[ Editorials | Letters | Selected Articles | Signature Series | Patient Handouts | Index ]

2002 Selected Articles

Cover/CME

Surgical Treatment of Genuine Stress Urinary Incontinence Part1

Dorothy N. Kammerer-Doak, MD; Rebecca G. Rogers, MD

A wide array of surgical treatments are available for genuine stress urinary incontinence (GSUI), with approximately 75,000 surgical procedures performed annually. More than 100 different anti-incontinence surgical approaches have been described, and an average of one publication per week addresses the surgical repair of GSUI.¹

Genuine SUI is the involuntary loss of urine that occurs with mild to moderate increases in intra-abdominal pressure (eg, laughing, coughing, sneezing) in the absence of a detrusor muscle contraction. Genuine SUI is the only common type of urinary incontinence that can be treated surgically, unlike detrusor instability or overactive bladder. This article discusses theories about what causes GSUI, as well anterior colporrhaphy and Burch retropubic urethropexy (RPU)—two of the most widely employed anti-incontinence procedures performed by gynecologists.

THEORIES OF GSUI

Two possible causes of GSUI have been postulated relative to how the bladder neck functions to maintain continence with increased intra-abdominal pressure. The passive, structural hypothesis of GSUI proposed by Enhorning^2,3 theorizes that continence is maintained by equal transmission of increases in intra-abdominal pressure to the bladder and the proximal urethra. This requires that the urethrovesical junction (UVJ) remain in its original intra-abdominal position. If the UVJ becomes hypermobile, the bladder neck can descend from its intra-abdominal position and disrupt the equal transmission of pressure, resulting in GSUI (Figure 1). At rest, urethral pressure exceeds bladder pressure in continent women due to the intrinsic urethral sphincter mechanism. With the UVJ in an intra-abdominal position, equal transmission of increased pressure ensures that urethral pressure remains greater than bladder pressure, and continence is maintained. When the urethra has descended or is hypermobile, increases in intra-abdominal pressure are transmitted to the bladder but not to the urethra. Bladder pressure may then exceed urethral pressure, resulting in GSUI.

An alternative theory of GSUI was proposed by DeLancey⁴ based on cadaveric investigation of the anatomic relationship between the pelvic floor and bladder. This “hammock hypothesis” suggests that the tissues under the urethra provide a hammock of support to compress it and keep it closed when intra-abdominal pressure rises. The underlying urethral support consists of the pubocervical adventitia/fascia and vagina, which are attached laterally to the pubic bone via the arcus tendineus fasciae pelvis and levator ani muscle (Figure 2). When the underlying hammock is defective, the UVJ becomes hypermobile and the urethra remains open when intra-abdominal pressure increases, leading to GSUI.

 

Figure 1. Passive structural theory of SUI		Figure 2. Hammock hypothesis
Ostergard, DR. Bent AE, ed. Urogynecology and Urodynamics: Theory and Practice. 3rd ed. Baltimore, Md: Lippincott, Williams & Wilkins; 1991:74.		U = urethra; V = vagina; ATFP = arcus tendineus fascia pelvis; PC = pubocervical DeLancey JO. Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol. 1994;170:1713-1720.

Genuine SUI can be divided into two classes based on UVJ support and function of the intrinsic urethral sphincteric mechanism. Approximately 90% of GSUI is associated with urethral hypermobility in the presence of a normal urethral sphincter mechanism. Urethral hypermobility is defined by a “cotton swab test.” To perform the test, a cotton swab is inserted into the urethra so that the cotton swab lies at the urethral vesical junction. Movement of greater than 30º from the horizontal with straining of more than more than 10 mm of movement assessed ultrasonographically is considered hypermobile. Less commonly, GSUI may be due to a deficient sphincter or low-pressure urethra, ie, intrinsic sphincteric deficiency (ISD). Intrinsic SD can be associated with either an immobile or hypermobile urethra, and typically results in severe incontinence. Risk factors for ISD include age greater than 50 years, previous anti-incontinence surgery or radiation therapy, neurologic disorders, severe pelvic organ prolapse, and urethral trauma.⁵

SURGICAL CONSIDERATIONS

Several important issues must be considered for the surgical treatment of GSUI. The ideal surgical procedure would make the patient continent, have consistent, good results in many hands with few complications, as well as durable results. Additionally, the ideal anti-incontinence surgery would not create a new problem such as urinary retention, overactive bladder, or prolapse, all of which have been reported with anti-incontinence surgeries. Therefore, most patients should be encouraged to try nonsurgical anti-incontinence therapies before resorting to operative solutions. Options include pelvic-floor (Kegel) exercises or other physical therapy with or without biofeedback, medications, behavioral modification, and devices such as pessaries and urethral plugs and patches. A single randomized trial⁶ comparing surgical with nonsurgical interventions for GSUI found that while surgery yielded significantly better results than pelvic-floor exercises, both objectively and subjectively, 42% of the women assigned to nonsurgical therapy were satisfied with their continence status and did not wish to undergo operative treatment. Thus, nonoperative intervention is a viable option that should be considered prior to surgical treatment of GSUI.

