Surgery:

There are nearly 200 surgical procedures for incontinence. Most are designed to restore the bladder neck and urethra to their anatomically correct positions in patients with stress incontinence. Injections of bulking materials are another option for women and men.

The choice of surgical procedure depends on a number of factors, including the presence of bladder or uterine prolapse, the severity of incontinence, and the surgeon� ' s experience in performing specific types of surgery.

In general, patients should weigh all options carefully. They should discuss the situation with their doctor, and ask about their surgeon's experience.

Sling Procedure

A sling procedure is the first-line surgical approach for stress incontinence in women who have either intrinsic sphincter deficiency or urethral hypermobility. It may also be useful for managing female urge incontinence. Sling procedures are also available for men who experience incontinence after prostatectomy.

High quality trials have shown as good if not better success rates for the sling procedure when compared to Burch colpsuspension. Post-operative urinary problems, such as voiding problems, common urinary tract infections, and urge incontinence may occur.

The percutaneous sling procedure generally works as follows:

• The surgeon makes an incision above the pubic bone and removes a layer of abdominal fasci (tissue that covers muscle fibers). This muscle strip is set aside and later serves as the sling.
• The surgeon makes an incision in the vaginal wall. The piece of muscle fiber or material is attached under the urethra and bladder neck, somewhat like a hammock, and secured to the abdominal wall and pelvic bone.
• This sling then compresses the urethra back to its original position. The sling must be supportive without being too tense, which can cause urinary obstruction.

Complications can include infection, bleeding, and the formation of fistulas (holes that form and are usually infected).

Vaginal Sling and Tape Procedures for Women. Newer outpatient procedures do not use abdominal incisions. Instead, they are performed through a small incision in the vagina. Typically, two small tacks are placed in the pubic bone. A sling is inserted into the vagina and is attached to the tack.

The tension-free vaginal tape (TVT) procedure uses a special gauze tape covered by a polypropylene coating, which is attached on each side of the urethra. The patient remains conscious and is asked to cough during the procedure so that the surgeon can determine if the tape is secure. Studies indicate that the procedure works as well as colposuspension (the standard suspension procedure), with stress incontinence cure rates of 84 - 100%. The benefits of TVT may last for up to 8 years for women with stress incontinence. However, women with mixed incontinence (a combination of stress and urge) may not do as well with the TVT procedure.

Sling Procedures in Men. For some men who have prostatectomy-induced incontinence, sling procedures may be a good option. Researchers have reported an 80% success rate, the same as an artificial urinary sphincter, which is the standard surgical treatment for such patients. The sling procedure has been less effective in men who have had radiation therapy, although improved techniques are making this approach useful even for these patients. Minimally invasive procedures are also being tested.

Retropubic Colposuspension (Burch Colposuspension)

Retropubic colposuspension using standard "open" surgery is an effective treatment for stress incontinence, especially over the long term. ("Open" surgery implies the use of a wide incision in order to "open" the abdominal area.) Long-term continence rates are about 85 - 90%.

The goal of colposuspension is to correct the position of the bladder and urethra by sewing the bladder neck and urethra directly to the surrounding pelvic bone or nearby structures. There are many variants, but, in general, they are effective only for women with urethral hypermobility. Most procedures require a general or spinal anesthetic and a 2-day hospital stay.

Burch Colposuspension. Burch colposuspension (sometimes called colpocystourethropexy) is a standard approach. It requires a wide abdominal incision and is often performed during abdominal surgeries such as hysterectomy or hernia operations. It is also performed along with sacrocolpopexy, a surgical procedure used to repair pelvic organ prolapse. (Pelvic organ prolapse occurs when the uterus or bladder slips from the pelvic cavity into the vagina. It is often due to pelvic muscle weakness that develops after childbirth.) Prolapse can lead to stress incontinence. However, prolapse surgery itself sometimes causes incontinence.

The surgeon secures the urethra and bladder neck with lateral (sideways) sutures that pass through thick bands of muscle tissue running along the pubic bones. Unlike an older suspension procedure, this procedure poses a much lower risk for obstruction of the urethra. It is more effective in premenopausal than postmenopausal women and may not be appropriate for all women.

