Urinary incontinence in females - Operative management

1. OPERATIVE CHAT
anti-Incontinence surgery in
females
- Dr. Abhishek Pandey

2. SURGICAL METHODS
 Needle Suspension
 Retropubic Colposuspension
 Pubovaginal Sling (PVS)
 Mid-Urethral Sling (MUS)
 Tension-free Vaginal Tape (TVT)
 Trans-Obturator Tape (TOT)
 Injection Therapy

3. The Pressure Transmission Theory
• Descent of proximal urethra & bladder neck from
intra-abdominal location
• As urethra became hypermobile, intraperitoneal
forces could no longer constrict it
• Enhorning – 1961
• Basis of –
– Needle Suspension surgeries
– Retropubic Colposuspension surgeries

4. Needle Suspension Procedures

5. The Pereyra Procedure – 1959
• Wire sutures passed through retropubic space via
carrier needle looped through vagina
• No cystoscopic guidance
• Sutures cutting through
• Poor outcomes

6. The Stamey Procedure – 1973
• Endoscopic Transvaginal Needle Suspension
• T-shaped vaginal incision
• Dacron Buttresses
• No. 1 Nylon suture
• Cystoscopy

7. Raz modification of Pereyra – 1981
• Helical suture through vaginal
wall & pubocervical fascia
• Vaginal Inverted U incision
• No. 1 Prolene – 3 pass
• Epithelium excluded
• Cystoscopy

8. The Gittes Procedure – 1987
• No. 1 Prolene on No. 6 Mayo trochar needle – deep
helical bites of vaginal wall
& paraurethral tissue
• No vaginal incision
• No buttress

9. Benderev – The Vesica procedure – 1994
• Titanium bone anchors over pubic tubercles
• Spacer device b/w pubis
& suture knot for tying
• “Z” suture technique

10. Overview
• Needle suspension of bilateral periurethral tissue ±
vaginal wall
• Poor outcomes – 50-70%
• Suture cut-through, Bladder injury, Urethral injury,
Vaginal hematoma, Nerve entrappment, AUR, Pain
• Historical

11. Retropubic Colposuspension
1. Burch Colposuspension
2. Vagino-Obturator Shelf (VOS) procedure
3. Paravaginal repair
4. Cystourethropexy / Marshall-Marchetti-
Krantz (MMK) procedure

12. • Retropubic procedures restore bladder neck & proximal
urethra to retropubic position
• Used when hypermobility is the important factor
• If significant ISD present → SUI likely to persist
• Both Open & Laparoscopic – equal results
• Indicated if –
– concomitant laparotomy / laparoscopy
– Limited vaginal access

13. Burch Colposuspension - 1961
• Approximating periurethral fascia to the Cooper /
iliopectineal ligament with 3 pairs of sutures

15. Paravaginal repair
• Richardson et al. – 1976
• Reattachment of lateral vaginal sulcus with its
overlying fascia to ATFP
• From pubis to the ischial spine, 6-8 sutures
• Inferior to colposuspension – Not recommended for
SUI alone
• Less postop obstructive symptoms

17. Vagino-Obturator Shelf (VOS) procedure
• Turner-Warwick – 1986
• Modification of combination of Burch & Paravaginal
• Anchor vagina to internal obturator fascia
• Robust anchorage

19. Cystourethropexy / MMK procedure
• Suspension of bladder neck towards symphysis
• Paraurethral tissue & vaginal wall
• 20% complication – Osteitis pubis in 1-3%
• Not recommended

20. Urethral Tethering Urethral Obstruction

21. Complications
• Post-colposuspension pain (12%) – Pain in groin at
the site of suspension.
• Postop Voiding difficulty – permanent in <5%
– May present as de-novo storage symptoms
• Vaginal Prolapse (22%) – aggravated posterior
vaginal weakness → Enterocele. Prophylactic
Culdoplasty
• 85% Cure Rate

22. The Hammock Hypothesis
• Posterior musculofascial/ligamentous support of
urethra → anterior vaginal wall → levator ani & ATFP
• DeLancey – 1994
• Basis for PVS

24. Pubovaginal Sling – PVS
• Highly versatile procedure
• PVS with autologous fascia – Gold standard for
management of all forms of SUI
• 80-95% cure rates
• Most common synthetic material – Polypropylene
mesh – macroporous (Amid type 1)
• Mesh perforation 15 times more in synthetic graft –
not recommended at bladder neck

25. Autologous Graft
Harvest
Fascia Lata hravest
(Crawford fascial stripper)
Rectus Sheath

26. Hydrodissection – NS/LA
Incision – Longitudinal/Inverted-U

27. Endopelvic fascia perforated
Stamey needle passed

28. Loading Sling sutures
Bilateral Stamey needles delivered

29. Sling Positioned
Sling fixed to periurethral tissue

30. Integral Theory
• Petros & Ulmsten – 1990
• Midurethra – site of the maximal continence zone
• Midurethral Complex –
– Pubourethral ligament
– Anterior vaginal wall supporting urethra
– Pubococcygeus
• Basis for Mid-Urethral Slings (MUS)

31. Mid-Urethral Sling (MUS)
 Tension-free Vaginal Tape (TVT)
 Trans-Obturator Tape (TOT) – Out-in / In-out
 Single Incision MUS
 Hammock style
 U-position
• 80-90% success

33. Tension-free Vaginal Tape (TVT)

34. Trans-Obturator Tape (TOT)

35. Single Incision MUS – U-Position
Endopelvic fascia - Retropubic

36. Single Incision MUS – Hammock style
Obturator Internus Fascia

37. Complications
Vaginal Mesh Exposure – 0.5-8%
Urethral Mesh Perforation – 0-0.6%
Trocar Injury – Retropubic (3-23%) > Transobturator (0-1.3%)

38. Urethral Seal Effect
• Multiple infoldings of transitional epithelium
• Subepithelial
vascular plexus
• Basis for
injection therapy

39. Injection Therapy
• Improve Urethral mucosal coaptation
• Injection of agent into submucosa or lamina propria
• Injection site –
– Bladder neck / Proximal urethra
– Mid-urethral injection
• Poorer results with high re-injection rates to
maintain continence

41. Injection Approaches
Transurethral
Periurethral

42. Thank You

43. A
• A