Laparoscopic Surgical Treatment for Stress Urinary
Urinary incontinence is the involuntary loss of urine to the degree that is socially and hygienically unacceptable to the patient. The amount of leakage, which varies from a few drops to a large gush, usually increases with age. However, urinary incontinence is not a normal consequence of aging. The different types of urinary incontinence are as follows:
- Genuine stress incontinence: Leakage resulting from any type of straining (coughing, laughing, sneezing, or lifting) that puts pressure on the bladder.
- Urge incontinence: Leakage from an overactive bladder which cannot be suppressed and controlled.
- Mixed incontinence: A combination of genuine stress and urge incontinence.
- Overflow incontinence: Leakage occurring with over-distention of the bladder, which usually results from partial obstruction of the urethra, thereby causing a constant dripping of urine.
Treatment for urinary incontinence varies depending on the type of incontinence. The first step in treatment is accurate diagnosis. This consists of the patient's medical and urological history, physical and pelvic examination, and some simple office tests, such as post void residual urine to determine the amount of urine left in the bladder after voiding, and the Q-tip test to determine the mobility of the urethra and the presence of any anatomic component to the incontinence. Additional tests may be necessary in more complicated cases. These may include multi-channel urodynamic studies, which tests nerve conduction and the dynamics of the various phases of bladder function, including the filling, storage, and emptying phases. A cystoscopic examination may also be necessary if any bladder irritability with incontinence is exhibited.
Conservative therapy may involve hormonal replacement, medication, pelvic floor exercises, bladder retraining, and life style modification such as weight reduction or avoidance of foods that irritate the bladder. Other options include the use of a urethral plug or a vaginal pessary. Surgical treatment is only effective with genuine stress urinary incontinence, in which the urethra becomes either hypermobile and unstable, or its intrinsic sphincter becomes incompetent, resulting in urine leakage with physical stress. The goal of surgery is to stabilize the hypermobile urethra and to restore competence of the urethral sphincter. Over 200 different anti-incontinence surgical procedures have been reported in the literature, the vast majority of which show poor long-term results. Recently there seems to be a consensus, especially among gynecologists and urogynecologists, that retropubic colposuspension (Burch procedure) is the surgical choice for incontinent patients with hypermobile urethra, and the suburethral sling procedure for patients with urethral sphincteric deficiency. With advanced technological development in laparoscopic and video equipment and the improved skill in performing operative laparoscopy, we have experienced highly successful laparoscopic Burch and laparoscopic suburethral sling procedures for our patients suffering from genuine stress urinary incontinence.
Advantages of Laparoscopic Surgery for Urinary Incontinence
The laparoscope is a small telescope-like instrument (one-half to one centimeter in diameter) inserted into the abdominal cavity through a tiny incision inside the navel. A bright light shines directly onto the operative field through the laparoscope, and with a very sophisticated video camera, the operative field can be greatly magnified onto the high resolution video monitor. This allows the surgeon to view the operative field in superb detail. With such visibility, the surgeon can then perform accurate tissue dissection in their right planes, thus greatly reducing blood loss, place sutures precisely, approximate tissues without undue tension, avoid damaging the blood vessels, and achieve perfect hemostasis. In minimally invasive laparoscopic surgery, only tiny incisions are used, blood loss is minimized, tissues can be gently handled, and disruption to the surrounding abdominal and pelvic organs is drastically reduced. The patient typically experiences much less discomfort and pain postoperatively, has quicker recovery and shorter hospital stay. Dr. Liu has been performing laparoscopic surgery for urinary incontinence for the past 16 years, and more than 90% of his patients go home within 23 hours of surgery as compared to an average of 3-5 days with traditional open surgery. Patients are allowed to drive within one week and to return to work within two weeks after surgery, provided that their job does not involve much physical exertion. Our long-term outcomes of the surgery (more than 5 years follow up) are equal to, if not better than, the results of traditional open surgery.
Laparoscopic Burch Procedure (Retropubic Bladder Neck Suspension)
The first report for retropubic bladder suspension for the treatment of urinary incontinence was in 1949 by Drs. Marshall, Marchetti, and Krantz. In 1961, Dr. John Burch modified the Marshall Marchetti-Krantz procedure to avoid complication and to improve surgical outcomes. In 1976, Dr. Emil Tanago modified the Burch procedure, which proved to be very effective in correcting stress urinary incontinence caused by hypermobility of the urethra. This surgical technique has become the gold standard for surgeons performing the Burch procedure. In 1991, Dr. Liu performed the first laparoscopic Burch bladder neck suspension using Tanago technique. With a bright fiberoptic light directly shining on the retropubic space and the magnification provided by video laparoscopy, Dr. Liu was able to view the anatomy in great detail and to perform delicate tissue dissection with minimal blood loss. Furthermore, he found greater precision in ability to place sutures and re-suspension of the bladder neck without undue tension. The patient's postoperative recovery was beyond expectations, with that first patient going home within 24 hours of surgery! Since 1991, he has performed more than 600 cases of laparoscopic Burch bladder neck suspension with excellent long-term results. In summary, laparoscopic Burch procedure is quick, almost bloodless, and very effective. Compared to the traditional open Burch procedure, the patient has no large abdominal scar, has much less postoperative discomfort and pain, and a shorter hospitalization and recovery period.
