Evidence summary
LE
Anterior colporrhaphy has lower rates of cure for UI especially in the longer term.
1a
Open colposuspension and autologous fascial sling are similarly effective for cure of SUI in women.
1b
Laparoscopic colposuspension has similar efficacy to open colposuspension for cure of SUI and a similar risk of voiding difficulty or de novo urgency.
1a
Laparoscopic colposuspension has a lower risk of other complications and shorter hospital stay than open colposuspension.
1a
Autologous fascial sling has a higher risk of operative complications than open colposuspension, particularly voiding dysfunction and postoperative UTI.
1b
Evidence summary | LE |
|---|---|
Compared to colposuspension, the retropubic insertion of a midurethral synthetic sling gives equivalent patient-reported cure of SUI and superior clinician-reported cure of SUI at 12 months. | 1a |
Compared to colposuspension, the transobturator insertion of a midurethral synthetic sling gives equivalent patient-reported and clinician-reported cure of SUI at 12 months. | 2 |
Insertion of a midurethral synthetic sling by the transobturator route gives equivalent patient-reported and clinician-reported cure rates at 12 months compared to retropubic insertion. | 1a |
The skin-to-vagina direction of retropubic insertion of midurethral sling is less effective than a vagina-to-skin direction. | 1a |
Midurethral sling insertion is associated with a lower rate of a new symptom of urgency, and voiding dysfunction, compared to colposuspension. | 1a |
The retropubic route of insertion is associated with a higher intraoperative risk of bladder perforation and a higher rate of voiding dysfunction than the transobturator route. | 1a |
The transobturator route of insertion is associated with a higher risk of chronic perineal pain at 12 months than the retropubic route. | 1a |
The skin-to-vagina direction of both retropubic and transobturator insertion is associated with a higher risk of postoperative voiding dysfunction. | 1b |
Evidence summary | LE |
|---|---|
Single-incision midurethral slings are effective in curing SUI in women in the short term. | 1b |
Operation times for insertion of single-incision midurethral slings are shorter than for standard retropubic slings. | 1b |
Blood loss and immediate postoperative pain are lower for insertion of single-incision slings compared with standard midurethral slings. | 1b |
Single-incision slings are less effective than other midurethral slings at medium-term follow-up*. | 1b |
There is no evidence that other adverse outcomes from surgery are more or less likely with single-incision slings than with standard midurethral slings. | 1b |
Evidence summary | LE |
|---|---|
Adjustable midurethral synthetic sling device may be effective for cure or improvement of SUI in women | 3 |
There is no evidence that adjustable slings are superior to standard midurethral slings. | 4 |
Evidence summary | LE |
|---|---|
Periurethral injection of bulking agent may provide short-term improvement in symptoms (3 months), but not cure, in women with SUI. | 2a |
Repeat injections to achieve therapeutic effect are very common. | 2a |
Bulking agents are less effective than colposuspension or autologous sling for cure of SUI. | 2a |
Adverse effect rates are lower compared to open surgery. | 2a |
There is no evidence that one type of bulking agent is better than another type. | 1b |
Periurethral route of injection may be associated with a higher risk of urinary retention compared to transurethral route. | 2b |
Recommendations for surgery for uncomplicated stress urinary incontinence in women | GR |
|---|---|
Offer the midurethral sling to women with uncomplicated stress urinary incontinence as the preferred surgical intervention whenever available. | A |
Offer colposuspension (open or laparoscopic) or autologous fascial sling to women with stress urinary incontinence if midurethral sling cannot be considered. | A |
Warn women who are being offered a retropubic insertion synthetic sling about the relatively higher risk of peri-operative complications compared to transobturator insertion. | A |
Warn women who are being offered transobturator insertion of midurethral sling about the higher risk of pain and dyspareunia in the longer term. | A |
Warn women undergoing autologous fascial sling that there is a high risk of voiding difficulty and the need to perform clean intermittent self-catheterisation; ensure they are willing and able to do so. | A |
Do a cystoscopy as part of retropubic insertion of a midurethral sling, or if difficulty is encountered during transobturator sling insertion, or if there is a significant cystocoele. | C |
Women being offered a single-incision sling device for which an evidence base exists, should be warned that short-term efficacy is inferior to standard midurethral slings and that long-term efficacy remains uncertain. | C |
Only offer single-incision sling devices, for which there is no level 1 evidence base, as part of a structured research programme. | A |
Only offer adjustable midurethral sling as a primary surgical treatment for stress urinary incontinence as part of a structured research programme. | C |
Do not offer bulking agents to women who are seeking a permanent cure for stress urinary incontinence. | A |
Complicated SUI Surgery in Women
Evidence summary | LE |
|---|---|
The risk of treatment failure from surgery for SUI is higher in women who have had prior surgery for incontinence or prolapse. | 1b |
Open colposuspension and autologous fascial sling appear to be as effective for first-time repeat surgery as for primary surgery. | 1b |
The midurethral sling is less effective as a second-line procedure than for primary surgery. | 2 |
Recommendations for surgery for complicated stress urinary incontinence in women | GR |
|---|---|
The choice of surgery for recurrent stress urinary incontinence should be based on careful evaluation of the individual patient. | C |
Women should be warned that the outcome of second-line surgical procedures is likely to be inferior to first-line treatment, both in terms of reduced benefit and increased risk of harm. | C |
Offer implantation of AUS or ACT as an option for women with complicated stress urinary incontinence if they are available and appropriate monitoring of outcome is in place. | C |
Warn women receiving AUS or ACT that there is a high risk of mechanical failure or a need for explantation. | C |
Surgical Treatment
Bulking Agents
The application of bulking agents has been performed for many years as the treatment for SUI and especially ISD. Various materials have been used like autologous fat, silicone particles, collagen or polyacrylamide hydrogel. The working mechanism is thought to be coaptation of the urethra. Since bulking agents are mostly applied in cases of ISD, they should enforce the urethra in order to compensate for the intrinsic sphincteric defect. The concept is not to keep the urethra in the proper position during intra-abdominal pressure increase like tapes, but to reinforce the sphincter itself by injecting material somewhere in the sphincteric complex.
