Diagnosis and surgical treatment of stress urinary incontinence.

Clinical Expert Series

Diagnosis and Surgical Treatment of Stress Urinary Incontinence Alan D. Garely,

MD,

and Nabila Noor,

MD

Stress urinary incontinence (SUI) is a major problem affecting more than 20% of the nation’s female population, with increasing prevalence as our population continues to age. Incontinence places a great burden on individuals, and the economic effect is large. Stress urinary incontinence occurs when there is involuntary leakage of urine during coughing, laughing, sneezing, or physical activity. It can be diagnosed during physical examination and by using low-cost office diagnostics. Although nonsurgical treatments provide some benefit, surgical interventions have demonstrated superiority with respect to subjective and objective cure and better long-term improvement. Corrective surgeries for SUI can be grouped into four categories: 1) slings (midurethral slings and slings placed at the ureterovesical junction), 2) retropubic urethropexy, 3) urethral bulking agents, and 4) artificial sphincters. The success and failure of each approach needs to be assessed in the context of individual patients and their circumstances. Slings and retropubic urethropexy are considered first-line surgical options. Since the advent of minimally invasive retropubic midurethral slings such as the tension-free vaginal tape, transobturator tension-free vaginal tape, and single-incision sling, retropubic urethropexy have fallen out of favor. Warnings about mesh use may contribute to a resurgence of retropubic urethropexy procedures such as the Burch procedure. A Burch procedure should still be considered for patients who have an aversion to mesh or if they are undergoing concurrent abdominal approach surgery. Urethral bulking agents are usually reserved for patients with a fixed, nonmobile urethra who cannot tolerate an operative experience or have failed previous antiincontinence procedures. Artificial sphincters should be considered an operation of last resort. (Obstet Gynecol 2014;124:1011–27) DOI: 10.1097/AOG.0000000000000514

S

tress urinary incontinence (SUI) is a major problem affecting 20–40% of all women. It can be defined as involuntary leakage of urine during coughing, laughing, sneezing, or physical activity.1 It can be diagnosed during physical examination and by using low-cost office diagnostics. Looking at recent data from the

From the Department of Obstetrics and Gynecology, South Nassau Communities Hospital, Oceanside, and the Department of Obstetrics, Gynecology, and Reproductive Science, The Icahn School of Medicine at Mount Sinai, New York, New York. Continuing medical education for this article is available at http://links.lww. com/AOG/A565. Corresponding author: Alan D. Garely, MD, Chair of Obstetrics and Gynecology, South Nassau Communities Hospital, One South Central Avenue, Valley Stream, NY 11580; e-mail: [email protected]. Financial Disclosure The authors did not report any potential conflicts of interest. © 2014 by The American College of Obstetricians and Gynecologists. Published by Lippincott Williams & Wilkins. ISSN: 0029-7844/14

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National Health and Nutrition Examination Survey, incontinence in general has affected 51% of women. Forty-nine percent of these had SUI, 29% urge urinary incontinence (UUI), and 18% mixed incontinence.2 Although it is impossible to determine the precise economic effect of incontinence, reasonable estimates show costs close to $20 billion per year.3 This takes into account nursing home admissions, adult diapers, medical and surgical treatments, and time lost from work. At the individual level, affected women tend to isolate themselves and stop participating in routine activities of daily living. Risk factors specific for developing SUI include age, history of childbearing, obesity, and history of pelvic radiation.4–12 Data compiled by the U.S. Social Security Administration (www.ssa.gov) show that a woman turning 65 years old today can expect to live, on average, until age 86 years. The 2010 Census bureau showed that between 2000 and 2010 there was

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a 20% population increase in women older than 65 years of age (www.census.gov/2010census/). Female life expectancy in the United States is 81.1 years. Gallup data show that between 1991 and 2011, the average American weight increased from 129 to 138 pounds (www.gallup.com). Given this rise in obesity and increasing age, urinary incontinence (UI) likely will become more prevalent in our patient population in the future. Stress urinary incontinence can be categorized further using urodynamic testing. The diagnosis of SUI by symptom, sign, and urodynamic investigation involves the finding of involuntary leakage during filling cystometry associated with increased intraabdominal pressure in the absence of a detrusor contraction.1 This differs from UUI, which is involuntary leakage accompanied by or immediately preceded by urgency.1 If both types of leakage are present, the patient has mixed incontinence. In cases in which the bladder does not empty, leakage occurs when the bladder reaches its capacity, resulting in overflow incontinence.13 From a physiologic perspective, incontinence occurs when the pressure in the bladder exceeds the closure pressure of the urethra (Pves.Pura). If this leakage occurs during a “stress” event, it is considered SUI. If it occurs because of “spasm” or contraction of the bladder detrusor muscle, it is UUI.1 Stress urinary incontinence must be looked at in the context relative to the pelvic floor. This can be broken down into two separate components: structural and functional. Looking first at the structural component, if the vagina is well-supported and there is no appreciable cystocele or apical descent, it can be assumed that any “stress” pressure applied to the bladder will be equally applied to the urethra. At rest, the closure pressure of the urethra exceeds the intravesical pressure (Pura.Pves). If a woman has no leakage at rest and experiences a stress event, which increases the urethral closure pressure and the intravesical pressure equally, no leakage will occur. In cases in which there is a cystocele and the urethra rotates downward and outward, this same stress event will apply pressure differently to the urethra and bladder. This can cause the pressure in the bladder to exceed the closure pressure of the urethra, resulting in leakage. In cases in which structural support of the vagina is excellent, leakage can also occur if the urethra has an inherent weakness.14 This is related to the functional aspects of the urethra. If there is any attenuation to the external urethral sphincter, or its innervation from the pudendal nerve, the continence mechanism is compromised and the risk of incontinence is elevated. Trauma from vaginal delivery is the most likely cause of functional

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deficits, but it can also be caused by radiation, previous trauma and surgery, or from extensive dilatation.15 The strength of the urethral sphincter can be measured. Poor sphincter strength is referred to as intrinsic sphincteric deficiency. Although women with poor structural support of the pelvis may not always have SUI, those with poor sphincter tone will almost always have leakage. Women with SUI are recognized to have a spectrum of urethral characteristics ranging from a highly mobile urethra with good intrinsic function to an immobile urethra with poor intrinsic function13 Clinically, women with intrinsic sphincter deficiency have more severe incontinence and a lower surgical success rate than women with SUI and relatively normal urethral function. It is easier to compensate for structural defects by simply putting things back where they belong than for functional defects, which require reinforcement of the underlying muscles and nerves. Based on data from the Nationwide Inpatient Sample, which was developed for the Healthcare Cost and Utilization Project, of the Agency for Healthcare Research and Quality, it is estimated that close to 100,000 procedures per year are performed to treat UI.16 Before 1998, when retropubic midurethral slings became U.S. Food and Drug Administration (FDA)–approved, the majority of procedures were retropubic urethral suspensions. This dramatically changed as minimally invasive slings became more pervasive.17 From 1992 to 2001, procedures such as needle suspension, Marshall-Marchetti-Krantz, anterior urethropexy, and Kelly plication were superseded temporarily by less-invasive procedures such as collagen injections and eventually replaced by sling procedures.18 Artificial sphincters also became available, although they were not performed routinely by gynecologists or urogynecologists. The popularity of these minimally invasive surgeries, despite minimal data from randomized controlled clinical trials, reflected a widespread surgical evolution toward more minimally invasive procedures with lower patient morbidity and durable efficacy.18 It has long been accepted that nonsurgical physiotherapy provides equivalent improvement compared with surgical intervention.19 A multicenter randomized controlled trial showed that surgical intervention using retropubic midurethral sling procedures yielded superiority with respect to subjective cure, objective cure, and improvement 1 year after surgery.20 This article focuses on making the correct diagnosis of SUI and intrinsic sphincter deficiency with and without urethral hypermobility and how to tailor the surgical approach.

