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Chapter 16 Abdominal,Vaginal or Laparoscopic Approach
made up by a shorter operating time (1 min costs roughly 5–25 euros depending on the
specific calculation of the clinic). Moreover, TVT requires shorter hospitalization periods and rarely a change to laparotomy.
Another fact, which was not considered in the comparative studies, is the alteration
of the pelvic floor by colposuspension.It leads to weakening of the posterior compartment resulting in complaints and further operations.
Because of all the above-mentioned results, we favor TVT as standard therapy for
urinary stress incontinence and have abandoned colposuspension. We use colposuspension only in connection with other abdominal surgeries. Laparoscopic colposuspension has become a procedure for exceptional circumstances. Even in cases of extensive laparoscopic hysterectomies in combination with sacrospinal fixation,we prefer the TVT procedure over laparoscopic Burch.
TVT is currently the standard surgical treatment for urinary stress incontinence.
According to recent studies and our own experience (Reisenauer et al. 2004), the transobturator approach seems to result in fewer complications than the conventional TVT
method. The TVT variant, TVT-O (Gynecare), is therefore our therapy of choice at
present (Fig.16.8).
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16
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16
Chapter 17
Chapter 17 Diagnostic and Surgical Management of Stress
Diagnostic and Surgical Management
of Stress Urinary Incontinence
Karl-Dietrich Sievert, Arnulf Stenzl
251
17
Contents
17.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . 252
17.2 Types of Urinary Incontinence . . . . . . . . . . . . . 252
17.3 Female Stress Urinary Incontinence . . . . . . . . . . . 252
17.4 Male Urinary Stress Incontinence . . . . . . . . . . . . 252
17.5 Evaluation of Urinary Incontinence . . . . . . . . . . . 252
17.6 Possible Approaches . . . . . . . . . . . . . . . . . . . 253
17.7 Patient History: Analysis and Examination . . . . . . . 254
17.8 Data Gathering Prior to the Office Examination . . . . 254
17.9 Office Examination . . . . . . . . . . . . . . . . . . . . 254
17.10 Urethral Bulking Agents (Injectables) . . . . . . . . . . 255
17.10.1 Historic Bulking Agents . . . . . . . . . . . . . . . . . 255
17.11 Successfully Introduced Bulking with the CE Mark . . 255
17.12 FDA-approved Bulking Agents . . . . . . . . . . . . . . 257
17.13 Tissue-engineered Stem Cells for Bulking:
Dream or Reality? . . . . . . . . . . . . . . . . . . . . . 258
17.13.1 Mid-Urethral Synthetic Slings . . . . . . . . . . . . . . 258
17.13.1.1 Transvaginal Needle Procedures . . . . . . . . . . . . . 258
17.13.1.2 Vaginal Slings . . . . . . . . . . . . . . . . . . . . . . . 258
17.14 Tension-Free Vaginal Tapes . . . . . . . . . . . . . . . 259
17.15 Comparison of Two Major Tapes . . . . . . . . . . . . 261
17.16 New Materials: The Resorbable Sling . . . . . . . . . . 261
17.17 Transobturatoric Tension-Free Tapes . . . . . . . . . . 262
17.18 Retropubic Suspensions . . . . . . . . . . . . . . . . . 262
17.19 Artificial Urethral Sphincter . . . . . . . . . . . . . . . 263
17.20 What to Do When All the Efforts Did Not Result
in a Continent Patient? . . . . . . . . . . . . . . . . . . 263
17.21 After a Tension-Free Sling Did Not Bring
the Desired Success . . . . . . . . . . . . . . . . . . . . 264
17.22 The Sling with Tension . . . . . . . . . . . . . . . . . . 264
17.23 Urinary Stress Incontinence in Men . . . . . . . . . . . 264
17.24 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . 266
References . . . . . . . . . . . . . . . . . . . . . . . . . 267
252
Karl-Dietrich Sievert, Arnulf Stenzl
17.1 Introduction
The awareness of urinary incontinence has increased during the last decade. Urinary
incontinence is no longer taboo.Industry has picked up the incontinence problem and
many public advertisements suggest using diapers to treat incontinence.However, the
attending urologist and gynecologist are asked to supply a more efficient and effective
medical treatment for urinary stress incontinence.
17.2 Types of Urinary Incontinence
There are many types of incontinence.Urinary stress incontinence (49%) accounts for
the highest percentage of incontinent patients, while other forms of incontinence such
as urge incontinence account for 22% of the patients. Mixed urinary incontinence accounts for 29% (Hampel et al. 2004).
