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Chapter 15 Innovative and Minimally Invasive Treatment
The points where the needles will exit at the skin level are identified by tracing a
horizontal line at the level of the urethral meatus. The exit points are located 2 cm
above this line and 2 cm outside the thigh folds. Then the anterior vaginal wall is incised at a length of 1 cm and at a distance of 1 cm proximally to the urethral meatus.After that, minimal paraurethral subvaginal dissections are then carried out laterally on
either side. This step is followed by introducing fine dissection scissors towards the
upper part of the ischiopubic ramus. Once the upper part of the ischiopubic ramus is
reached, the obturator membrane is perforated with the tip of the scissors. An introducer is pushed to the preformed dissection canal until it reaches and perforates the
obturator membrane.The open side of the introducer’s gutter must be facing the operator. The distal end of a tube is mounted onto the spiral segment of a needle and the
assembled device is gently slipped along the gutter of the introducer so as to pass
through the obturator foramen. After the tube has appeared at the previously incised
skin exit point, the tube is pulled from the supporting passer and the latter is retracted until the first centimeters of the tape become externalized. The same technique is
applied at the other side.After the ends of the tape have been cut, the tape is aligned
under the junction between the mid and distal urethra and the tension of the tape is
adjusted by exerting a traction on its two ends and by interposing a pair of scissors
between the tape and the urethra so as to create space and avoid any tension of the
tape. The plastic sheaths are then removed simultaneously. The tape ends are cut in the
subcutaneus layer and the incisions are closed.
De Laval did not observe any intraoperative complications in a study with 107 patients. During a short follow-up time of 1 month, only few postoperative complications
were observed. Minor vaginal erosion was noted in one patient. Three patients (2.8%)
had complete urine retention; 15.9% of the patients complained about pain or discomfort in the thigh folds for less then 1 week.
227
15.4 Conclusion
Unfortunately,minimally invasive surgery does not correlate with minimal costs. It is
evident that shorter hospitalization reduces the costs but on the other hand instruments and materials for minimally invasive surgery are very expensive.
References
Arunkalaivanan AS, Barrington JW (2003) Randomized trial of porcine dermal sling (Pelvicol
TM implant) vs tension-free vaginal tape (TVT) in the surgical treatment of stress inconti-
nence: a questionnaire-based study. Int Urogynecol J Pelvic Floor Dysfunct 14 :17–23
Bidmead J, Cardozo L (2000) Sling techniques in the treatment of genuine stress incontinence.
Br J Obstet Gynaecol 107:147–156
Bodelsson G, Henriksson L, Osser S, Stjernquist M (2002) Short term complications of the ten-
sion free vaginal tape operation for stress urinary incontinence in women.Br J Obstet Gynae-
col 109: 566–569
Choe JM, Kothandapani R, James L,Bowling D (2001) Autologous, cadaveric and synthetic mate-
rials used in sling surgery: comparative biomechanical analysis.Urology 58: 482–486
15
228
Christl Reisenauer,Konstantinos Gardanis,Diethelm Wallwiener
Claerhout F, Deprest J,Zheng F, Konstantinovic M,Lagae P, DeRidder D (2003) Long term evalu-
ation of the tissue response and mechanical properties of two collagen based and polypropy-
lene implants in a rabbit model for abdominal wall repair. Neurourol Urodynam 22: 516–517
Daher N, Boulanger JC,Ulmsten U (2003) Pre-pubic TVT: an alternative to classic TVT in select-
ed patients with urinary stress incontinence. Eur J Obstet Gynecol Reprod Biol 107:205–207
De Laval J (2003) Novel surgical technique for the treatment of female stress urinary inconti-
nence: transobturator vaginal tape inside-out.Eur Urol 44 :724–730
Debodinance P, Delporte P, Engrand JB, Boulogne M (2002) Tension-free vaginal tape (TVT) in
the treatment of urinary stress incontinence: 3 years experience involving 256 operations.Eur
J Obstet Gynecol Reprod Biol 105: 49–58
DeLancey JOL (1994) Structural support of the urethra as it relates to stress urinary inconti-