Stress Incontinence Evaluation and Treatment


DIAGNOSIS AND EXAMINATION History During evaluation of UI, it is essential to determine whether it is SUI, UUI, both, or neither. It is assumed that patients who leak urine with coughing, laughing, sneezing, and engaging in physical activity have SUI. It is also assumed that patients who say they have a sudden urgency that cannot be controlled have UUI. When we look at studies that correlate these symptoms with the actual assumed diagnosis, the association is not always perfect. Brown looked at the sensitivity and specificity of screening questions and developed the 3 Incontinence Questions, which is a simple, quick, and noninvasive test for classifying UUI and SUI. The 3 Incontinence Questions was developed as a tool for primary care practices as an alternative to time-consuming and extensive evaluations.21 Analysis of the 3 Incontinence Questions demonstrated that, for UUI, the sensitivity was approximately 75%, suggesting that approximately 25% of women with urgency incontinence will be missed; specificity was 77%, suggesting that approximately 23% of women with other types of incontinence may be inappropriately treated for UUI. Looking at SUI, the sensitivity was 86%, suggesting that approximately 14% of women with SUI will be missed; specificity was 60%, suggesting that approximately 40% of women with other types of incontinence may be inappropriately treated for SUI.21 Although the great majority of patients who truly had SUI were identified on questioning, 40% of patients who did not have SUI were diagnosed inaccurately. This is why additional testing is helpful. One of the best reasons to use a questionnaire is to correlate a patient’s symptoms to their quality of life. If there is no symptom bother, invasive treatment is probably not indicated. Among all existing screening tools looking at sensitivity and specificity, the International Continence Society has given three of these an “A” (highly recommended). These are the International Consultation on Incontinence Questionnaire, the Bristol Female Lower Urinary Tract Symptoms Scored Form, and the Norwegian Stress and Urge Incontinence Questionnaire. Among all questionnaires, none is considered the gold standard.22

Objective Testing The cheapest assessment tool is simple cystometrics, also called poor man’s cystometry. This involves placing a small catheter through the urethra and into the bladder. The catheter is attached to a catheter-tipped syringe that can hold at least 50 cc of fluid. The patient


should void immediately before the test. Although there are different ways to do this, for patient comfort, we prefer the supine position. Once the patient is positioned, the catheter is placed into the bladder, and the drained urine is measured. This is called the postvoid residual. Threshold values delineating what constitutes an abnormal postvoid residual are poorly defined. However, residual volumes lower than 75–100 cc are usually considered normal. Higher residuals can indicate urinary retention and should be correlated with the patient’s symptoms, because high residuals can contribute to overflow of urine, which can mimic SUI. Assuming a normal residual, the bladder is filled retrograde through the catheter. The patient is asked to state when she feels the water going in; this can be described as wetness, coolness, or pressure. This is called the first sensation and usually occurs at less than 100 cc of filling. As filling continues, the patient is asked to say when she feels full or feels like she would normally want to void. This is noted as fullness and usually occurs over 200 cc. The last measurement of filling occurs when the patient states she no longer can hold the water. This is the maximum capacity. As with postvoid residuals, there are no recognized standards for normal values. A reasonable range for first sensation is 100–200 cc, normal desire to void at 150– 350 cc, urgency at 250–500 cc, and a maximum cystometric capacity of 300–600 cc.23–25 Throughout the test, the clinician should be observing the meniscus of the fluid in the catheter, looking for a rise, rather than fall, of the fluid. It is also important to note that the level of the syringe affects the transmission of pressure back to the meniscus and that the syringe needs to be above the level of the bladder at all times. A rise or lack of filling may indicate a bladder detrusor contraction. In patients with overactive bladder symptoms, this is a highly confirmatory finding. Once the bladder is at maximum capacity, the catheter is removed and the patient is asked to cough. If a series of coughs fail to cause observable leakage, the supine patient should be asked to stand and repeat coughing. This is called a cough stress test. Any leakage during this phase of the test is considered positive. A cough stress test may also appear to be positive if there is a coughinduced detrusor contraction, which is a limitation of this test in some patients. A more detailed analysis of bladder function can be performed with multichannel urodynamic testing.26–31 This differs from the simple or bedside test in that a pressure-sensing catheter is placed in the bladder and one in the vagina or rectum. A computer monitors pressure in the bladder as the filling is increased. This test allows for measurement of the bladder pressures at rest, during filling, and during micturition. Bladder pressures can be correlated to urinary flow

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and retention. This test can also be combined with fluoroscopy to allow for visualization of the bladder neck, position of the urethra, and ureteral reflux.32 At specified increments during the test, the filling is stopped, and the patient is asked to cough with incremental increases in pressure or to slowly Valsalva. If leakage is demonstrated, the pressure when leakage occurs is marked on the study. This is called the leak point pressure, which is defined as the intravesical pressure at which urine leakage occurs resulting from increased abdominal pressure in the absence of a detrusor contraction.13 Lower leak point pressures usually indicate that the urethral sphincter is doing a poor job of holding urine in the bladder. The strength of the urethra can be measured directly by pulling a pressure catheter through the urethra or by measuring the pressure in the bladder when leakage occurs. A urethral closure pressure less than 20 cm of water or a leak point pressure less than 60 cm of water is commonly termed intrinsic sphincteric deficiency.33–36 The presence of intrinsic sphincteric deficiency has meaning when treatment options are discussed. The size of the catheter can influence the result, because larger catheters will obstruct the urethra more than smaller ones. For this reason, the smallest possible catheter should be used.35 Do we really need urodynamics to make an accurate diagnosis? The Value of Urodynamic Evaluation study looked at this question.37,38 Two groups were compared before surgical intervention: one was evaluated with a postvoid residual and cough stress test alone and the other group had the same evaluation plus multichannel urodynamics. Ninety-seven percent of patients who had a positive cough stress test had confirmatory findings on urodynamics. Analysis 12 months after surgical treatment showed that in the simple cystometric–only group, there was a 77.2% success rate (much better or very much better) on the Urogenital Distress Inventory scale. The combined group, who also had complex urodynamics, showed 76.9% improvement. At 1-year follow-up, the Value of Urodynamic Evaluation trial demonstrated that preoperative office evaluation alone (simple testing) was not inferior to office evaluation with multichannel urodynamics when looking at surgical outcomes. The American Urological Association has issued guidelines with respect to preoperative testing in patients planning treatment for SUI (Box 1).39 Using words such as “should” and “may,” the guidelines stop short of mandating specific testing before treatment. The assessment of urethral function may direct treatment to different types of surgery based on the leak point pressure or the urethral closure pressure. With respect to high preoperative postvoid residuals,

