retention, de novo urge incontinence, and dyspareunia occur in the 3-15% range.
• Up to 12% of patients experience postoperative enterocele and rectocele occurrence after Burch urethropexy.
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• Transvaginal bladder neck suspension

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• Complications include urinary retention and de novo obstructive symptoms. Retropubic bleeding may result in pelvic hematoma. De novo urge incontinence and de novo pelvic prolapse may also occur. If bladder perforation occurs, it is repaired transvaginally.
• Excessive tension of the suspending sutures or entrapment of subcutaneous tissue over the rectus fascia may lead to prolonged suprapubic pain. Lateral placement of suspension sutures may cause ilioinguinal nerve entrapment.

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• Percutaneous vesica urethropexy: Osteomyelitis and osteitis pubis are two well-known complications of percutaneous bladder neck suspension using bone anchors. Patients with infected pubic symphysis experience suprapubic pain and difficulty with ambulation. They often walk with a waddling gait.

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• Anterior vaginal repair and Kelly plication: Complications include urethral obstruction and urethral infection.
• Rectus fascia pubovaginal sling

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• Complications of sling surgery are similar to those of transvaginal bladder neck suspensions; however, the risk of urethral obstruction is higher. Chronic urinary retention, requiring self-intermittent catheterization for a lifetime, is uncommon but may occur following surgery.

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• The incidence of urethral obstruction after sling surgery is 2-10% and the incidence of obstructive voiding symptoms range 5-25% in the literature. De novo detrusor instability requiring anticholinergic therapy is found in 15-20% of the cases.
• Potential intraoperative complications include injury to the urethra, bladder, or ureters during the dissection and during transfer of the suspension sutures.

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• Fascia lata pubovaginal sling

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• As with any sling surgery, patients with fascia lata sling surgery may have difficulty with volitional voiding postoperatively. In some, detrusor instability may result in urge incontinence.

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• Potential complications of sling surgery may include erosion of the urethra, prolonged or permanent urinary retention, injury to the bladder or ureters, and detrusor instability. Leg pain is a complication unique to fascia lata sling operation.

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• Synthetic pubovaginal sling: Synthetic slings may be constructed from Gore-tex, antibacterial Gore-tex mesh, Prolene mesh, or Silastic. Complications unique to synthetic slings include urethral erosion, nonhealing of the vaginal wall, abscess, and vesicovaginal fistula. Antibacterial properties, mesh-type architecture, and short patch grafts will decrease infectious and erosive complications.

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• While TVT is a synthetic sling, it is placed over the mid-urethra, rather than the bladder neck. In addition, it is not fixed or tied anywhere along its length. The mechanism of action of TVT is to create a "kink" in the urethra when the patient performs a Vasalva maneuver. During a Valsalva maneuver, TVT prevents the posterior wall of the urethra from moving distally and opening up the bladder neck as the bladder neck descends. In other words, the TVT remains fixed and then compresses the posterior wall of the urethra to prevent a leak. When the patient relaxes, there is little or no compression of the urethra. However, if the patient strains to void, she will find it difficult or impossible to void at all, since this mimics a Valsalva maneuver.

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• Based on this "kinking" mechanism, the ideal patient for TVT is an incontinent woman with urethral hypermobility. Despite it's name, Tension-free Vaginal Tape is not tension-free unless the surgeon makes it as such intraoperatively as previously described.

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• Vaginal wall sling: Potential complications include retropubic bleeding, bladder perforation, and ureteral obstruction. The reported incidence of urinary retention is less than 5% with this procedure. Vaginal shortening has not been reported to be a problem to date. However, cyst formation with burying the island of vaginal epithelium is a potential complication.
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• Periurethral collagen injection

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• Urinary tract infection and irritative voiding symptoms are the most common side effects after periurethral collagen injection. Symptoms of urinary frequency and urgency are self-limited.

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• Permanent urinary retention has not been reported. Urinary retention responds well with temporary catheterization. Acute urinary retention after collagen should not be treated by indwelling Foley catheter, or it can "mold" the collagen and defeat the success of the operation.

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• Rather, intermittent catheterization is preferred. If an indwelling catheter is required in unusual situations, a suprapubic catheter can be placed percutaneously to protect the collagen implant.

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• Artificial urinary sphincter

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• Complications of artificial urinary sphincter include urethral injury during surgery, tissue atrophy, and delayed urethral erosion.

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• Mechanical problems include fluid leak from the system, tubing kink, and obstruction from particulate matters.

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• Infectious complications include suprapubic or perineal cellulitis and periprosthetic abscesses. Infection may lead to erosion and necessitate repeat surgery to remove a portion or even all of the device.

FUTURE AND CONTROVERSIES

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The management of long-term urinary retention after a sling surgery remains controversial. Postoperative urinary retention may be treated with indwelling catheter, intermittent catheterization, cutting of suspension sutures, incision of the sling itself, or complete urethrolysis with or without repeat sling procedure.

Acute urinary retention is initially treated with indwelling urethral catheter or self-intermittent catheterization. If a suprapubic tube had been placed intraoperatively, SPT is left indwelling. In majority of cases, patients are able to void spontaneously within three weeks and catheterizations are discontinued.

If urinary retention persists at three weeks, pressure-flow study must be performed to document a well-functioning detrusor and rule out urethral obstruction. If the patient has atonic detrusor, she needs long-term catheterization, intermittent or otherwise.

If the patient has a normal detrusor function, an alternative to intermittent catheterization is to takedown one or both suspension sutures. This procedure is performed by going through the original suprapubic incision and cutting ipsilateral suspension sutures. This may be done under local or general anesthesia. If the patient still remains obstructed after cutting the suspension sutures, one should perform urethrolysis.

Timing of urethrolysis is controversial. If urinary retention occurs after a rectus fascial sling, urethrolysis is recommended after three months of urethral obstruction. If urethral obstruction results after a synthetic sling, urethrolysis should be performed earlier than three months.

Regardless of the sling material used, this author recommends early intervention (usually at three weeks) rather than delayed since the patient's quality of life is impaired during the duration of retention.

Formal urethrolysis of autologous sling involves complete dissection circumferentially around the bladder neck and proximal urethra. Conversely, urethrolysis of a synthetic sling may require only an incision of one or both arms of the sling rather than complete dissection of an autologous sling.

After urethrolysis of rectus fascial sling, one may choose to place another autologous sling to prevent recurrent stress incontinence. If urethral injury is encountered, the urethral injury is repaired primarily and either Martius fat pad (fat pad from labia majora), omentum, or posterior peritoneum may be used to reinforce the closure. Whether to proceed with another sling at the time of urethrolysis should be tailored to each individual patient. At our institution, we have not resorted to placing a second sling as all our patients have remained continent after formal urethrolysis.

Despite these potential complications, it is important to realize that pubovaginal sling is an excellent operation for all types of female stress urinary incontinence. Many types of sling operations abound. Sling surgeries may involve autologous tissue, synthetic biomaterials, and cadaver allografts. A particular type of operation chosen depends on the patient’s preference and the surgeon’s expertise. When performed properly, the long-term cure rate of sling surgery should approach 90% with minimal complications.

The future of anti-continence surgical therapy is bright and promising. With advances in biomechanical engineering coupled with clinical and basic science research, our understanding of the incontinence disease process and the development of new surgical options are increasing rapidly. With current evolution of stem cell research and genetic engineering, more minimally invasive and technologically advanced surgical procedures will be forthcoming in the near future.