Indications
Bulking agents are applied in cases where no urethral mobility is present, e.g. after an earlier procedure for SUI. Since bulk can be applied locally, it is also frequently applied in those patients that can’t stand extensive operations. Other indications are minor to mild SUI and poor bladder emptying and those who can’t stand polypropylene tapes.
Technique
It is not known what the best position and the best way to apply bulk is. Bulk can be injected transurethrally, paraurethrally, at the bladder neck and midurethrally. Injection of bulk can be done under cystoscopic vision or blindly with standardised application device. If the bulk is injected blindly, it is possible to standardise the procedure and to combine results from various surgeons. The cystoscopic procedure allows better visual control and is preferred by many experienced surgeons. Normally, the bulk is injected at three to four locations opposite each other in order to be capable to coapt the urethral lumen.
Points of Interest
There are some important factors that have to be taken into account when injecting bulk:
When the injection is done under local anaesthesia, enough time should be allowed between applying the local anaesthesia and the injection of bulk.
The anatomy of innervation of the anterior vaginal wall and the urethra should be known in order to inject regionally effectively and not to close to the urethra in order to avoid extra oedema because of the local anaesthesia.
The bulk should be injected very slowly in order to inject the bulk between the tissue layers of the urethra without rupturing them.
Backflow of the material should be avoided by not withdrawing the needle too quickly.
After having finished the procedure, the bladder should preferably not be emptied or emptied with a small calibre catheter to avoid the bulking agent to be forced into the external layers of the urethra.
Bladder Neck Colposuspension
Background
Bladder neck colposuspension was first described by Burch in 1961. After having firstly described the attachment of the paravaginal fascia to the arcus tendineus, he later improved his technique by attaching the paravaginal fascia to Cooper’s ligament, which allowed for more firm fixation points and less chance of infection as compared to the Marshall-Marchetti-Krantz (MMK) procedure, which is another type of retropubic colposuspension. The goal of these procedures is to suspend and stabilise the urethra so that the bladder neck and proximal urethra are replaced intra-abdominally. This anatomic placement allows normal pressure transmission during periods of increased intra-abdominal pressure restoring continence. Although its durability has been proven, the open repair is less commonly performed due to the advent of less invasive procedures. Laparoscopic surgeons have also demonstrated that the repair can be performed via a laparoscopic approach, decreasing morbidity, while still providing a satisfactory outcome.
Technique
A catheter is inserted into the bladder. The incision is either a Pfannenstiel or lower midline abdominal incision to access the Retzius space. After incision of the rectus fascia, the rectus muscles are separated in the midline. Downward pressure behind and lateral to the symphysis pubis gives access to the lateral walls of the pelvis and to the endopelvic fascia. The peritoneal reflection is swept of the bladder. After dissection of the retropubic space, the bladder neck, the anterior vaginal wall and urethra are exposed.
The bladder neck is identified with palpation of the balloon of the catheter. The pubocervical fascia may be identified by sweeping away the overlying fat. To identify the anterior vaginal wall and distinguish this from the urethra, a gloved and protected finger can be inserted intravaginally in the vagina to tent the vagina laterally.
The bladder should be displaced medially and cranially away from the site of suture placement using a small swab. Haemostasis at this point of the procedure may be necessary. It is important to identify the white-coloured pubocervical fascia. This is the place where the suspending sutures must be placed.
Two to four sutures are placed on each side of the bladder neck through the pubocervical fascia. It is important to take good bites of overlying fascia and anterior vaginal wall. If nonabsorbable sutures are used, it is important not to incorporate the vaginal mucosa. If (slow) absorbable sutures are used, this is less critical. Double bites of tissue to lessen the risk of the suture pulling through can be applied.