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strategies to reduce retention should be used before treating incontinence. Patients in retention will definitely not improve after an anti-incontinence procedure. In light of the Value of Urodynamic Evaluation study, multichannel urodynamic testing may add more preoperative information but may not alter the treatment outcomes. It seems obvious that patients tested for SUI who do not demonstrate leakage with the catheter in place should have the Valsalva or cough component of the test repeated with the catheter removed. In cases of concurrent pelvic organ prolapse (POP), the urethra can kink as the anterior vaginal wall descends. This kinking can suppress leakage. It is not uncommon for patients with large vaginal vault prolapse or cystocele to relate that as the prolapse worsened, the incontinence got better. In previously continent women with POP, UI will develop in approximately 25% of the patients after prolapse repair.40 Visco et al41 discussed different prolapse reduction methods (manual, large cotton swab, ring forceps, pessary, and split speculum) and their respective rates of uncovering occult SUI after surgery. Although a prophylactic midurethral sling inserted during vaginal prolapse surgery resulted in a lower rate of UI at 3 and 12 months, they also had Box 1. Guideline Statements Stress Urinary Incontinence and Prolapse 1. Clinicians who are making the diagnosis of urodynamic SUI should assess urethral function. (Recommendation; Evidence Strength: Grade C) 2. Surgeons considering invasive therapy in patients with SUI should assess postvoid residual urine volume. (Expert Opinion) 3. Clinicians may perform multichannel urodynamics in patients with both symptoms and physical findings of SUI who are considering invasive, potentially morbid or irreversible treatments. (Option; Evidence Strength: Grade C) 4. Clinicians should perform repeat stress testing with the urethral catheter removed in patients suspected of having SUI who do not demonstrate this finding with the catheter in place during urodynamic testing. (Recommendation; Evidence Strength: Grade C) 5. Clinicians should perform stress testing with reduction of the prolapse in women with high-grade POP but without the symptom of SUI. Multichannel urodynamic study with prolapse reduction may be used to assess for occult SUI and detrusor dysfunction in these women with associated lower urinary tract symptoms. SUI, stress urinary incontinence; POP, pelvic organ prolapse. Data from American Urological Association. Guideline for the surgical management of female stress urinary incontinence: update (2009). Available at: http://www.auanet.org/education/ guidelines/incontinence.cfm. Retrieved July 10, 2014.



higher rates of adverse events including bladder perforation, urinary tract infection, major bleeding complications, and incomplete bladder emptying in the first 6 weeks after surgery.42

Pelvic Examination Understanding normal and abnormal vaginal support is essential in the diagnosis and treatment of SUI. For any incontinence procedure to work, the anterior vaginal wall must be stable with minimal descent. In the subset of women with incontinence and a cystocele, most will have a concurrent apical descent.43 If the diagnosis of cystocele or apical descent is missed, the treatment plan frequently will fail. This is why incontinence procedures must often be combined with concurrent apical prolapse surgery. Even in cases in which there is an isolated cystocele, failure to recognize and treat this will result in lower success rates specific to incontinence.44 The examination should initially be conducted in the supine position. Using a bivalve Simms speculum, the cervix or vaginal apex should be visualized. The patient is asked to Valsalva or bear down as if she is delivering a baby or having a bowel movement. As she pushes, the speculum should be gently withdrawn. This allows for visualization of cervical or apical descent. Using the validated POP quantification,45 a measurement is made from the hymen to the apex during strain. The speculum is then disassembled and the lower blade is gently reinserted into the vagina. The patient is again instructed to bear down. The speculum blade should be parallel to and resting on the posterior vaginal wall. Again, the blade is gently removed as the patient pushes. This allows for quantification of the anterior wall descent relative to the hymen. The blade is rotated so that it is resting under the anterior wall and the patient is again instructed to bear down. The most distal portion of the posterior vaginal wall is measured from the hymen. When there is a discrepancy between the patient’s complaints and the supine pelvic examination, digital palpation of the vaginal wall can be done with the patient in the standing position, bearing down. Some health care practitioners are interested in quantifying urethral mobility.46 When a urethra is well supported (minimal anterior vaginal wall descent), any force (cough, laugh, etc) will be transmitted equally to the bladder and the urethra. These forces essentially zero each other out. If the patient is dry at rest, an equal increase in pressure to the bladder and the urethra will not cause leakage because the pressure to the urethra is still greater than the pressure to the bladder. Looking at the pelvic floor


from a structural perspective, as mobility of the urethra increases (as the anterior vaginal wall descends), pressure forces are not transmitted equally, and the bladder pressure may exceed the closure pressure of the urethra resulting in leakage. The degree of urethral mobility can be measured by placing a cottontipped swab in the urethra and having the patient bear down (straining angle). The angle of the cotton-tipped swab to the horizontal, measured in degrees, is designated as the resting angle. Using a protractor, movement of the cotton-tipped swab at maximal strain can be measured. This angle is designated as the maximal straining angle. Urethral mobility resulting in a straining angle of greater than 30° is considered hypermobile. An angle change (the difference between the resting angle and the straining angle) less than 30° in the presence of incontinence points in the direction of intrinsic sphincteric deficiency. The problem with using urethral hypermobility in general is that it describes a structural issue in the pelvis, but not a functional one. Women can have hypermobility without incontinence or any other symptoms. This is why it is important to appreciate the muscular and neurologic contributions to continence from both the external urethral sphincter and the pudendal nerve. Most women do not like having anything inserted into their urethra, and a cotton-tipped swab is no exception. Aside from being uncomfortable, it also has the potential to increase posttest infection. A recent study comparing a visual assessment of urethral mobility with that of the cotton-tipped swab test demonstrated that the two modalities were statistically similar.47 Pelvic floor imaging with ultrasonography will provide the same information. In our practice, we do not find a clinical use for either the cotton-tipped swab test or ultrasonography in the evaluation of SUI. Applying our model of pressure transmission, in women with no mobility (a fixed urethra), equal pressure forces are applied to the bladder and urethra. If the urethra does not coapt or close, leakage occurs. This can occur when the urethra is stenotic secondary to conditions such as radiation treatment or previous urethral surgery.48

SURGICAL OPTIONS FOR STRESS INCONTINENCE Surgical interventions for SUI have three possible outcomes. The first is that our treatment does not increase urethral resistance enough, and the patient continues to leak during stress events. This woman is able to void normally, but she is still incontinent. The second is that we do something to make the urethra

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stronger, our patient is dry during stress events, and she can void normally (the optimal outcome). The third involves overdoing our intervention, making resistance in the urethra so high that the patient is dry during stress events but unable to void completely or at all. Corrective surgery can be grouped into four categories: 1) slings, 2) retropubic urethropexy, 3) urethral bulking agents, and 4) artificial sphincters. The success and failure of each approach needs to be looked at in the context as to why it was chosen and for whom. It is unfair to compare bulking agents with slings or urethropexy because they are used in different patient scenarios and do not result in the same cure or improvement rates. The overall reported success rate of periurethral bulking agents is 48–75%.49,50 Urethral bulking should be reserved for patients who cannot tolerate an operative experience or who have already undergone surgical intervention and desire greater improvement without going back to the operating room. Artificial sphincters are the last resort and should not be used unless the patient has already failed previous antiincontinence procedures.51 The majority of the surgical decision process will be whether to do a sling or a retropubic urethropexy. If a sling is chosen, the type of sling must be delineated. The National Institute for Care and Excellence has issued guidelines that can help make this planning easier (Box 2).52 Procedures such as needle suspensions, anterior repairs, and paravaginal repairs are not discussed because they are currently infrequently used secondary to a lack of efficacy.53–56

MANAGING EXPECTATIONS Not everyone is curable. As physicians who do not routinely deal with patients who have terminal illness, this is as close as we come to having patients who simply will not get better. A commitment to improving their lives will go a long way, and ultimately, improvement may be the best outcome one can obtain. There are reasons for failure. Certain underlying conditions such as obesity, prior surgery, or a history of radiation can predispose women to less than optimal outcomes. Early in our careers, lack of experience or not appreciating small nuances in technique can play a role in our results. Surgeons with higher surgical volumes have higher success rates. Regardless, nobody has a 100% cure rate. Because we know that every operation has an underling failure rate, the need for reoperation is real. Understanding this message is essential before entering the operating room. Equally important is engaging patients in an interactive consent process to ensure their input and expectations.

