Chapter 8: What can be done? Treatments for urinary incontinence and pelvic floor prolapse:

Surgical treatment for urinary incontinence

Perhaps one of the most important decisions you will take on the path to control of your bladder is whether you should have an operation.

Like any other surgical procedure, operations to correct urinary incontinence carry risks. You are the only person that can decide if these risks are worth taking. The reasons are quite obvious. Nobody dies of urinary incontinence. Unlike bypass heart surgery designed to save one from heart attacks and eventual death, urinary incontinence can influence your quality of life tremendously, but will put you at no risk for other serious illness or death. Therefore, nobody should tell you that you need to have an operation. You may want to have one to get rid of your bladder control problems, but it is not mandatory. Your number one responsibility is to determine if your urinary incontinence is a problem severe enough for you to have an operation.

Once a decision is taken you can discuss the best procedure for you with your doctor.

To date there are more than 200 variations on surgical procedures available to treat urinary incontinence.

This variety stems from attempts to perform less invasive procedures that will have the same therapeutic effect but will carry lower complication rate compared with the more established techniques used in the past. Surgery can be performed through the vagina, through the abdomen or in a combined approach with some steps of the surgery done through the vagina and some through the abdomen. No surgery, even the most advanced, is perfect. There is no surgery that has one hundred percent efficacy. Even in the best hands and with the most experienced surgeon only 9 out of 10 patients are cured of their stress urinary incontinence immediately after surgery. With time this rate of cure and improvement continues to deteriorate so that only 6 or 7 out of ten patients is cured of stress incontinence 10–12 years after they had the surgery.

Should these numbers discourage you from having surgery? If your problem is severe enough to significantly effect your quality of life then a 70 percent success rate years after the surgery is performed is not a bad deal.

We cannot discuss here for lack of space the 200 operations that exist for the treatment of stress urinary incontinence. Rather, here is a short description of the 3 most frequently used procedures.

Retropubic (abdominal) suspensions

There are many variations within this group of operations. The principle here is to suspend the vaginal wall and the bladder neck and the urethra to the back side of the pubic bone so that these structures are now re-positioned closer to their original location.

At times of increased abdominal pressure, the urethra and the bladder neck or outlet will be exposed to the same pressure elevations as the bladder and therefore urinary leakage will be prevented.

Named after their original performers, operations in this group include the Burch colposuspension (colpo is vagina in Latin/Greek-check) and the Marshal-Marchetti-Krantz (MMK) operation. Both procedures are performed by an abdominal incision (7-12 cm long) and differ in the way the anterior vaginal wall is suspended.

The major advantage of these procedures is that their efficacy is well established. There are now many reports that support their efficacy even after long periods of time. The disadvantage is that they require more extensive tissue dissection with longer hospitalization and recuperation than other procedures.

The same procedures can be performed using laparoscopic techniques. Here, instead of opening the abdomen the procedure is performed through several tiny openings in the abdominal wall through which a video camera and surgical instruments are introduced and operated. This technique is of course less invasive and better tolerated, but not all doctors agree as to their efficacy and some feel that it is less successful than the original open procedures.

Sling procedures

This is the most widely used group of surgeries for the treatment of stress urinary incontinence today. Here, a hammock-like structure called a sling is constructed to support the urethra and or the bladder neck to a structure located higher. The sling then serves as a hammock against which the bladder neck and the urethra are compressed when the abdominal pressure rises. This compression of the urethra and the bladder neck contribute to increased resistance at the outlet of the bladder and prevent leakage. There are many ways to skin a cat, but more ways to construct a sling. There are numerous variations in the way the sling is constructed, its position, and the material used.

In the traditional sling procedure, a long strip of muscular covering (fascia) is taken from the abdominal wall and then transferred and used as sling material through a vaginal incision. This procedure although proven to be highly effective necessitates a relatively long abdominal incision, which contributes to the length of recuperation.