nence: the hammock hypothesis.Am J Obstet Gynecol 170: 1713–1723
Delorme E (2001) La bandelette trans-obturatrice: un procédé mini-invasif pour traiter l`incon-
tinence urinaire d’effort de la femme. Prog Urol 11 :1306–1313
Fourie T, Cohen PL (2003) Delayed bowel erosion by tension-free vaginal tape (TVT). Int Urogy-
necol J Pelvic Floor Dysfunct 14: 362–364
Iglesia CB, Fenner DE, Brubaker L (1997) The use of mesh in gynecologic surgery. Int Urogyne-
col J Pelvic Floor Dysfunct 8: 105–115
Iglesias X, Espuna M (2003) Surgical treatment of urinary stress incontinence using a method for
postoperative adjustment of sling tension (Remeex System). Int Urogynecol J Pelvic Floor
Dysfunct 14 :326–330
Karram MM, Segal JL,Vassallo BJ, Kleeman SD (2003) Complications and untoward effects of the
tension-free vaginal tape procedure.Obstet Gynecol 101: 929–932
Kuuva N, Nilsson CG (2002) A nationwide analysis of complications associated with the tension-
free vaginal tape (TVT) procedure.Acta Obstet Gynecol Scand 81: 72–77
Liapis A,Bakas P, Creatsas G (2002) Burch colposuspension and tension-free vaginal tape in the
management of stress urinary incontinence in women. Eur Urol 41:469–473
Meschia M, Busacca M, Pifarotti P, De Marinis S (2002) Bowel perforation during insertion of
tension-free vaginal tape (TVT). Int Urogynecol J 13 : 263–265
Meschia M, Pifarotti P, Bernasconi F,Guercio E, Maffiolini M,Magatti F, Spreafico L (2001) Ten-
sion-free vaginal tape: analysis of outcomes and complications in 404 stress incontinent
women. Int Urogynecol J Pelvic Floor Dysfunct Suppl 2: 24–27
Moss E,Toozs-Hobson P, Cardozo L,Emens M, Pogmore JR, Constantine G (2002) A multicenter
review of the tension-free vaginal tape procedure in clinical practice. J Obstet Gynecol 22 :
519–522
Niknejad K, Plzak LS,Staskin DR, Loughlin KR (2002) Autologous and synthetic urethral slings
for female incontinence.Urol Clin North Am 29 : 597–611
Nilsson CG, Kuuva N, Falconer C, Rezapour M, Ulmsten U (2001) Long-term results of the ten-
sion-free vaginal tape (TVT) procedure for surgical treatment of female stress urinary incon-
tinence. Int Urogynecol J Pelvic Floor Dysfunct Suppl 2:5–8
Nilsson CGN, Rezapour M, Falconer C (2003) 7 years follow-up of the tension-free vaginal tape
(TVT) procedure.Abstract, IUGA Buenos Aires
Pelosi MA II,Pelosi MA III (2003) New transobturator sling reduces risk of injury.OBG Manage-
ment
Petros P, Ulmsten U (1993) An integral theory and its method for the diagnosis and management
of female urinary incontinence. Scand J Urol Nephrol 153: 1–93
Rechberger T, Rzezniczuk K, Skorupski P, Adamiak A, Tomaszewski J, Baranowski W, Jakowicki
JA (2003) A randomized comparison between monofilament and multifilament tapes for
stress incontinence surgery. Int Urogynecol J Pelvic Floor Dysfunct 14: 432–436
Rezapour M,Ulmsten U (2001) Tension-free vaginal tape (TVT) in women with recurrent stress
urinary incontinence – a long-term follow up.Int Urogynecol J Pelvic Floor Dysfunct Suppl
2: 9–11
Rezapour M,Falconer C,Ulmsten U (2001) Tension-free vaginal tape (TVT) in stress incontinent
women with intrinsic sphincter deficiency (ISD) – a long-term follow-up. Int Urogynecol J
Pelvic Floor Dysfunct Suppl 2:12–14
Shobeiri SA, Gasser RF, Chesson RR, Echols KT (2003) The anatomy of midurethral slings and
dynamics of neurovascular injury.Int Urogynecol J Pelvic Floor Dysfunct 14 :185–190
Chapter 15 Innovative and Minimally Invasive Treatment
Staskin DR, Plzak L (2002) Synthetic slings: pros and cons.Curr Urol Rep 3:414–417
Tash J, Staskin DR (2003) Artificial graft slings at the miduretrhra: physiology of continence.
Curr Urol Rep 4 : 367–370
Ulmsten U (2001) The basic understanding and clinical results of tension-free vaginal tape for
stress urinary incontinence. Urologe 40: 269–273
Vassallo BJ, Kleemann SD,SegalJ, Karram MM (2003) Urethral erosion of a tension-free vaginal
tape. Obstet Gynecol 101 :1055–1058
Ward K, Hilton P (2002) Prospective multicentre randomised trial of tension-free vaginal tape
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229
Chapter 16
Chapter 16 Abdominal,Vaginal or Laparoscopic Approach
Abdominal,Vaginal or Laparoscopic
Approach for Urinary Incontinence?