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Box 2. National Institute for Health and Care Excellence Guidelines 1) First-line therapy - Synthetic midurethral slings - Open retropubic urethropexy - Autologous rectus fascial sling 2) When offering synthetic slings: - Use devices that have proven data - Use devices on which you have trained - Use Type 1 macroporous polypropylene tape - Consider colored mesh to help with insertion and revision 3) When using a TVT-O, make patients aware of complications 4) Refer patients when they want a procedure you do not offer 5) Use “top-down” slings only as part of a clinical trial 6) Follow-up all patients within 6 months to assess for erosion 7) Laparoscopic urethropexy should only be done by experienced surgeons working in controlled trials 8) Do not offer anterior repairs, needle suspensions, paravaginal repairs or Marshall-Marchetti-Krantz procedures for SUI 9) When offering injectable bulking agents: - Repeat injections may be needed - Efficacy diminishes with time - Efficacy is inferior to mesh or rectus fascial slings 10) Artificial urinary sphincter should only be used if previous surgery has failed and requires lifelong follow-up 11) An annual workload of at least 20 cases of each primary procedure is recommended. Fewer than five cases per year should warrant review and support from internal clinical governance committees TVT-O, transobturator tension-free vaginal tape; SUI, stress urinary incontinence. Data from the National Institute for Health and Care Excellence. Urinary incontinence: the management of urinary incontinence in women. Available at: http://www.nice.org.uk/guidance/ CG171/chapter/1-Recommendations. Retrieved July 29, 2014.

Most patients do not know the difference between any of the surgical options. They depend on the surgeon to make the choice of procedure. Aside from making an accurate diagnosis, the surgical approach is probably the most important decision a physician can make that will influence the patient’s outcome. Again, the patient needs to be fully informed about what the procedure will entail and what complications can be expected. Having full preoperative knowledge about materials used, urinary retention, urinary tract infection, surgical site pain, and vaginal erosions will mitigate anger and anxiety later.44,57,58



SLINGS A sling is a hammock, which sits under the urethra. Slings can be classified as retropubic pubovaginal slings at the ureterovesical junction, midurethral slings, transobturator tension-free vaginal tape (TVT-O), and singleincision minislings. Historically, slings were developed using either autologous muscle or fascia. They were placed at the urethra–vesical junction and fixed to either rectus fascia or Cooper’s ligament. Although effective, the morbidity associated with these slings was significant.59 Patients developed hematomas and hernias at the harvest site. Postoperative urinary retention was high, and patients had to know how to self-catheterize before surgery. The early slings were effective but until the advent of the minimally invasive tension-free vaginal tape (TVT) slings, they were implanted by only a few well-trained urologists and gynecologists.60 In 1998, the FDA approved the use of the TVT sling (Fig. 1) in the United States. The TVT is a macroporous monofilament polypropylene mesh placed under the urethra. At the time of its introduction into the United States, the urologic community was already starting to see significant erosion problems with another synthetic sling called the ProteGen.61 ProteGen was a braided material impregnated with collagen. It was voluntarily recalled by its manufacturer because of significant safety concerns. The TVT mesh had a different weave and pore size and was not anchored into place. Controversy eventually caught up with the TVT and other synthetic mesh slings when complications related to mesh use in POP began to surface. Between 2009 and 2011, the FDA conducted a systematic review of the literature and found the safety and efficacy of mesh slings to be well-established. They found success rates on par with retropubic urethropexy (70–80%)62,63 and erosion and extrusion rates of 2%.64,65 Although the FDA stopped short of mandating a sling registry to track complications, they have issued guidelines, which are summarized in Box 3.66 The most common complications related to mesh slings in descending order of frequency are pain, mesh erosion through the vagina (also called exposure, extrusion, or protrusion), infection, urinary problems, recurrent incontinence, pain during sexual intercourse (dyspareunia), bleeding, organ perforation, neuromuscular problems, and vaginal scarring.66 Pain related to any sling usually requires surgical excision or release of tension. Erosions can be treated with topical estrogen,67 but in our experience, surgical excision or covering the mesh with vaginal epithelium is the most effective treatment. American Urological Association


Fig. 1. Tension-free vaginal tape runs under the urethra and traverses the retropubic space. From Rogers RG. Urinary stress incontinence in women. N Engl J Med 2008;358:1029–36. Copyright Ó 2008 Massachusetts Medical Society. Reprinted with permission from the Massachusetts Medical Society. Garely. Stress Incontinence Evaluation and Treatment. Obstet Gynecol 2014.

guidelines recommend that these slings not be used in stress-incontinent patients with a concurrent urethrovaginal fistula, urethral erosion, intraoperative urethral injury, urethral diverticulum, or a combination of these.39

TENSION-FREE VAGINAL TAPE SLING The patient is placed in the dorsal lithotomy position. The legs are placed in Allen stirrups and elevated so that the thigh is close to a 90° angle to the abdomen. Some surgeons advocate for a lower elevation to decrease the risk of nerve compression. The lower abdomen, vagina, and perineum are prepped. We like to use a laparoscopy drape, which has an opening for the abdomen and vagina, and a bag to drain fluid. When a synthetic graft is used, prophylactic intravenous antibiotics are administered. Starting on the abdomen, a dark pen is used to mark two spots, 5 cm apart, at the level of the pubic symphysis. Dilute anesthetic with epinephrine is injected at each of the marked areas. A small blade knife is used to make stab incisions at the marked areas. Injecting and cutting the abdomen before placing the Foley decreases vaginal contamination and avoids having to change gloves. An 18-French Foley is inserted into the bladder (which is drained) and clamped with a Kelly. A weighted speculum is placed on the posterior vaginal wall. The patient’s buttocks should hang slightly over

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Box 3. U.S. Food and Drug Administration Recommendations Regarding Management of Stress Urinary Incontinence Training Obtain specialized training for each suburethral mesh sling procedure and be aware of the unique risks and benefits of surgical mesh slings used in SUI repair. Patient Selection Recognize that mesh sling procedures are currently the most common type of surgery performed to correct SUI, measuring to approximately 250,000 procedures performed in 2010. Choose mesh surgery only after weighing the risks and benefits of surgery with mesh compared with all surgical and nonsurgical alternatives. Consider these factors before placing surgical mesh: - Surgical mesh is a permanent implant that may make future surgical repair more challenging. - Having a mesh surgery may put the patient at risk for requiring additional surgery or for the development of new complications. - Removal of mesh as a result of mesh complications may involve multiple surgeries and significantly impair the patient’s quality of life. Complete removal of mesh may not be possible and may not result in complete resolution of complications, including pain. - Mesh placement is contraindicated in women with current urinary tract infection, current pregnancy, or on current anticoagulation therapy. Informing Your Patient Inform patients that use of surgical mesh slings to treat SUI provides a less-invasive approach than nonmesh repairs, which require a larger incision in the abdominal wall. The multi-incision sling procedure can be performed using three incisions in two ways: with one vaginal incision and two lower abdominal incisions, called retropubic; or with one vaginal incision and two groin or thigh incisions, called transobturator. There is also a “minisling” procedure that uses a shorter piece of surgical mesh, which may be done with only one incision. Inform patients that surgical mesh in the form of a “sling” (sometimes called “tape”) is permanently implanted to support the urethra or bladder neck to correct SUI. This is commonly referred to as a “sling procedure.” Inform patients about the potential for serious complications and their effect on quality of life. The most common complications reported for surgical mesh slings for SUI repair, in descending order of frequency, include: pain, mesh erosion through the vagina (also called exposure, extrusion, or protrusion), infection, urinary problems, recurrent incontinence, pain during sexual intercourse (dyspareunia), bleeding, organ perforation during placement (especially bowel, bladder, and blood vessel), neuromuscular problems, and vaginal scarring. Many of these complications require additional medical intervention and sometimes require surgical treatment, hospitalization, or both. With the exception of mesh erosion, these complications can occur after a nonmesh surgical repair for SUI. Inform the patient about the benefits and risks of nonsurgical options, nonmesh surgery, and the likely success of these alternatives compared with surgery with mesh. Notify the patient if mesh will be used in her incontinence surgery and provide the patient with information about the specific product used. Ensure that the patient understands the postoperative risks and complications of mesh surgery as well as long-term outcomes data. Provide patients with a copy of the patient labeling from the surgical mesh manufacturer if available. SUI, stress urinary incontinence. Data from U.S. Food and Drug Administration. Urogynecologic surgical mesh: update on the safety and effectiveness of transvaginal placement for pelvic organ prolapse. Available at: http://www.fda.gov/downloads/MedicalDevices/Safety/AlertsandNotices/UCM262760.pdf. Retrieved July 29, 2014.

