Laparoscopic Surgical Treatment for Stress Urinary Incontinence

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. There are several different types of urinary incontinence:

Genuine stress incontinence is leakage resulting from any type of straining (coughing, laughing, sneezing, or lifting) that puts pressure on the bladder.

Urge incontinence is leakage from an overactive bladder. which cannot be suppressed and controlled.

Mixed incontinence is a combination of genuine stress and urge incontinence.

Overflow incontinence is leakage occurring with overdistention of the bladder, this 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 (the amount of urine left in the bladder after voiding), Q-tip test (this tells us how mobile the urethra is, and if there is an anatomic component to the incontinence). Additional tests may be necessary in more complicated cases. These may include multichannel urodynamic studies, which test the dynamics of various phases of bladder function, including bladder's filling, storage, and empting phases, plus nerve conduction . A cystoscopic examination may also be necessary if patient exhibit any bladder irritability with incontinence.

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 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 restore the competence of urethral sphincter. Over 200 different anti-incontinence surgical procedures have been reported in the literatures, the vast majority of them have 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 suburethral sling procedure for patients with urethral sphincteric deficiency. With advanced technologic development in laparoscopic and video equipment and the improved skill in performing operative laparoscopy, we have no difficulty in performing the Burch and suburethral sling procedures laparoscopically 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 directly shines 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 surgery with a laparoscope, a large abdominal incision can be avoided, blood loss minimized, tissue handled very gently, and disruption to the surrounding abdominal and pelvic organs greatly reduced. The patient typically experiences much less discomfort and pain postoperatively, has quicker recovery and shorter hospital stay. I have been performing laparoscopic surgery for urinary incontinence for the past 10 years, and more than 90% of my patients go home within the first 23 hours of surgery (versus an average of 3-5 days with traditional open surgery). All my patients are allowed to drive in one week and return to work within 2 weeks after surgery, providing their jobs do not require much physical exertion. Our long-term outcome 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 of Nashville, modified the Marshall Marchetti-Krantz procedure to avoid complication, and to improve the surgical outcomes. In 1976, Dr. Emil Tanago of San Francisco proposed some modifications to 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, I performed the first laparoscopic Burch bladder neck suspension by using Tanago technique. With a bright fiberoptic light directly shining on the retropubic space and the magnification provided by video laparoscopy, I was able to view the anatomy in great detail and to perform delicate tissue dissection with minimal blood loss. I was able to place sutures in a precise manner and to resuspend the bladder neck without undue tension. The patient's postoperative recovery was beyond our expectations. (My first patient went home within 24 hours of surgery!). Since 1991, I have 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 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 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 underneath the bladder neck and anchors both ends of the sling to the anterior abdominal wall or to the Cooper's ligament (a strong tissue located 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, we prefer using organic graft either obtained from the patient's own body(autologous graft) or from cadavera source (heterologus graft). I perform 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 patient's thigh if the patient is not frail and has good fascia. This does not cause much discomfort to the patient, but it does leave a small scar about half inch long on the lateral side of thigh just above the knee. If the patient is old and frail, I will use treated cadavera fascia which is expensive but almost as good as patient's own fascia. The fascia graft is placed into the retropubic space through the laparoscope after the retropubic space is dissected out laparoscopically. A small incision about an half inch then 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. Grasping one end of the sling graft and pulling it 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 few stitches. Unlike the traditional suburethral sling procedure which practically is performed blindly except by the tactile feelings of the surgeon 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 in laparoscopic approach to the suburethral sling. 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 6 years with very satisfactory results.

Dr. Liu is the pioneer who introduced the "Laparoscopic Burch Bladder Neck Suspension" and "Laparoscopic Suburethral Sling Procedure". The center has the largest series of laparoscopic Burch procedure and laparoscopic suburethral sling procedure by a single surgeon in the world.

Frequently Asked Questions

Can Surgery Be Used To Treat Urinary Incontinence?

Urinary incontinence never jeopardizes a woman's physical health, but it does play havoc with a woman's ability to live and enjoy her life. For those women who had tried medications and exercise for relief of incontinence but still are plauged by bothersome symptoms (socially embarrassing and hygienically unacceptable to her). For those women, surgery may restore a sense of basic good health and quality of life and free them of worry and wetness.

