Surgery for stress incontinence: Which technique for which patient?
When conservative treatments fail, operative therapy may offer better success—and an increasing number of methods are available. Our experts consider the full range of surgical options and offer guidance on tailoring treatment to the patient’s underlying problem, activity level, and desires.
- Peter K. Sand, MD, moderator, is professor of obstetrics and gynecology, Feinberg School of Medicine, Northwestern University, Evanston, Ill.
- G. Willy Davila, MD, is chairman, department of gynecology, Cleveland Clinic Florida, Weston, Fla.
- Karl Luber, MD, is assistant clinical professor, division of female pelvic medicine and reconstructive surgery, University of California School of Medicine, San Diego, and director of the female continence program at Kaiser Permanente, San Diego.
Deborah L. Myers, MD, is associate professor of obstetrics and gynecology, Brown University School of Medicine, Providence, RI.
Choosing appropriate surgical interventions is the focus of the second of our 2-part panel on stress urinary incontinence (SUI). The panelists discuss:
- how to weigh the factors that influence choice of technique, including Burch retropubic urethropexy and the various sling operations;
- the challenges of treating “mixed” stress and urge incontinence; and
- when to use bulking agents for intrinsic sphincteric deficiency.
The panelists also share tips on:
- how to help patients accurately describe their symptoms, and
- what issues to review with patients as they consider their options.
Part 1 covered medical therapies such as pelvic floor muscle rehabilitation, occlusive devices, and drugs. (Stress urinary incontinence: A closer look at nonsurgical therapies. OBG Management. 2003;15(9):40-51.)
Review surgical options with the patient
SAND: How do you counsel patients about surgical treatments for stress urinary incontinence?
MYERS: After the initial evaluation and diagnosis, I review the conservative options, and I also offer surgery. At this time, I discuss whether an operation is appropriate.
I work with the patient, going over her diagnosis as well as the different types of operations that are performed. Some patients are fairly well educated about their options, having looked up information on the Internet.
Next I explore whether other types of procedures need to be done concomitantly. For instance, does the patient need abdominal hysterectomy for some other reason? That would prompt me to offer an abdominal approach to the SUI. Do other types of vaginal surgery need to be done? Then I would probably opt for a vaginal approach.
I also look at the patient’s health status. Is she healthy and physically active? Or is she sedentary with comorbidities? In a woman who is a poor surgical candidate, I would consider less invasive procedures or procedures with less operative risk, such as urethral injections or the newer tape slings.
LUBER: When it comes to surgery for urinary incontinence, I like to reinforce the reconstructive nature of the repair, since patients tend to view surgical procedures as definitive. For example, when the uterus and ovaries are removed, they never bother that patient again. Incontinence procedures are different. Their effect is potentially time-limited, so it’s important to reinforce the patient’s understanding of their reconstructive and fallible nature.
At the first surgical consultation, I basically go through an informed consent. I do so again preoperatively, but I think it is a very important initial step for a patient who is considering surgery.
SAND: What if a patient isn’t sure she wants surgery?
LUBER: When a patient asks, “What should I do, Dr. Luber? Should I have an operation?” I like to use the example of standing in front of the refrigerator and asking, “Gee, am I hungry?” If you have to ask, you probably aren’t.
Potential surgical patients should feel extremely comfortable that they have exhausted all the nonsurgical options. Even if they have decided against nonsurgical therapy, they should feel very comfortable with that choice. Then I am confident we can work through any potential problems of surgery.
As for the operation itself, history has demonstrated the irresistible impulse to innovate during surgery for female stress incontinence. Literally hundreds of operations have been described, and dozens are currently in use; this reinforces the supposition that our techniques are imperfect, and the importance of basing what we do upon the available data. The 1997 American Urological Association guidelines are an excellent example. Looking forward, the National Institutes of Health are sponsoring studies comparing, for example, the goldstandard Burch to the goldstandard sling operation. In the next few years, we should have better evidence-based guidance.
Consider patient characteristics when choosing treatment
SAND: How do you select a surgical procedure for a particular patient?
MYERS: Because of all the different variables, I use various treatment arms. Since my institution does a large number of sling procedures, I am very comfortable performing those operations. I still do retropubic urethropexy. I also do the newer vaginal-tape procedures, and I use bulking agents for patients who have a demonstrated sphincter deficiency with no obvious support problems. Basically, I try to tailor my procedure to the patient.
For example, in a woman who requires a total abdominal hysterectomy for fibroids as well as an anti-incontinence procedure, I would do a Burch operation. For a woman who needed a vaginal hysterectomy, I probably would perform a sling procedure.
DAVILA: Ob/Gyns may be a bit unsure how to proceed at this point. For example, we formerly considered the Burch procedure the gold standard against which other procedures should be judged. Although I continue to view it as the standard, the Burch procedure increasingly is overlooked in favor of tension-free slings—due to increased marketing of the latter—for any form of stress incontinence. I think that has led us down a path that is not entirely beneficial for many of our patients.
In contrast to that approach, I use a basic evaluation of the patient to construct a treatment algorithm. In simple terms, 2 factors are taken into account: urethral sphincter function and bladder neck or urethral support. Using those 2 factors, I create a 2×2 table to select patients who do or don’t have urethral hypermobility and who do or don’t have sphincteric deficiency (TABLE).
For example, a patient with hypermobility and normal sphincter function has what we might consider “garden-variety” stress incontinence. Such patients do well with any form of treatment, whether it’s conservative therapy, a vaginal device, or a Burch procedure or tension-free sling.