the edge of the table, or the speculum will fall and it will be difficult to maneuver the sling. Additional local anesthetic is injected under and lateral to the urethra on the anterior vaginal wall. Some surgeons hydrodissect the vaginal incision site, the path of the trocars, or both. Either local anesthetic (with or

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without epinephrine) or sterile saline may be used. In the original description of the procedure, 40 cc of fluid was injected into the vaginal wall inferior and lateral to the urethra.60 An additional 60–70 cc of fluid was injected at the planned abdominal incision sites and downward along the back of the pubic bone to the



retropubic space. Alternatively, fluid may be injected into the retropubic space through the vaginal sulci. In our practice, we only hydrodissect on the vaginal wall using our local anesthetic with epinephrine. A vertical incision is made under the urethra, starting just distal to the urethrovesical junction (easily identifiable by gently pulling down on the Foley and palpating where the balloon rests) to just proximal to the urethral meatus. It is critical that the depth of the incision be deep enough so that the sling does not erode into the vagina but not so deep that it erodes into the urethra. Using either tenotomy or Metzenbaum scissors, the vaginal epithelium is elevated on both sides of the incision. This creates a pocket between the vaginal epithelium and the underlying tissue posterior to the urethra. A cutting rather than spread technique is preferred to avoid inadvertent injury to the urethra or bladder. The lateral depth of each pocket should only be a few centimeters, just enough to let the tip of the TVT needle rest along the superior posterior border of the pubic symphysis. A rigid catheter guide should be inserted into the Foley, which is deflected to the patient’s ipsilateral thigh relative to where the first TVT pass will occur. A left deflection means placing the TVT needle into the left pocket. Once the needle is in place, the weighted speculum is removed. The TVT needle is gently angled under the pubic bone aiming for the patient’s ipsilateral shoulder.68 Once the needle has passed into the space of Retzius, the needle angle is adjusted aiming for the ipsilateral stab incision on the abdomen. Throughout the needle passage, staying tight to the back of the pubic bone is essential to avoid injury to the bladder, bowel, or blood vessels.68 We use a “touch” technique, where the pubic bone is gently touched and advanced, rather than scraping along the bone. This “touch and go” approach decreases the risk of puncturing the vascular structures that sometimes cover the surface of the bone. By adjusting the needle angle medially once the tip has ascended anterior to the urethra and bladder, injury to the major vessels, namely the obturator and the external iliac, is greatly mitigated.68 Once the needle is visible through the abdominal stab incision, the rigid catheter guide is removed, and before removal, the Foley is open to drainage. In our experience, if the small amount of urine that has accumulated in the bladder is bloody, this may indicate that the bladder has been perforated. Clear urine does not mean that a puncture has not occurred, because most bladder perforations are small, tight, in–out injuries that rarely bleed. Cystoscopy is a mandatory component of the operation. We prefer a 70° or flexible cystoscope to visualize the bladder and urethra.60 The most likely place of injury is between


the 10 and 2 o’clock positions along the anterior bladder wall at the dome, depending on which side the needle is passed. If the needle has perforated the bladder, a Foley is reinserted, the needle is removed, and the needle is repassed. We try to make sure that the needle does not follow the same path as the first pass. If the bladder is punctured on three successive passes, we recommend stopping the procedure and closing as described subsequently. Predisposing factors for difficult needle placement include obesity, previous surgery in this space, and limited surgical experience.64 If the needle passage is acceptable, the needle and its attached mesh are pulled up and rested on the abdomen. Starting with reinsertion of the rigid catheter guide, the same exact procedure is repeated on the contralateral side. Because of numerous delivery systems, depending on the brand of sling, some devices pull the mesh upward by attaching a suture to the needle tip. This allows the suture to be clamped and placed on the abdomen before pulling up the sheath-encased mesh. After each needle is passed, cystoscopy should be done to confirm integrity of the urinary tract. If both the left and right passes are adequate, the weighted speculum can be placed back into the vagina, and the needles are pulled upward until the sheath is resting approximately 0.5 cm from the underside of the urethra. This is spaced with a Metzenbaum scissors (or a similar instrument). The sheaths on their respective sides are cut free from the needles. The sheaths are grasped with clamps, making sure that the mesh is not grasped, and the sheaths are pulled upward, leaving the mesh in place. We err on the side of tighter rather than looser. We have found that a wellsupported anterior wall typically will require tighter sling placement. Once the sling is tensioned, the Metzenbaum scissors are withdrawn. The arms of mesh coming through the abdominal stab incisions are cut by pushing a curved Mayo scissors downward and gently pulling up on the mesh. This allows the mesh to retract away from the skin edge, decreasing the risk of mesh exposure or irritation. The vaginal incision is closed with a running 2-0 Vicryl suture. Before finishing the closure, a liquid hemostatic matrix composed of gelatin and human thrombin is injected into the incision and pressure held for 1 minute. In our experience, this last step has greatly decreased postoperative bleeding and hematomas. An active voiding trial is initiated when the patient is able to ambulate. Brubaker69 noted that patients who immediately fail a postoperative voiding trial have a greater chance of cure at 1 year. No standard technique for the voiding trial has been established. There are variations in the amount instilled and what is considered

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a normal residual. In our approach, the bladder is filled retrograde with at least 200 cc of water or saline, stopping when the patient feels the need to void. The instilled fluid is measured and the patient is given 15 minutes to void into a hat. The difference between the volume instilled into the bladder and the volume voided is the postvoid residual. We use 75 cc as a postvoid residual cutoff to determine if the patient should go home with a Foley. If postvoid residual is elevated, the patient is given a leg bag and a night bag and instructed to follow-up in 3–4 days. A mild antibiotic such as nitrofurantoin at 50 mg per day is usually enough to prevent a urinary tract infection. If the residual urine continues to remain elevated on postoperative day 3 or 4, we encourage the patients to switch to intermittent self-catheterization until the residuals are consistently below 75 cc. If after 7–10 days the residuals remain high, a sling revision is indicated. Within 2–3 weeks after surgery, the sling can usually be loosened. After that time, cutting or removing the sling is the only option. Patients unable to self-catheterize are managed with the Foley and a repeat trial of void is attempted 3 days later. Again, the same management strategy applies. An alternative to the repetitive office trial of void is to place a suprapubic catheter and have patients measure postvoid residuals at home.