As we mentioned in our introductory section that there are basically four different types of urinary incontinences: Stress Urinary Incontinence, Urge Urinary Incontinence, Mixed Urinary Incontinence, and Overflow Urinary Incontinence. Surgery is most effective when stress incontinence is a major component of the incontinence, and it may help if some urgency accompanies stress incontinence. It is not likely to be effective for pure urgency or urge incontinence.

The goal of the surgery for the treatment of incontinence is to restore the bladder and urethra to their normal position or provide a sling compression of the bladder neck during stressful events.

What is the recovery like after a laparoscopic surgery for urinary incontinence?

Most women can go home within 23 hours of the surgery. Since the incisions are small, there is minimal pain, and you can be up and walk the next day of surgery. Since the supporting tissue for the bladder is involved during the surgery, a suprapubic urinary catheter (a tiny catheter put into the bladder suprapubically) is routinely used for draining the bladder for the first few days of surgery. The suprapubic catheter usually removed within the first 2-3 days after the laparoscopic Burch procedure and 5-6 days for laparoscopic suburethral sling procedure. You can be back to most normal activities within 7-10 days. However, as with all bladder operations, you will need to allow the sutures to heal and fibrosis (scarring) to firm up so that the repair work will hold. This healing process in our body takes about 3 months to complete, so no strenuous physical activities during that time.

What is TVT? What is PVT?

The Tension Free Vaginal Tape or TVT is a new procedure first developed in Sweden in 1995. This procedure is similar to the sling in principle it forms a hammock under the middle portion of urethra that bolsters it and stop the urine leakage when patient is under physical stress. Percutaneous Vaginal Tape is recently approved by FDA for the treatment of stress urinary incontinence. TVT and PVT are two new procedural choices for placement of synthetic sling material at the mid-urethra for the treatment of stress urinary incontinence. Both procedures use sling material composed of polypropylene mesh, a nonabsorbable synthetic material, placed at the level of the mid-urethra via an ategrade (PVT, using a percutaneous ligature carrier) suprapubic approach or retrograde (TVT, using vainal trocars) vaginal approach.

TVT has been performed widely over the Europe and United States with good results. The success rate is about 85 to 90% after 3 years which is comparable to Burch procedure. Surgery takes average about 45 minutes to one hour and may be performed under local or epidural anesthesia. Most women can leave the hospital within 23 hours of the surgery. Patient can usually urinate without problems immediately after surgery.

A thin strip of Prolene (a synthetic material) 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 properly below the mid-urethra, the extra material is trimmed, and the incisions on the skin 's surface are closed. PVT reverse the procedure of TVT by putting ligature carriers from suprapubic region down toward the mid-urethra.

The synthetic material ( polypropylene or Prolene) for the tape is well known to produce extensive scarring and fibrosis in human body, what kind of adverse effect will be on the neurovascular system around the urethra is yet to be determined. The TVT procedure is new, long-term outcomes and risks are still unknown. The major complications of TVT includes bowel and large vessel injury, bladder perforation, retropubic hematomas. TVT should not be performed on patients who have previous low abdominal or pelvic surgery due to higher rate of complication among those patients.

What is an anterior vaginal repair?

An anterior vaginal repair, or cystocele repair, is one of the older surgery 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 elevate the bladder and urethra back closer to their original positions. Unfortunately, this operation does not work very well for incontinence, with only37% of women having long-term cures (5 years). Many gynecologists in the United States are still suing this operation for correct the cystocele and incontinence even though it is no longer considered as an effective treatment for cystocele and incontinence.

What is a Needle Bladder Neck Suspension?

There are various techniques of Needle suspensions described for the treatment of stress Urinary incontinence that include Pereyra, Stamey, Raz, and Gettis procedures. However, the basic surgical techniques are the same except some minor modifications. Essentially, 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.

Where the Burch procedure attaches the urethra to an immovable pubic ligament, the vaginal needle suspension operation attach the urethra to connective tissue and muscles that move when you move and, therefore, can stretch or break the sutures. This stretching and breaking sutures probably account for the high failure rate of these operations (with cure rates in less than 45% after 5 years).

Can surgery be used to treat Mixed Urinary Incontinence?

Mixed urinary incontinence means the patient has both stress and urge incontinence. There are several issues 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 causes incontinence and wetness. To completely address mixed incontinence, surgery can be combined with proper diet, pelvic muscle exercise, and medications.

Some women with prolapse have both stress and urge incontinence. Fixing the prolapse will cure both in 2/3 of these women. This is especially likely if the urge incontinence only developed after the prolapse developed. The other 1/3 will still require medication to quiet down the urinary urgency.