A rigorous study published compared the effectiveness of the Burch colposuspension to the sling procedure, another type of surgical treatment for stress incontinence. The study found that the sling procedure had better results for achieving dryness. However, more women who had the sling procedure had post-operative urinary problems, especially urinary tract infections. Overall, women were satisfied with the outcomes of both procedures.

Marshall-Marchetti-Krantz (MMK). The MMK approach requires a wide abdominal incision. The surgeon then elevates the urethra and bladder neck using sutures. These structures are then secured and anchored to underneath the pelvic bone.

Laparoscopy. Some newer less invasive procedures use laparoscopy, which requires only one or two small incisions over the pubic bone. Laparoscopy has a faster recovery time and less postoperative pain, but its long-term effectiveness is not yet known.

Postoperative Considerations for Most Procedures. Following most standard procedures, patients usually leave the hospital on the second or third day, but need a urinary catheter for about 10 days. Newer procedures may require shorter stays and less intensive postoperative care.

Complications after surgery include:

• Some risk of damage to the surrounding nerves or vessel. This can result in internal sphincter deficiency. (In some cases it may already have been present before the operation.)
• Difficulty in urinating from surgical overcorrection. (This may require additional surgery.)
• Poor wound healing.
• Adhesions (scar tissue) that obstruct the urethra. This complication is higher with older standard procedures.
• Vaginal abnormalities (prolapsed vagina).

Artificial Sphincter

In cases of sphincter incompetence, or complete lack of sphincter function, an artificial internal sphincter may be implanted. This procedure is generally used for men, such as those who have experienced incontinence following radical prostatectomy.

This device uses a balloon reservoir and a cuff around the urethra that is controlled with a pump. The patient opens the cuff manually by activating the pump. The urethra opens and the bladder empties. The cuff closes automatically several minutes later. The two major drawbacks of the internal sphincter implant are malfunction of the implant and risk of infection.

Bulking Material Injections

Injections of materials, such as collagen, that provide bulk to help support the urethra are proving to be beneficial for the following patients:

• Women with severe stress incontinence who cannot or do not wish to have surgery that involves anesthesia.
• Men who have slight incontinence caused by prostate surgery. Men who have bulking injections after TURP (transurethral resection of the prostate) have a continence rate that is equal to the rate in women. After radical prostatectomy (removal of the prostate gland in prostate cancer), collagen injections can achieve some level of continence in up to nearly half of men. (Collagen injections are not beneficial after radiation therapy for prostate cancer.)

The Procedure.

• The basic procedure involves injecting bulking material into the tissue surrounding the urethra.
• The material used is usually animal or human collagen. (Collagen is the basic protein in bones, muscles, and all connective tissue.) Synthetic bulking materials, such as carbon-coated beads, are also being used.
• The doctor passes the collagen-containing needle through a cystoscope, a tube that has been inserted into the urethra. The collagen can also be injected into the skin next to the sphincter.
• The injected collagen tightens the seal of the sphincter by adding bulk to the surrounding tissue.
• The procedure takes about 20 - 40 minutes, and most people can go home immediately afterward.
• Two or three additional injections may be needed to achieve satisfactory results.

Postoperative Care. People may experience immediate improvement followed by a temporary relapse after a week or so. Patients must be taught to use a catheter tube for withdrawing urine for a few days following the procedure. In general, it takes about a month for the full benefits to be apparent.

Complications.

• There is a risk for infection and urinary retention, although these conditions are temporary.
• The procedure may not be appropriate for patients with certain cardiac conditions.

Duration of Effectiveness. Collagen is absorbed over time, so injections generally need to be repeated every 6 - 18 months.

Sacral Neurostimulation

The sacral nerves, located near the sacrum (“tail bone”), appear to play an important role in regulating bladder control. A sacral nerve stimulation system (InterStim) may help some patients with urge incontinence. The system uses an implanted device to send electrical pulses to the sacral nerves to help retrain them. InterStim is reserved for the treatment of urinary retention and the symptoms of overactive bladder in patients who have failed or cannot tolerate less invasive treatments.

Complications include infection, lower back pain, and pain at the implant site. The system, however, does not cause nerve damage and can be removed at any time.

Patients have reported improvement in the frequency and volume of urination, as well as the intensity of urgency and their quality of life.