TRANSOBTURATOR TENSION-FREE VAGINAL TAPE SLING In contrast to the TVT sling, the TVT-O perforates the obturator foramen and runs under the urethra to the contralateral obturator foramen (Fig. 2). The purpose of this sling is to achieve the same results as the TVT, but without the associated rare complications of bladder and bowel perforation, vessel injury, and urinary retention.70–73 The TVT-O sling also lies flatter under the urethra and carries a lower risk of urethral obstruction, urinary retention, and subsequent need for sling release compared with retropubic slings.74–76 Because the TVT-O goes around the medial aspect of the obturator foramen, this creates a pivot point for the mesh, which can form a subepithelial band. In sexually active patients this band can cause dyspareunia, which is a disadvantage. The proximity of the deep external pudendal vascular structures to the TVT-O needle passage has been attributed to hematomas and pain. Although there are minimal risks of bowel or major vessel perforation with this method, patients experience more complications referable to the groin (pain and leg weakness or numbness).76,77 The patient is positioned similarly to the TVT. A Foley is placed, but no catheter guide is used.

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Fig. 2. Transobturator tape perforates the obturator foramen on each side and runs under the urethra. Reproduced with permission from: Nager CW, Tan-Kim J. Stress urinary incontinence in women: transobturator midurethral slings. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on July 18, 2014.) Copyright Ó 2014 UpToDate, Inc. For more information, visit www.uptodate.com. Garely. Stress Incontinence Evaluation and Treatment. Obstet Gynecol 2014.

Instead of cutting the abdomen, marks are made at the level of the clitoris, 2 cm superior to urethra, at the medial edge of the obturator foramen. This medial edge is identified by feeling for the notch, where the angle of the foramen changes. The suburethral incision is made, and a pocket is developed (similar to the TVT) with dissection all the way to the obturator membrane, close to the inferior aspect of the ischial ramus. This can be confirmed by pressing your contralateral index finger to the side wall. The TVT-O needle can be passed from inside the vagina to the outer labial skin (inside-out) or vice versa (outsidein). A meta-analysis showed no difference in outcome or complications between the two approaches.78 We prefer the outside-in method because we have greater control of the needle as it is passed around the bone and into the pocket. We guide the needle by pressing our index finger tight to the sidewall and guiding the needle inward. With our fingers we follow the needle all the way into the vagina. It is then clamped or fastened onto the TVT-O sheath. The TVT-O needle then is pulled out and the sheath is clamped to the drape. The same technique is done through the other foramen. With the sling in place, the Foley is removed and cystoscopy performed. The risk of a bladder perforation is much lower than in a TVT, but it can still occur. The usual place of injury is at the 7 and 5 o’clock positions close to the posterior bladder wall. Although rare, the urethra must also be inspected for injury.



SINGLE-INCISION SLINGS

RETROPUBIC URETHROPEXY

Single-incision slings were developed to shorten operative time, decrease the use of anesthesia, and possibly bring slings into the office setting. These slings are also commonly called minislings. They follow the basic approach as TVT-O slings but stop short of perforating through the obturator membrane or pubocervical fascia. They use an anchor system rather than depending on tissue resistance for support. Compared with midurethral slings, minislings show lower success rates, lower patient satisfaction, and higher reoperation rates.79 Long-term data are lacking and continued surveillance will be needed.

Retropubic urethropexy procedures are procedures that support the urethra with sutures to either the iliopectineal (Cooper’s) ligament or to the pubic periosteum. When the sutures are placed through Cooper’s ligament, this is the Burch Procedure (Fig. 4). When the sutures go through the periosteum, this is the Marshal Marchetti Krantz procedure. Because of the associated rare complication of osteitis pubis (0.74–2.5%), the Marshal Marchetti Krantz has been all but abandoned for the Burch, which has similar cure rates with lower complication rates.82 These can be done through an open incision as well as laparoscopically. The following discussion will focus on the open Burch procedure. The purpose of the retropubic urethropexy is to support the tissue lateral to the urethra and bladder neck so that there will be limited mobility of the suburethral tissue or pubocervical fascia. When a force such as a cough is applied to the bladder and urethra, fixation of the pubocervical fascia allows coaptation of the urethra. In patients with low leak point pressures, it is assumed that attenuation of the supporting musculature and fascia has occurred. Depending on this damaged tissue as a backstop of support is not always enough to treat incontinence.83 This is why a sling is preferred in severe cases of leakage. The sling sits directly under the urethra and not just lateral. The description here pertains to an open abdominal technique of the Burch procedure, which was modified in 1976 by Tanagho.84 Candidates for this procedure include patients who are having

AUTOLOGOUS RECTUS FACIAL SLING Using native tissue instead of synthetic mesh is an alternative approach to a minimally invasive sling. The autologous pubovaginal sling supports the proximal urethra and bladder neck to achieve continence by providing a direct compressive force on the urethra and bladder outlet or by reestablishing a reinforcing platform or hammock against, which the urethra is compressed during increased abdominal pressure (Fig. 3).80 The use of either rectus fascia or fascia lata preceded synthetic slings by more than 80 years. These slings had equal or better success rates than the TVT, but also had higher complication rates.81 Urinary retention, hematomas, and hernias were common. As with the Burch procedure, rectus fascial slings are finding a resurgence as patients may shy away from the use of mesh. This procedure should only be done by experienced surgeons. Fig. 3. Autologous sling procedure consists of a strip of rectus fascia that is placed beneath the proximal urethra through a vaginal incision. The two ends of the sling are passed behind the pubic bone and secured anteriorly, either to each other or to the rectus fascia. From Albo ME, Richter HE, Brubaker L, Norton P, Zimmern SR, Chai TC, et al. Burch colposuspension versus fascial sling to reduce urinary stress incontinence. N Engl J Med 2007;356:2143–55. Copyright Ó 2007 Massachusetts Medical Society. Reprinted with permission from the Massachusetts Medical Society. Garely. Stress Incontinence Evaluation and Treatment. Obstet Gynecol 2014.


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Fig. 4. Burch procedure involves periurethral permanent sutures placed in the anterior vaginal wall at the level of the bladder neck and proximal urethra, which are then sutured to the iliopectineal or Cooper’s ligament. From Albo ME, Richter HE, Brubaker L, Norton P, Zimmern SR, Chai TC, et al. Burch colposuspension versus fascial sling to reduce urinary stress incontinence. N Engl J Med 2007;356:2143–55. Copyright Ó 2007 Massachusetts Medical Society. Reprinted with permission from the Massachusetts Medical Society. Garely. Stress Incontinence Evaluation and Treatment. Obstet Gynecol 2014.

a concurrent abdominal surgery such as a hysterectomy or for POP. The Burch procedure as a first-line surgery for isolated SUI has become rare since the advent of minimally invasive slings. Patients who have an aversion to mesh used in the sling will still consider a Burch procedure by itself, but it is almost always done concurrently with an open abdominal procedure. Tanagho used absorbable sutures. A review of 17 studies comparing absorbable with permanent suture showed no significant differences in success rates.85 Further review of the literature shows that suture type varies with no clear consensus other than a preference toward nonabsorbable sutures.86,87 The patient should be placed in the dorsal lithotomy position with legs in Allen stirrups. If this is being done without any other procedures, a smallminilaparotomy incision is done. A transverse skin incision is made 2 cm above the pubic symphysis. We measure our incision length at 5 cm. With the aid of a small Richardson retractor, dissection with electrocautery is carried down to the fascia. For better exposure through this small incision, we open the fascia vertically (Kustner technique), but a transverse opening (Pfannenstiel) is acceptable. Once the fascia is open, the rectus muscle is gently separated in the midline. With the index finger, the tissue is gently swept inferiorly, staying on the underside of the muscle, aiming toward the symphysis. Lateral or posterior dissection risks trauma to the surrounding plexus of blood vessels. An O’Conner–O’Sullivan self-retaining retractor is placed under the rectus muscles and the blades are separated until there is resistance from the skin incision. A Richardson retractor is used to pull on the inferior edge of the incision. If the surgeon is standing on the patient’s left side, the left hand is placed between the patient’s legs. Two fingers are inserted into

