Stress Incontinence: An evidence-based management approach Prof. Hesham Salem. M.D. Ob. Gyn Alexandria University

USI as recently defined by the International Continence Society, is the complaint of involuntary leakage of urine during effort or exertion or during sneezing or coughing. More than 200 operative procedures have been described for the treatment of USI. Many of these are modifications of the same procedure; but there is not one single definitive operation. Surgery is recommended if conservative treatment fails i.e. cure rates of around 50% have been reported with physiotherapy.

Anterior repair Evidence level Ia RCOG Guideline No. 35 Anterior repair is less successful as an operation for continence than retropubic procedures and has been superseded by sling procedures. Anterior repair still has a role in the treatment of prolapse without incontinence.

Anterior repair The Cochrane Collaboration. Anterior vaginal repair was found to be less effective than open abdominal retropubic suspension. This was based on woman-reported continence rates in eight trials both in the short and long term These findings held irrespective of the coexistence of prolapse. The correct operation for the woman with stress incontinence in the presence of anterior wall prolapse is currently unclear.

Burch colposuspension Evidence level Ia RCOG Guideline No. 35 Burch colposuspension is the most effective surgical procedure for stress incontinence, with a continence rate of 85–90% at one year. The continence rate falls to 70% at five years; this shows better longevity than other methods of treatment.

Burch colposuspension The Cochrane Collaboration. A Cochrane review concluded that open colposuspension is the most effective surgical treatment for stress incontinence, especially in the long term. There was no evidence of increased morbidity or complication rate with open colposuspension compared with other techniques, although posterior pelvic-organ prolapse is more common than after anterior colporrhaphy and sling procedures.

Burch colposuspension To do It is sometimes easier to dissect the bladder from the vagina with 50 or 100 cm 3 of water or urine in the bladder, because the bladder’s boundaries are easier to recognize. Let the assistant tie the sutures while the surgeon’s left hand remains intravaginally to control the ‘tension’ of the sutures, or vice versa. Not to do Excessive mobilization causes denervation. Sutures tied too tightly cause urge and residual urine.

Alternative suprapubic surgery Evidence level Ia RCOG Guideline No. 35  The role of other suprapubic operations such as Marshall–Marchetti–Krantz (MMK), paravaginal repair and laparoscopic colposuspension, is unclear.  The operation was less successful than Burch colposuspension at correcting a cystocele.  In a Cochrane review,MMK was more likely to fail at five years than Burch colposuspension.

Alternative suprapubic surgery Evidence level III RCOG Guideline No. 35 Paravaginal repair was first described by White in Randomised comparison of colposuspension with paravaginal repair; at six months follow-up, there was an objective continence rate of 100% for those patients undergoing colposuspension but only 72% for those undergoing paravaginal repair. Currently, the importance of recognition or repair of paravaginal defects is uncertain.

Laparoscopic colposuspension Evidence level Ia RCOG Guideline No. 35 Laparoscopic colposuspension has been the subject of several case series and cohort studies,which show similar continence rates between laparoscopic and open Burch colposuspension.

Laparoscopic colposuspension the Cochrane collaboration A Cochrane review published in 2002 examined eight eligible trials, of women receiving laparoscopic Vs. open colposuspension. Subjective continence rates were similar at 6 –18 months (85–100%) but there was some evidence of poorer objective outcomes for the laparoscopic operation There were no significant differences for postoperative detrusor overactivity or voiding difficulty. There were trends towards a higher complication rate and longer operative times, shorter hospital stay and earlier return to normal activities for the laparoscopic procedure.

Needle suspension procedures Evidence level Ia RCOG Guideline No. 35 Needle suspension procedures should not be performed: initial success rates are not maintained with time and the risk of failure is higher than for retropubic suspension procedures. The first procedure was described by Peyrera and numerous procedures have subsequently evolved from this, including the Gittes and the Stamey procedure, using suspending sutures and patch materials. Procedures have evolved to include the percutaneous bladder-neck suspension using bone anchors and a suspending system.