17.3 Female Stress Urinary Incontinence
The cause and mechanism of female stress urinary incontinence is still relatively unknown. Currently, the integral theory of Petros and Ulmsten (1993) seems to be the
most accepted theory of the female urinary continence mechanism, although the previous investigations by Hofner and Dorschner (1989) describe the phenomenon even
more accurately. Even in the more advanced histological work done by Carlile et al.
(1988), as well as the functional and anatomical work of Colleselli et al. (1998) and
Stenzl et al. (2000),the mechanism of female urinary continence is still not completely understood.
17
17.4 Male Urinary Stress Incontinence
Male urinary stress incontinence is better understood and occurs primarily after a
transurethral prostate resection or radical prostatectomy. The more repayable continence mechanism of the male seems to depend on the longer functioning urethra.
17.5 Evaluation of Urinary Incontinence
The treatment of incontinence must be initiated with an analysis of the patient’s medical history and a full 3-day and night micturition diary. This initial analysis can provide critical information in the treatment approach of incontinence.The analysis must
include a test of the actual vesical pressure,urethral closing pressure and urethral mobility in order to choose the best surgical technique. In addition,before incontinence
can be successfully treated, a urodynamic evaluation, a urethrocystoscopy and a pad
test must first be performed to determine the type of incontinence. Any other co-factors such as prolapse,stool incontinence, etc. need to be considered in the diagnosis.
Depending upon the degree and type of urinary stress incontinence, there are a
number of different approaches. Urgency incontinence should be treated first with
noninvasive treatments such as drugs (anticholinergics) before a surgical approach is
Chapter 17 Diagnostic and Surgical Management of Stress Urinary Incontinence
even considered.With further co-morbidities (e.g., vesical of rectal prolapse), the gynecologist or urologist needs to decide whether a modification or combination of other techniques is required. Other types of urinary incontinence or pelvic pathologies
need to be reviewed and the treatment strategy must discussed with the patient.
17.6 Possible Approaches
Using a step-ladder approach (Fig. 17.1), weight reduction is often necessary as a first
step.In addition to weight reduction, pelvic floor exercises, supported by biofeedback
and/or electrostimulation is recommended (see Chap.13.
The following varied techniques have been evaluated starting from minimally invasive to those that are invasive.It is important to keep in mind that each patient’s case
needs to be evaluated and treated individually.The recommended surgical treatment
depends upon the patient’s requests, their symptoms, the evaluation results and the
surgeon’s experience.
Before a surgical approach is attempted,a medical drug treatment is one possibility
for those with minor symptoms of stress urinary incontinence. Recently, the drug Yentreve twice 40 mg (Millard et al. 2004) has been released.This drug can be tried initially if the female patient does not want a surgical approach (e.g., urethral bulking
agents, surgery and artificial sphincter). It should not be underestimated that almost
one-third of the patients treated with this drug have experienced nausea (27.9%); how-
253
Fig. 17.1. The approach to treat SUI depends on the type of SUI, age,co-morbidities, the conservative approach required, surgical possibilities and patient’s wish
Ileum pouch or ileum conduit
Continent vesicostomy
Artificial sphincter
Bulking agent, micro-balloons, readjustable sling
Previous step combined with another technique to solve the additional problem (anterior and/or
posterior prolapse,etc.)
Open or laparoscopic approaches (Burch,MMK)
Mid urethral slings (e.g., TVT, TOT)
Minimally invasive surgery (e.g., bulking agents depending on the co-morbidities, age and
patient’s wishes)
Pelvic floor muscle training
With or without medical supplement
With or without biofeedback
With or without electrostimulation
Weight reduction and local hormone replacement
254
Karl-Dietrich Sievert, Arnulf Stenzl
ever, only 5.3% of them reported severe nausea and therefore stopped the treatment
(van Kerrebroeck et al.2004a).
17.7 Patient History: Analysis and Examination
An analysis of patient’s history and voiding habits are essential. It demonstrates the
impact of continence and their life quality. Included in the analysis should be questions about the prior medical history of urinary infections and certain illnesses such
as diabetes mellitus, Parkinson’s disease, multiple sclerosis,and previous surgeries of
the pelvis or pelvic floor.Neurogenic bladder dysfunctions or spinal cord or peripheral nerve changes (e.g., disc prolapse, nerve damage after disc surgery, hysterectomy,
etc.) should be evaluated. They might be the reason for postoperative,or if not corrected, long-term retention.