I am more concerned when the patient has hypermobility with a significant degree of sphincteric deficiency. In recent years, the tendency has been to treat such patients with a tension-free sling. Although the literature is not absolutely clear, the success rate of tension-free slings in a patient with intrinsic sphincteric deficiency (ISD) is not as high as in a woman without ISD. 1 So in these patients, I do a traditional sling.
Atrophy can cause significant urgency and nocturia symptoms.—Dr. Davila
The other 2 groups of patients have no hypermobility. I think most of us would agree that a woman with ISD and no hypermobility would best be treated with a bulking agent such as Contigen (C.R. Bard, Murray Hill, NJ) or Durasphere (Advanced Uroscience, St. Paul, Minn).
I have had good success rates with bulking agents. I do not think current data would support a tension-free sling in these patients.
Finally, there is the patient without hypermobility who has normal sphincter function. These patients do fairly well with conservative therapy, including pelvic floor exercises. They usually have mild forms of stress incontinence to begin with.
Stress urinary incontinence treatment choices based on urethral support and urethral sphincteric function
URETHRAL SPHINCTERIC FUNCTION
Bladder neck mobility (Q-tip test)
Poor urethral function function
MUCP >20 cm H20
LPP <20 cm H20
VLPP <60 cm H20
VLPP >60 cm H20
>30 degrees (hypermobility)
Tension-free vaginal tape
Source: GW Davila, MD
EBST = empty bladder stress test;
MUCP = maximal urethral closure pressure;
VLPP = Valsalva leak point pressure
NOTE: Urethral plugs may function in all categories
Simple method to assess sphincter function
DAVILA: This is the algorithm I tend to follow. It does entail evaluation of the urethral sphincter mechanism, but there are simpler ways to do that than with multi-channel urodynamics. For example, if the patient leaks with a Valsalva maneuver, after voiding, in a supine position, that suggests she has ISD and therefore is likely to have a low-pressure urethra or a low leak-point pressure. Multiple centers have reported on this.2,3
Role of urethral function in choice of treatment
LUBER: There seems to be 2 schools. The first dichotomizes urethral function to reasonable (“good” urethral function) versus unreasonable (“poor” urethral function or ISD) and selects the operation based on that. Thus, a Burch or supportive operation would be used for good urethral function with hypermobility, and a sling operation would be selected for poor urethral function or ISD.
More recently, some experts have preached an inclusive approach, whereby all patients undergo sling operations. That strategy evolved out of frustration over the difficulty of identifying which patients have poor urethral function. Unfortunately, we lack good long-term data on the potential downside of performing sling procedures on all patients with incontinence. Hopefully, over the next 3 years, the National Institutes of Health data will help clarify whether we need to dichotomize patients in terms of urethral function.
Meanwhile, at our center, we continue to consider urethral function the deciding factor as to whether patients will undergo a gold-standard Burch procedure or a sling. We steer toward a sling procedure when the patient clearly has poor urethral function or ISD. Of course in cases of the fixed immobile and poorly functioning urethra, we also make bulking agents available.
Additional factors in the choice of treatment
SAND: We throw 2 other things into the algorithm at our center: One is detrusor overactivity, which is very important when considering surgical treatment of stress urinary incontinence. The second is voiding function.
Activity level of the patient is an additional measure, as Dr. Myers commented on earlier. I’m not as concerned about age as I am about the patient’s physical activity and expectations for the operation over time. For example, for a woman who is relatively homebound and not physically active and has poor voiding function (underactive detrusor) and prolapse with normal intrinsic urethral function, a Kelly Kennedy procedure at the time of an anterior colporrhaphy may be more appropriate than a Burch procedure.
Detrusor overactivity is important because, in the trial that we performed, the Burch retropubic urethropexy had a 55% objective cure rate of concurrent detrusor overactivity and a 70% subjective cure rate of the symptom of urge urinary incontinence. In contrast, over the last 12 years, the sling procedure has had a resolution rate of between 20% and 28% for recurrent detrusor overactivity. Recent subjective data at 1 year for midurethral slings fall into the same range: 20% to 30% resolution of recurrent urge incontinence.
Another factor is de novo detrusor overactivity. The rate of de novo detrusor overactivity and urge incontinence in our sling patients seems consistently higher, compared with our retropubic urethropexy patients. We all know that the patient with urge incontinence is far more upset about her condition than the patient who has predictable stress incontinence, because urge incontinence can be far more destructive to quality of life. I try to encourage gynecologists to consider this factor.
Voiding function is less clear-cut. Basically, because intrinsic urethral function declines with age, it is not uncommon to see a woman in her 70s or 80s with ISD who also has absent detrusor contractions during voiding studies. The physician can assess this function by ultrasound or urodynamic testing, or by measuring the postvoid residual volume, which usually falls in the range of 100 to 200 mL, especially if no prolapse is present. Thus, even in cases in which I normally would want to do a sling for ISD, I opt against it if the patient has poor voiding function. That’s because the risk of permanent retention may rise as high as 15% to 20% in some of these patients.
Evaluation and treatment of mixed incontinence
DAVILA: I think we all agree that incontinence is easier to address than “hypercontinence” resulting from postoperative urethral obstruction, urinary retention, and irritative voiding symptoms. But what about patients with mixed incontinence? How do you evaluate them? Is there a role for surgical procedures in patients with primary urge incontinence?