Laparoscopic Suburethral Sling Procedure
The suburethral sling procedure is the surgical treatment of choice for severe stress urinary incontinence caused by incompetence of the internal sphincter of urethra. In such cases, the internal sphincter of the urethra is incompetent and is open with small amounts of urine retained in the proximal part of the urethra which drives the entire urethra open during physical stress, thereby causing leakage. The Burch bladder neck suspension is ineffective in treating this type of incontinence; however, the suburethral sling has more than 90% cure rate for this type of incontinence. The suburethral sling procedure places the center of the graft beneath the bladder neck and anchors both ends of the sling to the anterior abdominal wall or to the Cooper's ligament (a strong tissue just above the pubic bone in the pelvis). The sling graft works as a block to close the bladder neck during increases in intraabdominal pressure caused by physical stress. There are basically two types of graft materials available for the sling; organic and synthetic materials. Because synthetic graft materials have high a incidence of infection, erosion, and rejection by the body, organic graft either obtained from the patient's own body(autologous graft) or from cadavera source (heterologus graft) is preferred. Dr. Liu performs the laparoscopic suburethral sling procedure first by obtaining a strip of fascia (a very strong and tough tissue just on top of the muscle) from the patient's thigh if she is not frail and has good fascia. This causes only minimal discomfort to the patient, but a small half-inch long scar above the knee on the lateral side of the thigh is left. If the patient is old and frail, treated cadavera fascia which is expensive but almost as good as patient's own fascia is used. The fascia graft is placed into the retropubic space through the laparoscope after the retropubic space is dissected out laparoscopically. A small half-inch incision is made over the bladder neck on the anterior vaginal wall. A long clamp with a sharp end is then put into the retropubic space on one side of the bladder neck through the vaginal incision. One end of the sling graft is grasped and pulled back into the vagina by the clamp, and then with the sling at the tip of the clamp, the clamp is again placed back into the retropubic space vaginally on the other side of the bladder neck. Both ends of the sling graft then are sutured to the Cooper's ligament laparoscopically, and the vaginal incision is closed with a few stitches. Unlike the traditional suburethral sling procedure which basically is performed blindly with the surgeon using tactile feelings of his/her fingers to guide the placement of the sling, the laparoscopic suburethral sling procedure is carried out entirely under the direct visualization of the operative field. The sling graft can be placed with precision. Furthermore, a complete hemostasis can also be achieved by the laparoscopic approach. We have been using laparoscopic suburethral sling procedures for our patients who suffer from severe urinary incontinence due to incompetent urethral sphincter for the past six years with highly satisfactory results.
Being the pioneer and developer of the Laparoscopic Burch Bladder Neck Suspension and the Laparoscopic Suburethral Sling Procedure, Dr. Liu has performed the largest series of laparoscopic Burch procedure and laparoscopic suburethral sling procedure in the world.
Frequently Asked Questions
Can surgery be used to treat urinary incontinence?
Although urinary incontinence does not jeopardize physical health, it does interfere with a woman's lifestyle. For those who have tried medication and exercise for relief of incontinence but are still plagued by bothersome symptoms, surgery is an option that may restore a quality of life free from wetness, worry, embarrassment. As mentioned in our introductory section, four basic types of urinary incontinences exist:
- Stress urinary incontinence.
- Urge urinary incontinence.
- Mixed urinary incontinence.
- Overflow urinary incontinence.
The goal of surgery is to restore the bladder and urethra to their normal positions or to provide a sling compression of the bladder neck during stressful events. Surgery is most effective when stress incontinence is a major component of the incontinence. Surgery is less effective for urge incontinence.
How is recovery following a laparoscopic surgery for urinary incontinence?
Most women can go home within 23 hours of the surgery. Because the incisions are small, there is minimal pain, and the patient can be up and walking the next day after surgery. Since the supporting tissue to the bladder is involved during surgery, a suprapubic urinary catheter (a tiny catheter placed into the bladder through a small incision above the pubic bone) is routinely used for draining the bladder during the first few days of surgery. The suprapubic catheter usually is removed within the first 2-3 days after the laparoscopic Burch procedure and 5-6 days after a laparoscopic suburethral sling procedure. Normal activities can be resumed within 7-10 days. However, as with all bladder operations, the sutures must heal and fibrosis (scarring) must firm up so that the repair work will hold. This healing process takes about 3 months to complete, so no strenuous physical activities should be undertaken during that time.