17.8 Data Gathering Prior to the Office Examination
One of the best ways to analyze symptoms is the patient’s preparation of a micturition
and voiding diary over a minimum of 3 full days. This data helps the attending urologist or gynecologist characterize the problem. The diary should contain a significant
amount of detail such as actual drink time along with the volume, micturated volume,
incontinence (when and how),pad/cloth change,pain, and the whether the patient had
the feeling that the bladder was emptied completely. The patient should prepare this
diary prior to the first consultation with the doctor. This will help to evaluate the relevance of any urine incontinence and help to determine the impact on the patient’s life.
17
17.9 Office Examination
One of the best ways to evaluate bladder function is video urodynamic evaluation and
a transvaginal ultrasound with an improved scanning head. Most likely in the future,
3D or even 4D ultrasound imaging will be used. The 3D imaging seems to ensure the
same accuracy and is less invasive, less expansive and less time consuming than dynamic MRT.
If during the examination any sign of urgency incontinence is revealed,those problems need to be treated first. Urgency or urgency incontinence can worsen or appear,
which is called de novo urgency if any of the surgical techniques described in the sections below are used. Even in a urodynamic evaluation, bladder overactivity cannot
necessarily be seen and therefore it cannot be proven that there is no overactivity. A
cystogram should be performed if it is not possible to do a video urodynamic evaluation. A urethrocystoscopy will exclude any pathology such as bladder tumors or urethral strictures. With the stress (Valsalva) test, the leaking can be revealed and prolapse (anterior or posterior) usually appears.After the voiding (urine-flowmetry), the
urine residual volume should be determined in order to obtain better knowledge of
the bladder function, as any of the surgeries described in the following sections causes an increase in outflow resistance.All these examinations will not only help to predict other kinds of malfunctioning or pathologies, but it is the only objective way to
follow up on the outcome of any treatment. Urinary incontinence and prolapse need to
be repaired, and if possible,using the same surgical approach.
Chapter 17 Diagnostic and Surgical Management of Stress Urinary Incontinence
17.10 Urethral Bulking Agents (Injectables)
17.10.1 Historic Bulking Agents
Because of insufficient external urethral sphincter, bulking agents can be used to raise
the mucosa in this location.The submucosal application decreases the diameter of the
urethra.The ideal bulking agents should be easily injectable, stay permanently in place
and conserve volume over time. They should be hypoallergenic, biocompatible, non-
agent treatment and increased the pressure transmission ratio in the proximal quarter
of the urethra. In their opinion,the bulking agents administered in the proximal quarter of the urethra prevents the bladder neck from opening under stress (Monga et al.
1995). However, Khullar argued that placing the bulking agent just below the bladder
neck improves the intrinsic sphincter deficiency and creates an outlet obstruction
(DSD) (Khullar et al. 1997) (Fig. 17.2).
McGuire et al.defined the indication by a low leak pressure point correlated with a
poorly functioning bladder neck and proximal urethra (ISD). The higher leak point
pressures correlated to types 1 or 2 hypermobility of the urethra (McGuire et al. 1993).
One of the first bulking agents used was Polytetrafluoroethylene (Teflon). The primary result was cure rates of 55%–61% or an improvement of up to 71% after 17–30 months. However, in the long-term follow-up, the success rate dropped to below 30%
(Herschorn and Glazer 2000; Lopez et al. 1993).Further reports found that the Teflon
particles had migrated because of phagocytosis. They were even found as a foreign
material in organs such as the lung. In addition to this side effect, Teflon was difficult
to use and required very high pressure points to inject.
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17.11 Successfully Introduced Bulking with the CE Mark
Several bulking agents are already successfully used in Europe such as silicone (Macroplastique), hyaluronic acid and dextranomer (Deflux/Zuidex) (Table 17.1). Silicone
needs to be injected with high pressure as a mixture with a water-based carrier.In follow-up,success rates decreased down to 30% over 3 years (Herschorn 2001). Currently, long-term follow-up data does not exist.Hyaluronic acid was originally used for the
vesicoureteral reflux and seems to have no immunological potential.With a special applicator (Zuidex), the material is simultaneously injected in four locations under the
urethral submucosa and provides bulking (van Kerrebroeck et al. 2004b; Stenberg et
al. 2003) (Fig. 17.3). In addition, Deflux was also introduced as a treatment in male
Table 17.1. The most common bulking agents (material, trade name and the producing/selling
company)
Material Trade name Company
Silicon Macroplastique Innovamed
Collagen Contigen BARD
Hyaluronic acid Deflux,Zuidex Q-med
CaHA Coaptite BioForm
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Karl-Dietrich Sievert, Arnulf Stenzl
17
Fig. 17.2a, b. The way to perform the injection using the transurethral (a) and paraurethral (b)
approach is to place a bulking agent.Picture 1: Application of Deflux
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