Postoperative Evaluation of Patients Operated with the New Technique for Stress Urinary Incontinence

Abbreviations

AUA: American Urological Association; MMK: Marshall Marchetti Krantz; BMI: Body mass index; TVT: Tension- free tapes; MUS: Mid-urethral slings; FDA: Food and Drug Administration.

Introduction

Urinary incontinence is defined by the International Continence Society as ‘involuntary loss of urine that is a social or hygienic problem’. In community studies, it is estimated that 20-30% of women are affected, but only 7-12% perceive it as a problem [1].

Stress urinary incontinence treatment was updated again by the American Urological Association (AUA) in the panel convened in 2011, by evaluating large meta-analyses [2].

Accordingly, the first step of stress incontinence treatment is conservative treatments consisting of behavioral treatments, drug therapy, and pelvic floor exercises. For patients who cannot benefit from this step, the most appropriate alternative for the patient should be chosen among surgical treatment options. Surgical methods used today in the treatment of stress incontinence are retropubic suspensions (open and laparoscopic Burch operation), sling operations, of which many types have been described, periurethral injections, and artificial urinary sphincter applications [2]. The most well-known retropubic urethropexy procedures are Marshall Marchetti Krantz (MMK) and Burch operations. MMC cystourethropexy is based on the transabdominal suspension of the vesicourethral junction or bladder neck to the periosteum of the symphysis pubish [3] .

Our practice is to place a non-absorbable 2/0 polyester suture under the vesicourethral junction transvaginally. It should not be confused with the classic Kelly plication. In the classic Kelly plication, the pubocervical fascia under the bladder neck is brought closer to the midline and plicated, and the bladder neck and proximal urethra are lifted and supported. Absorbable sutures are preferred [4].

The prominent advantages of our technique are the use of non-absorbable sutures, the placement of sutures in the vesicourethral junction, the use of solid tissues such as muscle fascia, and the fact that all these procedures are performed transvaginally, unlike the MMK operation.

Results

The age range of the patients included in the study varies between 26 and 74 years. The average age is 46.19 years. The duration of stress incontinence in patients varies between 2-15 years. The average duration of stress incontinence was found to be 6.85 years. General characteristics of the patients are given in Table 1.

Incontinence was observed in 6 patients after the operation. Complete cure was achieved in 294 of the patients and it was found to be statistically significant (p=0.000). The success rate of the method was found to be 98% in our study. The changes in the stress test and Q-type test results before and after the operation were found to be statistically significant (p=0.000). The changes detected in the postoperative pad test were found to be statistically significant (p=0.004). No intraoperative complications related to the operation were observed. Urinary retention was observed in 12 patients after the operation. Frequent urination, feelings of urgency, pain, and dyspareunia were not observed. Postoperative findings are given in Table 2.

BMI: Body Mass Index, CS: Sezaryan Doğum, VD: Vajinal Doğum. Table 1: General Characteristics.

*A value of P<0.05 was considered significant within the 95% confidence interval. Table 2: Postoperative Findings.

Discussion

Urinary incontinence is an important sociocultural health problem with a high prevalence. Considering that quality of life is becoming increasingly important and average life expectancy is increasing, SUI treatment will become even more valuable in the coming years as the number of geriatric individuals increases [5].

Today, mid-urethral slings (MUS) are considered the gold standard in the treatment of SUI [5]. This notion is supported by a large population-based cohort analysis by the National Health Service in England, which demonstrated a low removal rate of 3.3% and a low failure rate of 4.5% after 9 years of follow-up in more than 90,000 women receiving MUS [6].

However, controversy has arisen regarding complications associated with surgical incontinence procedures, leading to several court cases against the use of vaginal slings and tapes in the United States, Canada, the United Kingdom, and some European countries [7, 8].

For this reason, minimally invasive surgeries that do not use mesh have an important place. Again, mid-urethral slings can be made from the vagina without the use of minimal mesh, which is a great convenience for the patient and the physician. Our study is completely vaginal and minimally invasive. In addition, not using mesh is a great advantage for the patient and the surgeon.

More than 25 years ago, Ulmsten et al. A new type of surgery for stress urinary incontinence in women was introduced. It revolutionized the surgical treatment of stress incontinence. A tension-free alloplastic sling (preferably made of polypropylene) implanted under the middle third of the urethra and removed behind the pubic bone stabilizes the pubourethral ligaments and suburethral fascial structures [9, 10].