Needle suspension procedures Cochrane review Needle suspensions were more likely to fail than open retropubic procedures and there were more perioperative complications in the needle suspension group. Needle suspensions may be as effective as anterior repair but carry a higher morbidity.

Sling procedures Evidence level III RCOG Guideline No. 35  Sling procedures, using autologous or synthetic materials, produce a continence rate of approximately 80% and an improvement rate of 90%, with little reduction in continence over time.  Only one synthetic sling procedure (tension-free vaginal tape) has been subjected to randomised study to date.

Conclusion 1 American Urological Association The American Urological Association considered that ‘Retropubic suspensions and slings are the most efficacious procedures for long-term success based upon cure/dry rate. However, in the panel’s opinion, retropubic suspensions and sling procedures are associated with slightly higher complication rates. In patients who are willing to accept a slightly higher complication rate for the sake of long-term cure, retropubic suspensions and slings are appropriate choices. The Second International Consultation on Incontinence concluded that suburethral slings represented ‘an effective procedure for genuine stress incontinence in the presence of previous failed surgery

Tension-free vaginal tape (TVT)  The Prolene® (Ethicon) tension-free vaginal tape (TVT) is relatively new, although increasing numbers of cohort studies of its use are being reported.  The six-month subjective and objective results of a randomized trial between TVT and Burch colposuspension showed a similar continence rate from both procedures.  Complete dryneness in both groups was 38% and 40% respectively (based on a rigorous definition of cure).

Suburethral slings Cochrane review  A Cochrane review compared suburethral slings with open abdominal retropubic suspensions.  For short-term cure, overall rates are similar to open abdominal retropubic suspension.  About 1/11 had a complication during TVT, most commonly bladder perforation, although serious consequences are rare.

TVT-O procedure A new TVT-O procedure (Gynecare, Ethicon) using an inside-out approach to minimize urethral and bladder injury has been proposed. But, at this time, there is no objective evidence that it is any safer than the out-inside type sling procedure. Neuman compared two anti-incontinence operations: the TVT and the TVT-O for the first two 75 patients groups. In this studies, the TVT-obturator patients seem to have less intra-operative and post-operative surgical complications than the TVT patients with the same early therapeutic failure rates, respectively 1.3% and 2.7% with one year follow-up.

Transobturator Tension-Free Sling Operations To do Whenever you are not sure about the bladder’s integrity, do a cystoscopy. Be as cautious with transobturator systems as you would be with retropubic systems. If you think you will have to do an anterior colporrhaphy at the same time, use a transobturator system; this cannot shift towards the bladder neck because of its different fixations on both sides. Not to do Do not apply tension to the tape. Do not use a hook-shaped instrument to go from the inside out—you may lose your way and end up in the obturator vessels.

Injectable agents Evidence level III RCOG Guideline No. 35 oInjectable agents have a lower success rate than other procedures: a short-term continence rate of 48% and an improvement rate of 76%. oLong term, there is a continued decline in continence. oHowever, the procedure has a low morbidity and may have a role after other procedures have failed,

Artificial sphincters Evidence level III RCOG Guideline No. 35 Artificial sphincters can be successfully used after previous failed continence surgery but have a high morbidity and need for further surgery (17%)

Preoperative management Evidence level Ia RCOG Guideline No. 35 It is recommended that women undergoing surgery for urodynamic stress incontinence should have urodynamic investigations prior to treatment (including cystometry).

CONCLUSIONS The Burch colposuspension has been considered as the gold standard, as a result of long-term objective incontinence cure rates. Since 1996, when TVT was first introduced, it has been used extensively with high success rates, equivalent with Burch colposuspension and with less morbidity. In 2001, the transobturator vaginal tape was introduced, using either the out-in or the in-out approach for the placement of the tape. The TOR is appealing because of its simplicity, safety, and the lower risk of bladder perforation. The RCTs showed no difference in outcomes between out-in and in-out approaches. Experience showed a shorter learning curve with the in- out route,

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