Over the last decade many minimally invasive techniques to construct slings were made available. Ingenious ideas and very active marketing made these techniques popular. Sling procedures have become easier for the doctor to perform and for the patient to tolerate. These include the use of synthetic and other sling materials such as cadaveric and non-human (porcine-derivative for example) processed sling materials.

Using these sling materials precludes the need for extensive dissection to harvest a sling material. However, since the use of these procedures and materials is relatively new there are no long-term studies on how well they are tolerated and how effective they are. Some studies have been ongoing for 3 years or more of follow-up and are believed by many doctors to be sufficient for efficacy evaluation.

One of the major points that need to be considered is your doctor’s experience. No one can feel comfortable with every procedure available today. Most doctors will use one or two procedures that they feel comfortable with. If you trust your doctor and if he is known to obtain good results using one of these techniques you may leave the decision on the details of the technique he will use to him. You should, however, be aware and keep a record of what technique and materials were used to construct your sling preferably with a copy of your operative report in your files. This information may become valuable to you in the future.

Periurethral bulking agents

Periurethral bulking agents represent another group of surgical procedures for treating stress urinary incontinence. In this procedure, a material or agent is injected around the urethra to give it more bulk. This in turn will narrow the urethra and sometimes elongate it to increase resistance at the bladder neck.

Injections are performed with local anesthesia only with no need for general anesthesia. Most physicians will perform this as an outpatient procedure.

The bulking agent is injected through a thin needle. The physician is able to monitor the procedure with a cystoscope and see the area of the bladder neck and the urethra and how well they expand using the bulking agents. The procedure can be repeated twice or three times several weeks apart to achieve optimal results. Three bulking agents are currently approved by the Food and Drug Administration of the USA: collagen, Durasphere and fat.

Collagen is the oldest agent in use. It is made of purified porcine collagen. Prior to your treatment with collagen a skin test should be performed to exclude possible allergic reaction to the agent. It is easy to deliver and is relatively stable. Durasphere is a new material. Short term results are similar to those of collagen. No skin test is required prior to administration.

Fat has to first be taken or harvested from your own body, usually from your abdominal fat (even if you are skinny you will have enough fat to allow this). Although approved by the FDA for the treatment of stress urinary incontinence, fat is less effective than the other materials. Cells of the immune system readily absorb it. Add to that the fact that it has to be harvested—a source of additional discomfort and you will see why its use fell out of favor.

In general, periurethral bulking agents are less effective than sling and retropubic suspensions (about 60% of patients will be cured of their stress incontinence or at least significantly improved compared with 85% with the other procedures). The main role of injectable materials is for women who are too frail to undergo a surgical procedure with general anesthesia and for women who prefer not to take the risks of a more traditional surgery. It can also help women who have had surgery that improved their symptoms, but did not completely cure their incontinence.

Risks and complications

No surgical procedure is risk free and every operation carries some risks of complication. Complications that can follow any surgery include infection at the incision site or at a remote site such as pneumonia, excessive bleeding, and even death.

With the advent of modern anesthesiology and surgery these complications are extremely rare. The chance of dying due to surgery performed to treat urinary incontinence is 5 in 10,000 cases.

According to one of the latest reviews summarizing a considerable number of publications on anti-incontinence surgery, significant intraoperative complications that require additional measures in order to be overcome appear in up to 3% of the procedures. These include damage to the bladder, ureter or urethra. According to the same review, the rate of less severe complications occurring during or shortly after surgery can reach up to 7%.

Complications specific to procedures performed to correct stress urinary incontinence include de novo urgency. This means the emergence of urinary urgency that was not present before surgery in 5-11% of the patients and urinary retention or the inability to void for a period of more that 4 weeks in up to 8% of the patients. Sounds scary? Again, surgery is not a day in the park and you should have it only if your urinary incontinence represents a real issue in your life and a real burden on your quality of life. Moreover, most complications can be managed by simple measures such physiotherapy, medications and temporary catheterization of the bladder. It is the rare case where additional surgery is required to treat a complication resulting from surgery performed to treat urinary incontinence.