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the vagina, feeling along the anterior vaginal wall for the Foley catheter and balloon. This allows for orientation of the urethra–vesical junction. With the right hand, a sponge stick is used to gently retract the bladder medially, relative to the side that the sutures will be placed. If starting on the left side, the vaginally placed fingers should both be to the left of the urethra. This protects the urethra and bladder neck. Once the sponge stick is positioned, it is given to the surgical assistant to hold. With the surgeon’s free right hand, the sutures are ready to be thrown. Optimally, two figure-of-eight sutures should be placed on each side of the urethra. The first should be 2 cm lateral to the midurethra and the second 2 cm lateral to the urethra–vesical junction. These sutures can be placed with a regular needle holder, but we prefer to use an automatic suture driver, such as the Capio device. We use 2-0 braided nylon sutures because these are permanent and easy to tie. Pushing the vaginal fingers upward, the tip of the device is placed at the desired location next to the urethra and the needle tip is pushed through the tissue close to the vaginal fingers. To avoid sutures pulling or ripping out, we try to get full-thickness bites. To prevent a suture granuloma, placing the suture into the vagina should be avoided. After the two sutures are thrown on both sides of the urethra, the vaginal fingers are withdrawn and the glove changed. Staying under the rectus muscle, the handheld Richardson retractor is deviated to the left side. Pulling the muscle anteriorly and inferiorly, the Cooper’s ligament should be visible. Feeling along the underside of the pubic symphysis, the pubic tubercle is used to orient the midline. The sutures that were placed at the midurethra are sutured first to the Cooper’s ligament 2 cm from the tubercle on



their respective sides. The sutures placed at the urethra–vesical junction are sutured 4 cm lateral to the tubercle. The sutures are then tied down gently. The key component in tensioning these sutures is that there should be no major elevation of the urethra or bladder neck. The urethra should be positioned at the level of the arcus tendineus fascia pelvis. This allows the tissue under the urethra to act as a hammock. We use a surgeon’s knot followed by approximately seven additional throws, watching carefully that the knots do not tighten and raise the tissue. We cut the sutures long in case we need to go back and remove them (if they are in the bladder or kink the ureters). Suture bridges should be visible. Overcorrection of the bladder neck will contribute to urinary retention and lower urinary tract symptoms. Cystoscopy must be performed to confirm that there are no injuries to the bladder, ureters, or urethra. The space of Retzius is very vascular. Bleeding caused by retraction or from suture placement is common. Placing sutures to stop bleeding usually makes it worse. We prefer to use a liquid-based hemostatic agent placed on the underside of an absorbable hemostatic matrix. Using a forceps, the hemostatic material is placed directly onto the bleeding tissue and pressure is held with a sponge stick for a minimum of 5 minutes. If bleeding continues, the same technique is repeated for 10 minutes. If bleeding still continues, we repeat this again for 15 minutes. In our experience, rarely will bleeding continue after 30 minutes. In these cases, suture ligation may be needed. As with slings, a voiding trial is needed. Patients with long-term incomplete bladder emptying may ultimately need to go back to the operating room to cut the sutures and straighten out the urethra if it was overcorrected.

URETHRAL BULKING AGENTS The purpose of urethral bulking is to cause a static increase of resistance in the urethral outlet (Fig. 5). A material is injected into the suburethral tissue, which narrows the lumen of the urethra. Originally developed in the early 1990s with the advent of bovine collagen injections, a multitude of injectable products has been come to the market.88 Each of these has its pros and cons, but as a treatment class, it is usually not considered a first-line therapy for SUI. Success rates are variable and range from 60% for short-term improvement to a 50% 1-year cure. Long-term success rates are fleeting and treatment needs to be repeated within a year or two.88,89 Bulking agents can be synthetic or biologic. No optimal material or technique has been identified that would make one significantly


Fig. 5. Periurethral bulking agents are injected into the submucosa of the bladder neck and proximal urethra for stress urinary incontinence. Reprinted from Rackley RR, Gill B, Firoozi F, Schwartz BF, Talavera F. Injectable bulking agents for incontinence. Image reprinted with permission from Medscape Reference (http://emedicine.medscape. com/), 2014, Available at: http://emedicine.medscape.com/ article/447068-overview. Garely. Stress Incontinence Evaluation and Treatment. Obstet Gynecol 2014.

superior to the others. This therapy is usually reserved for patients who are absolutely not candidates for any other type of surgical intervention or for patients who have failed a previous sling or Burch procedure and need further improvement. The procedure is designed to be done in the office. The material can be injected either externally, lateral to the urethral meatus, or internally, through a cystoscope inside the urethra. We have found that cystoscopic injection yields more accurate placement. We topically anesthetize the urethra with 2% lidocaine jelly. Depending on the material used, the needle gauge may vary, but the needle should be placed through the operative channel of a 12° cystoscope before starting the procedure. The material usually comes preloaded in 1-cc syringes. A syringe is screwed onto the needle hub. Using a video system, the scope is inserted through the urethra and into the bladder with the water flowing through the scope. The needle is advanced until it is visible at the tip of the scope. The syringe with the injectable is pushed gently until the material is seen at the needle tip. The needle is withdrawn into the scope. With the water still running, the scope is slowly pulled back into the urethra. The bladder neck will come into view followed by circumferential visualization of the urethra. Based on the average urethral length of 4 cm, the scope is placed approximately 2 cm from the bladder neck. There is no consensus regarding where or how much material to place, but we prefer to inject at the 12, 3, 6, and 9 o’clock positions. We can usually see good coaptation of the urethra with between 1 and 3 cc of

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injected material. At this point the cystoscope is withdrawn and the bladder emptied with a pediatric Foley catheter. A small amount of bleeding is expected. Although postprocedure urinary retention is possible, it is not common and usually resolves spontaneously once tissue swelling abates. We have the patient take nitrofurantoin twice daily for 3 days.

ARTIFICIAL SPHINCTERS An artificial sphincter is basically a blood pressure cuff around the urethra. Inflating the cuff maintains continence, and deflating allows voiding. The use of this device has never been indicated as a primary treatment modality in the United States. Reasons for its lack of popularity include surgical complexity and a high rate of postoperative infections. Patients who have an intact urethral sphincter but are unable to achieve continence with slings or retropubic urethropexy are candidates for artificial urethral sphincters. Continence rates after implant range from 70% to 90%. The major complications are erosion of the cuff into the urethra and infection.90,91 Over a 10-year period, 10–20% of implants will result in a complication. Artificial sphincters are implanted by very few surgeons and definitely not by general gynecologists. Description of the surgical technique is beyond the scope of this article.

