Incontinence (cont.)

Surgical Treatment

Anterior Vaginal Repair

This procedure's primary purpose is to repair a cystocele in women (bladder descended into the vagina). A vaginal incision is used for vaginal repair; a vaginal or abdominal incision is used for the variation called paravaginal repair. The purpose of the procedure is to do two things: reduce the cystocele and reinforce the tissues that support the bladder and urethra.

This procedure was first described in 1913 and today is most commonly used when cystocele is an issue in addition to incontinence. Other procedures have had better success rates at curing stress incontinence.

Bladder Neck Suspension

First described in 1959, this type of surgery stabilizes the bladder and urethra. Several different techniques are used and may be referred to as retropubic suspension, transvaginal suspension and Marshall-Marchetti-Krantz (MMK) and Burch procedures, for example. These techniques basically elevate the bladder and urethra and are used for stress incontinence.

Generally, the surgeon stitches into the ligaments and tendons that provide support to the pelvic organs and these stitches are tied to the pelvic bone, for example, to provide support to the bladder and urethra. This can be done either through the vagina with a long needle or with an incision into the abdomen.

The laparoscopic Burch Procedure is a newer approach that accomplishes the suspension laparoscopically. Using an endoscope, which goes through the belly button, the abdomen is inflated and the tissue next to the bladder is lifted to reduce the pressure the bladder places on the urethra. The three to four small incisions require just a couple of stitches or surgical tape. The laparoscopic Burch procedure also offers a short hospital stay (one or two days), reduced recovery time and pain, lower cost, and smaller scars.

Sling Procedure

This procedure is most often performed for women with stress incontinence and is rarely used for men. The purpose of the procedure is to repair weakened urethral sphincter muscles by using a sling to compress the sphincter. This prevents urine from leaking when laughing, coughing, or doing other activities that can cause stress incontinence.

The sling is made out of abdominal tissue or synthetic tissue. The tissue is formed into a sort of hammock for the sphincter and is attached to pubic bone or the front of the abdomen (just above the pubic bone). The technique requires a small abdominal incision and (in women) a vaginal incision.

A recent advance is the Tension-Free Vaginal Tape Procedure. Also called TVT surgery for short, this variation on the sling procedure uses mesh-like tape under the urethra, which acts like a hammock to provide compression to the urethra sphincter. The TVT procedure requires no sutures and takes just 30 minutes under local or sedation anesthesia. The tape is inserted through small incisions in the abdomen and vaginal wall. You may be released the same day as surgery or stay overnight. People undergoing TVT typically have minimal pain and discomfort during and immediately after the procedure, but are instructed to avoid sex and strenuous activity for several weeks. Long-term success rates are very good and range from 80-90%.

Bulking Agent/Collagen Injection

This minor outpatient procedure is used for stress incontinence in men and women when the sphincter controlling outflow of urine is weakened or incompetent. Done under local anesthesia, collagen or another substance is injected into the area around the urethra. This adds bulk, which better compresses the sphincter. A skin test is required before the procedure to determine if any allergic reaction might occur to the collagen, if used.

The cure rate of this procedure is reported to be somewhat higher for women than men. The collagen used can be absorbed by the body over time, so the procedure may need to be repeated. In addition, other materials exist that work as effectively as collagen and may last longer (silicon-coated beads and Coaptite).

Artificial Urinary Sphincter

Performed most often for men and only rarely for women, this procedure creates a functioning artificial urinary sphincter using a cuff, tubing and pump. The cuff goes around the sphincter and is connected to a pump, which is placed in the scrotum for men and the labia for women. Squeezing the pump causes the pressure to be released in the cuff, thus allowing urination to begin.

This procedure is generally considered only after other treatments have failed, and it is most commonly done for men after prostate surgery. Because of where the pump is placed, activities such as bike riding may not be recommended.

Expectations

Each procedure has published cure rates that can range between 75 and 95%. If you are considering surgery for stress incontinence, ask your surgeon what his or her success rates have been for the proposed surgery. If surgery does not cure incontinence, it often does improve symptoms significantly.

Several factors can influence the success of any surgical procedure, such as medical conditions like diabetes, other genital or urinary problems, or previous surgical failures. Be prepared to undergo a thorough physical and testing to determine not only the cause of urinary incontinence, but also other factors that may influence success of a procedure.

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