What are TVT, PVT, and TOT?
TVT, PVT, and TOT are new procedural options for placement of synthetic sling material at the mid-urethra for the treatment of stress urinary incontinence.
TVT (Tension Free Vaginal Tape) is a new procedure developed in Sweden in 1995, and has since been performed widely over Europe and United States with good results. The procedure is similar to the sling in that a hammock is formed under the middle portion of the urethra to bolster it and prevent urine leakage when the area is physically stressed due to such activities as coughing, laughing, or jogging. The procedure takes approximately 45 minutes to one hour and may be performed under local or epidural anesthesia. Usually, patients can urinate without any problem immediately afterwards, and they can leave the hospital generally within 23 hours after surgery. The success rate has been found to be about 85-90% in women 5 years after their surgery, a rate comparable to the Burch procedure. However, because the TVT procedure is new, long-term outcomes and risks are still unknown. The major complications of TVT include bowel and large vessel injury, bladder perforation, and retropubic hematomas. Furthermore, TVT should not be performed on patients who have had low abdominal or pelvic surgery, because of a higher rate of complications among those patients. To avoid complications in those patients, TOT may be performed.
PVT (Percutaneous Vaginal Tape) and TOT (Trans-Obturator tension-free vaginal Tape) have been recently approved by FDA for the treatment of stress urinary incontinence. Both procedures use sling material composed of polypropylene mesh, a non-absorbable synthetic material, placed at the level of the mid-urethra via a suprapubic approach (PVT) or via the vaginal approach (TOT).
A thin strip of Prolene tape is used to form a hammock under the middle portion of urethra. Like the sling, the procedure is performed through a small (2 cm) incision in the vagina at the level of mid-urethra. A loose hammock is made beneath the urethra, and the ends of the hammock are pulled up through two very small incisions made side by side in the skin just above the pubic bone. The tape is carried up to the abdominal wall with an instrument that avoids the need for surgeon to make a tunnel. The tape is placed below the mid-urethra, the extra material is trimmed, and the incisions on the skin's surface are closed. PVT uses the reverse procedure of TVT by putting ligature carriers from the suprapubic region down toward the mid-urethra. The tape of TOT is placed through the obturator foramen in the pelvis.
Because the synthetic material (polypropylene or Prolene) of the tape is known to produce extensive scarring and fibrosis, the long-term adverse effects on the neurovascular system around the urethra is yet to be determined. The TVT procedure is new, and long-term outcomes and risks are still unknown. The major complications of TVT include bowel and large vessel injury, bladder perforation, and retropubic hematosis.
What is an anterior vaginal repair?
An anterior vaginal repair, or cystocele repair, is one of the older surgeries developed to support the bladder and urethra to prevent incontinence. The anterior vaginal repair is performed through a vaginal incision just under the bladder and urethra and uses absorbable sutures to plicate the strong vaginal tissue for support. This pushes and elevates the bladder and urethra back closer to their original positions. Unfortunately, this operation does not work very well for incontinence, with only 37% of women experiencing long-term cure (5 years). Many gynecologists in the United States are still using this operation for cystoceles and incontinence even though it is no longer considered an effective treatment.
What is a needle bladder neck suspension?
There are various techniques of needle suspensions used for the treatment of stress urinary incontinence, including Pereyra, Stamey, Raz, and Gettis procedures. The basic surgical techniques are the same except some minor modifications. Basically, a small vaginal incision is made around the urethra exposing the supporting tissues of the urethra. Through this vaginal incision, non-absorbable stitches are placed in the supporting tissue next to the bladder neck and proximal part of urethra. The end of these long sutures are then threaded through the end of a long, narrow instrument and pulled back through a small (2 cm) incision over the pubic bone. The sutures are then tied to the layer of strong fascia on top of the abdominal muscles.
Whereas the Burch procedure attaches the urethra to an immovable pubic ligament, the vaginal needle suspension operation attaches the urethra to connective tissue and muscles that move and, therefore, can stretch or break the sutures. This stretching and breaking of sutures probably account for the high failure rate (with cure rates less than 45% after 5 years).
Can surgery be used to treat mixed urinary incontinence?
Mixed urinary incontinence means the patient has both stress incontinence and urge incontinence. There are several issues the patient needs to understand before agreeing to surgery. Surgery can put the urethra and bladder back where they belong, but this may only cure the stress component of the incontinence. However, the symptoms of urgency may continue and cause incontinence and wetness. To completely address mixed incontinence, surgery should be combined with proper diet, pelvic muscle exercise, and medications.
Some women with prolapse have both stress and urge incontinence. Repairing the prolapse will cure both types of incontinence in approximately two-thirds of these women. This is especially likely if the urge incontinence developed only after the prolapse. The other one-third of women will still require medication to address the urinary urgency.