The most distal suture is placed just distally or at the level of the bladder neck and approximately 2 cm laterally. The sutures are placed in the pubocervical fascia and anterior vaginal wall proximal to the bladder neck about 1 cm apart. The sutures are placed into the Cooper’s ligament at the same level. Care must be taken to leave a suture bridge and do not apply excessive tension. Sometimes the most distal sutures need to be placed in the periosteum and in the fibrous insertion of the rectus muscle instead of in Cooper’s ligament. Elevation of the anterior vaginal wall with a gloved and protected finger in the vagina helps with tying the sutures without tension. The goal is to approximate the anterior vaginal wall to the lateral wall of the pelvis. Tension may lead to pulling through of the sutures.
Points of Interest
Avoid entry into the peritoneal cavity.
Identify the white-coloured pubocervical fascia to place the suspending sutures properly.
When using nonabsorbable sutures, care must be taken not to perforate the vaginal mucosa.
Leave a suture bridge and do not apply excessive tension in order to overcorrect the descended bladder neck.
Cystoscopy can be performed to rule out injury to the bladder.
Pubovaginal Slings
Background
Many types of pubovaginal slings have been described more than 100 years ago. Only after numerous improvements and reintroduction by McGuire in 1978, the pubovaginal sling became more popular. Traditionally the sling has been used only when other incontinence procedures, like especially the Burch colposuspension, have failed.
Indication
The most common indications for a pubovaginal sling are intrinsic sphincter deficiency with or without urethral hypermobility and a prior failed incontinence procedure. Also certain patients with SUI due to urethral hypermobility may be better served with a sling procedure, because of the long-term success and durability of the pubovaginal sling.
Technique
It is beneficial to teach the patient clean intermittent catheterisation before surgery because incomplete emptying is common for a short while postoperatively. One dose of intravenous antibiotics can be given preoperatively. General or regional anaesthesia can both be used.
The procedure is performed in the low lithotomy position. The legs should only be moderately flexed at the hips to allow simultaneous exposure to the vagina and the lower abdomen. A Foley catheter is placed and the balloon inflated to allow palpation of the bladder neck and urethra. A vaginal speculum is placed ad good view on the anterior vaginal wall should be possible. A pfannenstiel incision is made. The rectus fascia is cleared, and a fascial area is selected that looks strong and is scar free. A fascial sling of about 10 cm length and 2 cm width is obtained by incising parallel to the fibres. This can be done lengthwise or widthwise. It is possible to make a so-called sling-on-a-string in this way. If you want to leave one end fixed to the body, you should leave the part of the sling close to the pubic bone intact and cut the other end of the sling in order to use that part to wrap it around the urethra. The sutures on the sling may be placed before or after transection. Make a choice for the type and size of suture based on personal preference. The suture should be strong and durable like 1-0 or 2-0 vicryl absorbable suture. The sutures are placed perpendicular to the direction of the fibres at 1.0 cm from the ends incorporating all of the fibres in the bites.
The vaginal part starts by placing an Allis clamp midway between the bladder neck and the urethral meatus. Hydrodisection by injecting saline over the urethra can be used to facilitate the dissection. A midline incision of 3 cm is made over the proximal urethra. The vaginal dissection is performed in the proper plane, superficial to the white-coloured periurethral fascia. The dissection is continued to the lateral area. Afterwards the retropubic space is entered at bladder neck level, inferiorly to the ischium. The endopelvic fascia is perforated with curved Metzenbaum scissors. Blunt finger dissection should not be used in order not to cause bladder damage.
Through the abdominal incision a lateral defect is created at the level where the rectus muscle inserts onto the symphysis. With gentle dissection, easy access is obtained to the retropubic space. This can be done by finger dissection or with scissors over the posterior pubic bone. This can be helpful after prior procedures. After completion no tissue should be palpable between fingers inserted from above and from the vaginal incision. Make sure that the bladder is not between the pubic bone and the dissection plane. A similar procedure is performed on the opposite side.
After having developed the plane left and right, two clamps can be passed on both sides. Cystoscopy can be performed to look for urethral or bladder damage. The sling sutures are pulled into the abdominal incision and the sling is placed under the proximal urethra. It is critical that a good portion of the sling extend into the retropubic space to allow good fixation. Some absorbable sutures are placed through the edge of the sling and superficially through the periurethral fascia to secure its place. The sling sutures are passed through the rectus fascia. The vagina is closed. The sling sutures are pulled up and tied over the rectus. A clamp can be used to hold tension on the untied sutures until the appropriate tension is obtained. The appropriate tension is when one or two fingers can easily slide under the suture knot. In the situation where the patient does not void and permanent urinary retention is desired, increased tension can be applied. The skin is closed and a vaginal pack can be placed.
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