Wolfgang Zubke, Ines Gruber, Diethelm Wallwiener
231
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Contents
16.1 Kelly Plication . . . . . . . . . . . . . . . . . . . . . . . . . 232
16.2 Anterior Colporrhaphy With and Without Kelly Plication 233
16.3 Needle Suspension . . . . . . . . . . . . . . . . . . . . . . 237
16.4 Different Colposuspension Techniques . . . . . . . . . . . 238
16.5 Comparison Between Anterior Colporrhaphy
and Colposuspension . . . . . . . . . . . . . . . . . . . . . 239
16.6 Tension-Free Tape . . . . . . . . . . . . . . . . . . . . . . 241
16.7 Comparison of Colposuspension and TVT . . . . . . . . . 243
16.8 Endoscopic Colposuspension . . . . . . . . . . . . . . . . 244
16.9 Comparison of Endoscopic Burch and TVT . . . . . . . . 245
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 247
232
Wolfgang Zubke, Ines Gruber, Diethelm Wallwiener
Urinary incontinence is extremely widespread. In general more women suffer from
urinary incontinence than from diabetes, coronary disease or hypertension. Urinary
incontinence is not a disease of recent decades.Throughout human existence,women
have suffered from incontinence.There were different attempts to cure these patients
conservatively or by surgery.In the oldest medical document in history, the Ebers papyrus, urinary incontinence is already mentioned with the therapeutic approach of
vaginal pads. It is unclear whether they were used to raise the urethra or to apply certain medications. Nothing is known about the success of these early attempts.However,all we know is that even 3,500 years ago women suffered from urinary incontinence
and were treated with a standardized therapy that was a conservative and not surgical
one. Surgical approaches during this time are not yet described.
Which approach did surgeons of more recent times choose to cure urinary incontinence? In 1907 Giordano mobilized part of the musculus gracilis and wrapped it
around the urethra.At this time, no further development of this technique took place.
However nowadays,we again find similar surgical approaches to cure urinary incontinence.
In 1910 Goebell described the first surgical technique of retropubic suburethral
slings. He separated the two parts of the musculus pyramidalis, led them retropubically through the spatium retzii.Then he connected both tips underneath the urethra, in
the area of the vesicourethral angle,with the intent of tightening the suburethral tissue
and stabilizing the urethra. This approach was later modified by Stoeckel in 1917. The
pyramidalis muscle was no longer used because of its insufficient length and was replaced by parts of the aponeurosis, located ventral to the m.pyramidalis and m. rectus
abdominis. The Goebell-Stoeckel surgical technique uses an abdominal approach
combined with a small vaginal incision. There are no valid studies documenting the
success rate of this surgery or long-term results. Nevertheless this technique was fully
accepted for decades.However,there was an attempt to look for improvements. For example, one major disadvantage of this method was the dissolution of the tendinous
membrane after a certain time and therefore the loss of functional stabilization of the
urethra. The effort to improve this method by the concept of a retropubic suburethral
sling was one of the early versions of the TVT used today. No long-term results can be
found.
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16.1 Kelly Plication
In the USA, Kelly introduced a different surgical technique to elevate the urethra. He
attached the periurethral tissue at the vesicourethral angel underneath the symphysis
by Kelly plication (Kelly and Dumm 1914).In 1937 Kennedy modified this procedure by
padding the total length of the urethra. However, in the USA Kelly plication is still used
in connection with anterior colporrhaphy and therefore evaluated in most studies as
part of the procedure. Early published results were good, but a number of newer studies analyzed the combined Kelly plication/anterior colporrhaphy procedure and
showed much lower success rates (see below).
A study was undertaken by Gordon et al.in 1999 to evaluate the efficacy of Kelly plication in preventing postoperative urinary stress incontinence in clinically continent
patients undergoing surgery for genitourinary prolapse. Thirty patients with grade-3
genitourinary prolapse were found to have a positive stress test in a preoperative urodynamic setting. In addition to the genitourinary prolapse repair, these patients underwent Kelly plication. Fifty percent of the patients developed postoperative stress in-
Chapter 16 Abdominal,Vaginal or Laparoscopic Approach
Fig. 16.1.
Kelly plication
(from Benson 2000)
continence subjectively and objectively; 37% developed objective postoperative stress
incontinence with no subjective complaints. Therefore Kelly plication does not qualify as a prophylactic procedure in preventing postoperative urinary stress incontinence
in clinically continent patients who undergo surgery for genitourinary prolapse.
Eberhard et al. (2003) conclude that periurethral tightening of the tissue is now obsolete for the treatment of incontinence because of extensive tissue damage, which
lowers the neutral pressure of the urethra without increasing the pressure transmission over time (Fig. 16.1).