CONCLUSION AND FUTURE CONSIDERATIONS The prevalence of SUI will only increase as our population continues to age. Before treatment, women who have urinary leakage will often experience a significant decrease in quality of life. Predictably, avoidance mechanisms come into play. Women will isolate themselves, stop engaging in social activities, and some will drop out or limit participation in the workforce. All of these factors put pressure on the family unit and, in cases where women are older, may result in nursing home placement. Using low-technology office diagnostics, SUI is a relatively easy condition to diagnose. Treatment options range from pelvic floor muscle training to surgery. Recent data confirm a long-held belief by many gynecologic surgeons that surgical intervention has higher cure rates than conservative therapy. Since the 1990s, minimally invasive approaches to treatment have exploded. Inpatient laparotomies have been replaced with outpatient slings. We have transformed the treatment paradigm with outstanding success. Today, there are few women who do not qualify for at least some form of therapy. This review emphasizes the importance of proper diagnosis and treatment. Formal education and training

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such as that mandated in the 2014 Bulletin for subspecialty certification in Female Pelvic Medicine and Reconstructive Surgery from the American Board of Obstetrics and Gynecology ensures that competent and skilled physicians are qualified to provide appropriate care. The hallmark of a good surgeon goes beyond being a skilled technician. The ability to handle both acute and chronic complications is paramount. Although all of our current surgical strategies are based on repositioning and recorrecting weakened anatomy, the future is even more exciting. Working on the premise that all we need for success is a stronger urethral sphincter, preliminary studies using stem cells have shown promise. Rather than support weakened tissue, progress is being made to replace it and make it better. Early research with skeletal muscle-derived stem cells has given rise to adipose-derived stem cells, which are easier to cultivate and inject.92 In the age of molecular and regenerative medicine, the next cadre of physician scientists will be directing the field of female pelvic medicine and reconstructive surgery into new arenas. State-of-the-art bioengineering and well-designed clinical trials will hopefully provide curative therapy for all. REFERENCES 1. Haylen BT, de Ridder D, Freeman RM, Swift SE, Berghmans B, Lee J, et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female pelvic floor dysfunction. Neurourol Urodyn 2010;29:4–20. 2. Dooley Y, Kenton K, Cao G, Luke A, Durazo-Arvizu R, Kramer H, et al. Urinary incontinence prevalence: results from the National Health and Nutrition Examination Survey. J Urol 2008;179:656–61. 3. Wilson L, Brown JS, Shin GP, Luc KO, Subak LL. Annual direct cost of urinary incontinence. Obstet Gynecol 2001;98: 398–406. 4. Thorp JM Jr, Norton PA, Wall LL, Kuller JA, Eucker B, Wells E. Urinary incontinence in pregnancy and the puerperium: a prospective study. Am J Obstet Gynecol 1999;181: 266–73. 5. Burgio KL, Zyczynski H, Locher JL, Richter HE, Redden DT, Wright KC. Urinary incontinence in the 12-month postpartum period. Obstet Gynecol 2003;102:1291–8. 6. Fritel X, Ringa V, Varnoux N, Fauconnier A, Piault S, Bréart G. Mode of delivery and severe stress incontinence. a cross-sectional study among 2,625 perimenopausal women. BJOG 2005;112:1646–51. 7. Viktrup L, Lose G. The risk of stress incontinence 5 years after first delivery. Am J Obstet Gynecol 2001;185:82–7. 8. Subak LL, Richter HE, Hunskaar S, Obesity and urinary incontinence: epidemiology and clinical research update. J Urol 2009;182(suppl):S2–7. 9. Melville JL, Katon W, Delaney K, Newton K. Urinary incontinence in US women: a population-based study. Arch Intern Med 2005;165:537–42.



10. Grodstein F, Fretts R, Lifford K, Resnick N, Curhan G. Association of age, race, and obstetric history with urinary symptoms among women in the Nurses’ Health Study. Am J Obstet Gynecol 2003;189:428–34. 11. Nout RA, van de Poll-Franse LV, Lybeert ML, WárlámRodenhuis CC, Jobsen JJ, Mens JW, et al. Long-term outcome and quality of life of patients with endometrial carcinoma treated with or without pelvic radiotherapy in the post operative radiation therapy in endometrial carcinoma 1 (PORTEC-1) trial. J Clin Oncol 2011;29:1692–700. 12. Erekson EA, Sung VW, DiSilvestro PA, Myers DL. Urinary symptoms and impact on quality of life in women after treatment for endometrial cancer. Int Urogynecol J Pelvic Floor Dysfunct 2009;20:159–63. 13. Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al. The standardisation of terminology in lower urinary tract function: report from the standardisation sub-committee of the International Continence Society. Urology 2003;61:37–49. 14. McGuire EJ, Lytton B, Kohorn EI, Pepe V. The value of urodynamic testing in stress urinary incontinence. J Urol 1980; 124:256–8.

27. Byrne DJ, Stewart PA, Gray BK. The role of urodynamics in female urinary stress incontinence. Br J Urol 1987;59:228–9. 28. Cantor TJ, Bates CP. A comparative study of symptoms and objective urodynamic findings in 214 incontinent women. Br J Obstet Gynaecol 1980;87:889–92. 29. Summitt RL Jr, Stovall TG, Bent AE, Ostergard DR. Urinary incontinence: correlation of history and brief office evaluation with multichannel urodynamic testing. Am J Obstet Gynecol 1992;166:1835–40. 30. Jensen JK, Nielsen FR Jr, Ostergard DR. The role of patient history in the diagnosis of urinary incontinence. Obstet Gynecol 1994;83:904–10. 31. Weidner AC, Myers ER, Visco AG, Cundiff GW, Bump RC. Which women with stress incontinence require urodynamic evaluation? Am J Obstet Gynecol 2001;184:20–7. 32. Barnick CG, Cardozo LD, Benness C. Use of routine videocystourethrography in the evaluation of female lower urinary tract dysfunction. Neurourol Urodyn 1989;8:447–9. 33. Sultana CJ. Urethral closure pressure and leak-point pressure in incontinent women. Obstet Gynecol 1995;86:839–42.

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16. HCUP Nationwide Inpatient Sample (NIS). Healthcare cost and utilization project (HCUP). Rockville (MD): Agency for Healthcare Research and Quality; 2007–2009.

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Artículos de las Series de Especialidad Clínica— Ahora en Español! La traducciones de los artículos de las Series de Especialidad Clínica publicados a partir de abril de 2010 están disponibles en línea solamente en http://www.greenjournal.org. Para ver la colección entera de artículos traducidos, haga click en “Collections” y luego seleccione “Translations (Español).” rev 7/2013


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Diagnosis and surgical treatment of stress urinary incontinence.

Incontinence: Stress urinary incontinence treatment--surgery first?

[Diagnosis of urinary stress incontinence in men].

Surgical treatment of neurogenic stress urinary incontinence: A systematic review of quality assessment and surgical outcomes.

[Urogynecology II: urinary incontinence in men and women: surgical treatment of urinary incontinence and prolapse].

Treatment of recurrent stress urinary incontinence in women: comparison of treatment results for different surgical techniques.

Non-surgical treatment of stress incontinence.

Urinary incontinence: Comparing AFS and TVT for stress urinary incontinence.

Diagnosis, Evaluation, and Treatment of Mixed Urinary Incontinence in Women.

Committee opinion: evaluation of uncomplicated stress urinary incontinence in women before surgical treatment.

Urinary incontinence and neuropathy after radical prostatectomy: diagnosis and treatment.

Nationwide database of surgical treatment pattern for patients with stress urinary incontinence in Korea.

Committee Opinion No. 603: Evaluation of uncomplicated stress urinary incontinence in women before surgical treatment.

Single-Incision Slings (SIS) - a New Option for the Surgical Treatment of Female Stress Urinary Incontinence.

Intraurethral injection of autologous minced skeletal muscle: a simple surgical treatment for stress urinary incontinence.

Classification of stress urinary incontinence.

Cost utility of the treatment of stress urinary incontinence.

Treatment of stress urinary incontinence with a generic transobturator tape.

Physiotherapy for stress urinary incontinence.

[Modern operative treatment possibilities in male stress urinary incontinence].

[Treatment of female stress urinary incontinence. Value of classical incontinence operations].

[Surgical procedure in stress incontinence].

Surgical Treatment of Stress Urinary Incontinence in Women in the Mainland of China: Current Status and Outlook.

Conservative management of stress urinary incontinence.