Previous posts have discussed different types of incontinence and how to distinguish one from another. Surgical treatment for stress incontinence is an option many women pursue, either after having an unsatisfactory response to physical therapy or because they are unwilling or unable to undergo a course of physical therapy. Since there are no approved medications for treatment of stress urinary incontinence (in the US), the next step may be surgical. There are two basic approaches to treating stress incontinence (leakage of urine with coughing, sneezing, physical straining, laughing, etc): transabdominal surgery (through the abdomen) or transvaginal surgery (through the vagina).
Transabdominal surgery: This indicates going through the abdominal wall to access the pelvic organs. It can be done with an open incision, for example, at the time of an abdominal hysterectomy or other abdominal procedure, or laparoscopically, through tiny incisions in the abdomen. With the proper surgical skills, the surgery can be performed identically regardless of the size of the incision. Also known as a Burch procedure, or its variant, the Marshall-Marchetti-Krantz procedure, this involves entering the space between the pubic bone and the bladder and extending down to the level of the vaginal wall on either side of the urethra. The tissue connected to the urethra is sutured and the suture then attached to the tissue coating the pubic bone. When the sutures are tied, the urethra is lifted up into the abdominal cavity and the urethral angle is changed, making it harder to leak with coughing or other abdominal straining. This has been a “gold standard” procedure to treat stress incontinence for many years. Five year success rates are reported in the range of 85 per cent, which is excellent. The likelihood of failure of the procedure tends to increase over time, as does the failure rate of any anti-incontinence procedure. The biggest advantage of this procedure is that it involves no synthetic materials (other than suture) and has a good track record for most types of stress incontinence. If performed laparoscopically, it can be an outpatient procedure. Disadvantages of the procedure include the need for prolonged catheterization, usually a few days following the surgery are needed with an indwelling catheter before normal emptying resumes. In addition, the development or worsening of urgency related urinary symptoms may result in problems. Although it is rare for the procedure to be “too tight” and remain so for any length of time, it is possible for the repair to lift the urethra to an extent that it is difficult to empty the bladder fully. This may require intermittent self-catheterization (a woman emptying her bladder herself using a small tube which she learns to insert), usually for a short period of time if at all. Very rarely the procedure may have to be “taken down” or loosened due to being too tight.
Transvaginal surgery: This indicates going through the vagina to approach the urethra and bladder. An incision is made in the vagina under the urethra and lower portion of the bladder and the supporting tissues exposed. Next, a hammock is placed under the urethra and brought out either just above the pubic bone or outside of the labia on the groin. The material used for the hammock can be of two types: tissue or synthetic mesh.
1. Tissue slings are usually fashioned from a woman’s own tissues harvested from another part of her body, such as the outside of her thigh or on her abdominal wall. This surgery for stress incontinence is actually the oldest procedure described for this problem. It is highly effective resulting in an 85-90% success rate over the first 5 years, with an increase in failure rates noted over time, similar to the Burch procedure. The advantage of the tissue sling is that it is not foreign material (other than the suture used to secure it in place) so there is no risk of a reaction to the tissue. It may be too tight or too loose, resulting either in difficulties emptying or continued leakage with straining, and therefore sometimes needs to be revised, divided or tightened. It may also be associated with a longer period of time before a woman is able to urinate normally, requiring the use of a catheter for a week or longer. In addition, there is the possibility of a need to perform intermittent self-catheterization (see above) until the tissues are relaxed enough to allow normal emptying. There is also an increased incidence of urgency related symptoms, which may require treatment. The other disadvantage is that it requires harvesting of tissue from another part of the body, necessitating an additional ( usually fairly small) incision to obtain the tissue.
2. Polypropylene mesh slings have been in the news quite a lot lately. There are a number of companies manufacturing these slings, and together they comprise the majority of anti- stress incontinence surgeries done in the world today. There should be some distinctions made, however, between an anti-incontinence sling and a prolapse mesh. While transvaginally placed prolapse meshes have been shown to be no better than standard repairs without mesh, this is not the case with the incontinence sling. The tension-free vaginal tape, or TVT, has been extensively studied and has been found to have an 85% success rate over time, similar to the previously described procedures. One of the benefits of the TVT is that it requires no harvesting of tissue from the patient, and in addition, is less likely to result in difficulties emptying. The majority of women having this procedure are able to empty their bladders the day of surgery and do not require prolonged catheterization. It is possible for the sling to be too tight, too loose, or ineffective in some women, just as with the other procedures. Recovery tends to be fairly quick with few restrictions on activities. The TVT has a “sibling”, the TOT, or trans-obturator tape, which is similar but has some notable differences. Because of the way it is placed, it is less likely to injure the bladder or bowel during the procedure, but it may not work as well for a very weak urethral sphincter muscle, and because it lies more horizontally than the TVT, the TOT may result in discomfort during sex in some women with a narrower pubic arch. The primary advantage of the TOT is that it is rarely associated with difficulty emptying the bladder or increases in urgency related symptoms. The disadvantage of the mesh sling is fairly well known now: it is a synthetic material which may not work well in some women. The risk of mesh erosion (exposure of mesh through vaginal tissue) is reportedly approximately 5 per cent for mesh slings.
All surgical procedures for incontinence have risks (though serious complications are uncommon) including (but not limited to) infection, bleeding, scarring, damage to bowel, bladder, ureters (tubes from kidneys to bladder), major blood vessels; need for more extensive surgery or a repeat operation, blood clots, pneumonia, anesthesia complications, failure, pain, prolonged catheterization, failure to prevent leakage, or new symptoms of urinary urgency and frequency.
Urethral bulking: This is in a category of its own because it is a procedure but not as invasive as any of the others. A gel-like agent (there are a few types available) is injected around the urethra to “tighten” the opening. Women with a very weak urethral sphincter muscle may find this somewhat helpful as it will reduce leakage that may occur simply because the urethra itself does not hold shut normally as it should. It is 60-70% effective in treating stress incontinence, however, the effects may wear off after a year or two. Rebulking is possible but usually is less effective after two repeat procedures. The primary advantage is that it has no “downtime” and requires only local anesthetic. Risks are fairly small, including bladder infection, transient blood in the urine and/or stinging with urination, and rarely, difficulty emptying the bladder (usually lasting no more than a day). Serious complications are very rare, but may include allergic reaction to the material or migration of the material within the body.
Essentially, the most important thing to remember is that there is no perfect anti-incontinence surgery. All procedures for stress incontinence have benefits and risks. However, when conservative, non-surgical treatment is ineffective or unsatisfactory, it is reasonable to consider these options. Having a frank discussion about the options and your specific problem is the best way to make the right choice.
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