233
16.2 Anterior Colporrhaphy With and Without Kelly Plication
The theory that a cystocele might be the cause of urinary incontinence has been considered for a long time. This is why the anterior colporrhaphy has been favored as a
treatment for urinary incontinence.The idea was to reconstruct the original anatomy
and functionality of the pelvic floor.In fact, many retrospective studies showed good
postoperative results.
Vahlensiek and Schander (1985), anterior colporrhaphy plus Kelly plication, Beck et
al. (1991),anterior colporrhaphy plus Kelly plication,and Tamussino et al.(1999), anterior colporrhaphy without Kelly plication, report continence rates up to 75% after
5 years and longer.Park and Miller (1988), also obtained optimistic result with anterior colporrhaphies with Kelly plications.After 1, 5 and 10 years,80%, 70% and 66%,respectively, of the patients were cured.Tamussino differentiated his results according to
the severity of urinary incontinence. Continence rates after anterior colporrhaphy
were 82% among patients with mild stress incontinence but only 49% among those
with moderate or severe incontinence.
Bergman and Elia’s (1995) purpose was to evaluate the long-term results of anterior
colporrhaphy with Kelly plication. The objective success rate after 5 years was only
37%, while after 1 year it reached 63%.
The prospective study of Liapis et al. analyzed the success rate of anterior colporrhaphy with Kelly plication.It revealed a cure rate of 57% within a 3-year postsurgical
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234
Wolfgang Zubke, Ines Gruber, Diethelm Wallwiener
evaluation.Harris et al. (1995) also reported a similar cure rate of 46% within a 5-year
postsurgical evaluation.
Kammerer-Doak et al.(1999) analyzed objective and subjective success rates of anterior colporrhaphy without Kelly plication in a prospective study. The objective success rate after 1 year was 31%,while the subjective success rate was only 19%.This emphasizes the obvious difference between objectively measured and subjectively evaluated results. De Tayrac et al. (2002) had similar results with anterior colporrhaphy
without Kelly plication in terms of the difference between subjective and objective
success rates. The objective success rate after 36 months was 53.6%,while the subjective success rate was 57.1%.
In a prospective long term study over a mean follow-up time of 14 years, Colombo
et al. (2000) describe an objective success rate of 42% and a subjective success rate of
52% for anterior colporrhaphy without Kelly plication.
It is not clear whether success rates are attributable to the Kelly plication. There
have been similar success rates whether Kelly plication was used or not.It seems that
older studies show higher success rate than more recent ones.It also appears that success rates were higher when subjectively evaluated than objectively measured. It was
shown that the success rate for anterior colporrhaphy depends very much on the severity of preoperative urinary incontinence.It seems that anterior colporrhaphy has a
high success rate in short-term cure but the long-term results are nowhere near as
good. Taking the above-mentioned limitations into consideration,it is difficult to evaluate a general success rate of anterior colporrhaphy by meta-analysis. However, including the limitations a relative success rate of 62% can be concluded. This result correlates with the meta-analysis by Glazener and Cooper (2003). They report a success
rate of 68%.However, this number does not reflect the tendency that more recent studies show less optimistic results.Anterior colporrhaphy did not prove adequate as standard therapy because of its poor long-term results.
Eberhard et al. (2003) designate the diaphragmatic plastic surgery as obsolete for
treating urinary incontinence. Because of the stretching of the urethra, the transmission forces are being reduced.
Finally,a study by Weber et al. (2001) has to be mentioned. They compared different techniques of genitourinary prolapse repair. They observed to what extent anterior colporrhaphy might cause urinary stress incontinence. Preoperatively 18% (15/82)
of the patients had urinary incontinence, of which 73% (11) were cured after 2 years.
Five of the 66 previously continent patients developed de novo urinary stress incontinence. The anterior colporrhaphy obviously can cause urinary stress incontinence.
But anterior colporrhaphy rarely leads to complications. Beck et al. (1991) mention
only 1% of relevant complications. They rarely observed complete urinary retention,
and de novo urinary incontinence occurred in no more than 8% of patients.
In the above studies,anterior colporrhaphy was proceeded in order to correct cystoceles. The etiology of these defects was not mentioned.It can be presumed that most
of them were to the result of central defects.There are in fact other pelvic floor defects
leading to a cystocele such as the lateral defect. It is possible that some of theses studies would have shown other results if the etiology of the cystocele had been taken into
consideration during surgery. Figure 16.2 illustrates the surgical approach of a combined cystocele with a central and paravaginal defect as performed in our hospital.
Chapter 16 Abdominal,Vaginal or Laparoscopic Approach
235
Fig. 16.2a–d.
236
Wolfgang Zubke, Ines Gruber, Diethelm Wallwiener
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