In our method, there is a surgery that works with the same logic but does not use mesh. Therefore, mesh-related complications are prevented. As for effectiveness, Ulmsten et al. While the success rate in the method he described was 78%, it was found to be 98% in our method [9, 10].

The support of the urethra depends on its fascial connection to the pelvis of the tendinous fascia arch and its connective tissue connection to the pubis [11]. It should be remembered that tension-free tapes and colposuspension target urethral hypermobility, while bulking agents, autologous fascia straps, and artificial sphincter muscles focus on intrinsic sphincter insufficiency [12].

The potential of laser therapy cannot be evaluated with certainty at this time. This technique needs further study [13].

For several decades, transvaginal tension-free tapes (TVT) have become an established treatment for female SUI. Comparable results were observed between colposuspension and TVT implantation [14].

However, transvaginal access causes side effects that affect sexuality, and implantation of nonabsorbable slings or MESH may cause complications due to material stiffness or tissue erosion. That’s why the US Food and Drug Administration (FDA) has issued a warning. This led to a change in surgical strategies for women and led to a revival of classical surgical techniques such as colposuspension [15, 16].

Our study is designed to recreate anatomical support without using MESH. Additionally, it does not cause sexual activity problems in patients. Patients can return to their social lives earlier.

Tension-free vaginal tape (TVT), one of the most widely used methods in the surgical treatment of stress urinary incontinence in women, was developed in 1990 by Ulmsten and Petros within the scope of integral theory. The cure rate of TVT operation has been reported between 66% and 91% [17, 18].

In our study, our cure rate was found to be 98%. A high cure rate was found compared to the methods in the literature. As it was observed that the perioperative complications of TVT (bladder perforation, bowel, and major vascular injuries) were mostly due to penetration into the retropubic space, the need to develop alternative techniques to TVT arose. The Transobturator technique, developed by Delorme in 2001 to reduce morbidity, has advantages such as avoiding the Retzius area and working in limited proximity to the peritoneal cavity [19].

In our study, urinary retention was observed in 12 patients. Since our follow-up period was 2 years, we may not have been able to detect long-term complications.

The needleless technique, one of the newest methods used in the surgical treatment of stress urinary incontinence, is a minimally invasive mid-urethral sling surgery that uses a polypropylene mesh and does not require the use of any needles or guides. Preserving the tension-free concept with the needleless technique is aimed at avoiding major complications that may occur during the passage of the needles used in sling surgeries. In surgeries such as TVT and TOT, bladder rupture, obturator nerve damage or vascular injuries may occur during the needle’s passage through the trans-obturator route. Needleless is a new method developed to reduce these possible complications [20].

Not entering the Retzius space and the pelvic cavity are two important advantages of the procedure. This is why no complications were observed in our study. 80-90% of women who undergo retropubic or transobturator sling procedures improve or are treated for their stress incontinence symptoms after surgery. Single-incision sling procedures are relatively new and success rates are still being monitored [20]. The success rate of our study was found to be 98%. However, multicenter studies with a larger patient population are needed. A 63-97% subjective and 59-100% objective cure rate has been reported for Burch colposuspension [21, 22, 23]. A subjective cure rate of 72-100% and an objective cure rate of 71-100% have been reported for the Marshall- Marchetti-Kranz operation [24, 25, 26, 27]. Subjective success rates of 50-97% and objective success rates of 40-93% have been reported for needle suspension surgeries [28, 29, 30, 31]. Subjective success rates of 60-100% and objective success rates of 78- 100% have been reported for sling operations [32, 33, 34]. The general subjective success rate of periurethral injections varies between 30-95% and the objective success rate varies between 31-70% [35, 36, 37, 38].

High success rates are achieved with appropriate methods in the treatment of SUI that have been correctly diagnosed with current methods. However, there is still some confusion in evaluating the results of surgical interventions for SUI. Some researchers use terms such as “improvement” when giving their results, but the definition of this improvement is different for each researcher. Moreover, when talking about the success of the operation, is the most important criterion to be based on the objective success rate determined by physical examination and urodynamic tests? Is it the subjective success rate determined by the patient’s statement? Or is it the patient’s satisfaction with the postoperative continence status? There is no consensus that it is. In our study, the cure rate was determined based on objective data.

Conclusion

Our study aimed to draw attention to an effective method in the treatment of SUI. The success rate of our study is quite high compared to the literature. The absence of complications during and after the operation is very advantageous for this method. We think that our study will contribute to the literature.