1. Urinary Stress Incontinence Surgery-
historical perspective with a look at
future treatments
Debkumar Chowdhury

2. Contents
• Why choose this topic
• What is meant by stress incontinence?
• Overview of Pathophysiology
• Hammock’s hypothesis
• Integral theory
• Different surgical techniques
• Drawbacks
• Outcomes
• Patient’s perspective
• Surgeon’s perspective
• Future treatment
• Conclusion

3. Why chose this topic?
• Interested in surgical topics, comparing
techniques
• Has major impact on patient’s quality of life
• Magnitude of problem- 3-17% of adult women
• Can be potentially cured
• Improvement in the individual’s life
• Better understanding of the different procedures

4. Urinary Stress Incontinence
Complaint of involuntary leakage of urine during
effort or exertion or during sneezing or coughing
International Continence Society
• No clear distinction between hypermobility and
intrinsic sphincter deficiency
• Instead should be viewed as a continuum
• Peaks between 45-49 yrs at 65% then decline
• Older women with less activity - harder to
distinguish from urge incontinence

5. General Information
• Lower closing urethral pressures
• Intra-abdominal pressure exceeds urethral pressure
• Factors affecting the urethral pressure

6. Pathophysiology
• Exact pathophysiology not known
• Various theories hypothesized
• Early 1900s- Bonney- defined symptom complex
• Functional theories of Barnes
• Intrinsic sphincteric dysfunction
• In 1961, Enhorning hypothesis
• Fortified McGuire's studies
• DeLancey ‘s theory- Hammock hypothesis
• Petros and Ulmsten- Integral theory

7. Hammock hypothesis-DeLancey’s
• Hammock hypothesis of USI(1996)
 Tissues below bladder neck ,proximal urethra -strong support
 Occlusion of the urethra allows increased abdominal
pressure.
 Continence of hypermobile urethra
 Urethral compression against hammock structure

8. Integral theory- Ulmsten and Petros
• Integral theory of stress and urge
incontinence
Not attributed to the position of bladder
Efficacy of the support- pubourethral ligament
and anterior vaginal wall to the mid-urethra
Explains pelvic organ prolapse
Laxity in the vagina or its supporting ligaments

10. Retropubic Urethropexy
• Burch Colposuspension
• Urethrovesical angle
• Emil A. Tanagho modification-
• Longest-term follow up studies
• Long-term continence rates-
good
• LUTS( Lower urinary tract
symptoms)-high
• Laparoscopic procedure
• Marshall Marchetti Krantz
• 8th
June 1944
• Modifications
• High position of the anterior wall.
• Mainprize and Drutz in 1980s
• Low urethral pressure and
hypermobility of the urethra
 MMK better at 1 yr than Burch( 93%
vs. 53%)

11. Problems encountered
Problems relating to procedures- over elevation
of vaginal wall
Taken into account with DeLancey’s hammock
hypothesis
Degree of anterior vaginal wall elevation- not in
studies
Apposition of wall to Cooper’s ligament -higher
incidence of prolonged voiding dysfunction and
enterocele formation
Anterior colporrhaphy should not be done in
isolation

12. Transvaginal Tape (TVT)
 Introduced in 1996
 Primary incontinence
procedure.
 Poor outcomes of needle-
suspension procedure
 less invasive pubovaginal
sling- TVT
 Misconception of intrinsic
sphincteric deficiency
 Drawback- pts undergoing
TVT w/o evaluation of
anatomy

13. Evidence
• Cochrane review of pubovaginal slings
• Retropubic suspension vs. TVT
• Short term results comparable
• Nilsson et al. 5 yr data- cure rate of TVT
at 84.7%, similar at 7 yrs
• Ward and Hilton- similar cure rates

14. Mid-urethral slings
• SPARC sling, IVS sling and I-Stop
slings
• SPARC - implanted topside –to –
down- reduces risk of retropubic
haematoma
• IVS is implanted in retropubic
space similar to TVT
• IVS gives a more rigid mesh
• I-stop device
Delorme 2001- transobturator
route
•Lower risk compared to TVT
•Varities exist e.g.
Aris(Coloplast), I-
Stop(Uroplasty) etc.

15. Patient perspectives
• Best done in terms of questionnaire
• At times subjective perception different from objective
perception
• Mallett VT et al. 2008
• Patient expectation of surgical outcome after pre-op
counselling
• 655 women- RCT- rectus fascial sling and Burch
colposuspension
• Urine leakage(98%), embarrassment (88%),
frequency(74%), physical activity( 72%) and
urgency(70%)
• Best surgical approach

16. The surgeon’s perspective
• Surgeons trained in the last generation are familiar
with Burch
• Currently TVT most common approach- comfort of
surgeon
• The reasons being;-
o Surgeons more trained in TVT than the newer mid-
urethral slings
o Less invasive than Burch
o Good follow-up studies showing good results with
TVT
o Burch -more complicated than TVT (risks for patient)

17. Future Treatment
• Stem cell therapy
• Augment rhadosphincter
regeneration
• Autologous multipotent stem cells
• Muscle derived and Adipose tissue
derived
• Could be used in combination with
surgical procedures
• Use of myoblasts and autologous
fibroblasts
• Myoblasts- injected within
rhabdosphincter- promote
regeneration

18. Treatment Contd.
• Fibroblasts administered to urethra
submucosa
• 80% of pts cured at 2 yr follow up + further
10% patients improved
• Similar results – published at European
Association of Urology and American
Urological Association
• Cohort of 185 patients

19. Conclusions
• Research for USI since early 1900s
• Since then different hypotheses proposed with
different surgical techniques
• Integral theory and Hammock theory- basis of
many techniques
• Popularity- Burch colposuspension then TVT
• TVT widely used in UK, advantages over Burch
• Newer treatments such as stem cell transplant is
being looked at

20. References
• Abrams P, Cardoze L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al. The
standardisation of terminology of lower urinary tract function: report from the
StandardisationSubcommittee of the International Continence Society. Neurourol
Urodyn 2002;21:167–78.
• Wolin LH. Stress incontinence in young healthy nulliparous female subjects. J Urol
1969;101:545–9.
• Sampselle CM, Harlow SD, Skurnick J, Brubaker L, Bondarenko I. Urinary
incontinence predictors and life impact in ethnically diverse perimenopausal
women. Obstet Gynecol 2002;100:1230–8.
• Novara G, Artibani W, Barber MD, et al. Updated systematic review and meta-
analysis of the comparative data on colposuspensions, pubovaginal slings, and
midurethral tapes in the surgical treatment of female stress urinary incontinence.
Eur Urol 2010;58:218–38.
• Bonney V. On diurnal incontinence of urine in women. J Obstet Gynaecol Br Emp.
1923;30:358-365.
• Novara G, Artibani W. Myoblasts and fibroblasts in stress urinary incontinence.
Lancet 2007;369:2139–40.

21. Thank you for listening!