Anterior Colporrhaphy

Anterior colporrhaphy, first described by Kelly in 1913 and later modified by Kennedy, was based on the concept that GSUI resulted from a “torn” urethral sphincter that could be surgically repaired or plicated. This procedure was the mainstay of surgical treatment of GSUI for years.⁷ Modified anterior colporrhaphy is associated with marked variability in success rates, ranging from 27% to 91%.^8-11 However, many authors report nonobjective cure rates, and the majority of studies on outcomes of anterior colporrhaphy are retrospective. Beck10 has obtained consistently high success rates with modified anterior colporrhaphy, demonstrating objective cure rates at 2 years of approximately 91% in a large series of patients. The author describes the procedure in detail as a vaginal RPU with plication of the periurethral fascia to elevate and fix and compress the UVJ in a retropubic position without obstructing it. Using delayed absorbable 0-vicryl, two figure-of-eight sutures are placed to plicate the periurethral tissues. The long axis of the needle is inserted parallel to the urethra at a right angle to the fascia, with the needle directed deep toward the inferior border of the pubic symphysis. When tied, the suture plicates the fascia lateral to and under the ure thra, elevating it (Figure 3).

Figure 3. Beck's vaginal retropubic urethropexy

Beck RP, McCormick S, Nordstrom L. A 25-year experience with 519 anterior colporrhaphy procedures. Obstet Gynecol. 1991;78:1011-1018.

Beck's objective success rates¹⁰ have not been consistently duplicated by other gynecologic surgeons. Bergman et al¹² performed a randomized trial yielding a 65% objective cure rate for GSUI at 1 year with the modified anterior colporrhaphy using 0-vicryl sutures, but this figure fell to 37% at 5 years. While the modified anterior colporrhaphy utilized in the Bergman study¹² was not the same procedure described by Beck,¹⁰ a more recent objective study also reported low success rates in women with prolapse and coexisting GSUI or potential/occult GSUI utilizing posterior pubourethral ligament plication (PULP).¹¹ This procedure is a modified anterior colporrhaphy described by Nichols as a means of performing vaginal RPU.¹³ The PULP approach is very similar to the procedure described by Beck.¹⁰ The objective GSUI cure rate for PULP in this study with 3 to 9 years of follow-up was only 27%.¹¹

Burch RPU

Because of the variable success rates for anterior colporrhaphy and the evolution in understanding of the pathophysiology of GSUI, additional surgical procedures have been developed, including Burch RPU.⁷ Success rates for Burch RPU are remarkably consistent at about 85%.^12,14 Advantages include avoidance of vaginal dissection to limit possible scarring or neurologic damage to the periurethral tissues. Burch noted that this repair of GSUI also corrected mild cystocele, and termed the procedure a colpourethrosuspension.¹⁵ Burch RPU also uses a consistent, strong, easily recognizable anchoring point at Cooper's ligament. By utilizing Cooper's ligament instead of the periosteum or cartilage of the symphysis pubis, Burch RPU avoids the rare but debilitating complication of osteitis pubis that can occur with the Marshall-Merchetti-Krantz procedure.

At these authors' institutions, the Tanago modification of the Burch RPU is utilized (Figure 4).¹⁶ Two nonabsorbable sutures, such as 0-ethibond or gortex sutures are placed on each side, 1 to 2 cm lateral to the urethra (Figure 5). The first suture is at the level of the UVJ, which is identified by the Foley catheter bulb within the bladder. The second suture is slightly distal and lateral to the first. The free ends of each suture are brought through Cooper's ligament and tied down with suture bridges at an angle of -10º to 0º as estimated by cotton swab placed within the urethra. A single randomized trial of laparoscopic Burch RPU compared the use of two sutures to one suture noted a significantly greater cure of GSUI with two sutures (83% versus 58%, relative risk [RR] 1.42, 95% confidence interval [CI] 1.14 to 1.77).¹⁷ No studies have addressed the issue of which suture type (permanent versus absorbable) might be more effective. Similar results have been reported with absorbable and permanent sutures, and most of the long-term data are obtained from procedures utilizing absorbable sutures.

Figure 4. Tanago modification of Burch RPU	Figure 5. Retropubic space anatomy
Courtesy of Dorothy N. Kammerer-Doak, MD.	X identifies suture placement during Burch procedure. Paraiso M, Falcone, T. Laparoscopic Surgery for Genuine Stress Incontinence. In: Walters, MD, Karram MM, eds. Urogynecology and Reconstructive Pelvic Surgery. 2nd ed. St. Louis, Mo:Mosby-Year Book;1999:199.

It should be noted that at 5 to 10 years of follow-up, the success of Burch RPU declines to approximately 75%.^10,18-20 However, even with follow-up to 20 years, the success rates remain stable and plateau at about 60% to 70%. By contrast, the success of anterior colporrhaphy markedly decreases with long-term follow-up to approximately 35%.^10,20

Most studies comparing modified anterior colporrhaphy to Burch RPU are either retrospective or prospective and nonrandomized, introducing possible bias in patient selection. Only four randomized trials compare the procedures with at least 1 year of follow-up, report objective cure rates, and utilize pre- and postoperative multichannel urodynamic testing.^10,21-23 All four studies reported significantly higher cure rates of GSUI following Burch RPU than modified anterior colporrhaphy, although the cure rates with Burch RPU in the Lalos study²² are markedly lower than those reported in the other three trials (Figure 6).

A recent comprehensive review of the literature evaluating the surgical results for anterior colporrhaphy and Burch RPU noted significantly greater objective GSUI cure rates with Burch RPU (82% versus 53%, RR 2.77, 95% CI 2.0 to 3.84).24 Subjective cure rates were also significantly greater for Burch RPU than anterior colporrhaphy (RR 2.63, 95% CI 1.98 to 3.49). The repeat surgery rate for recurrent GSUI was significantly greater following anterior repair than Burch RPU (RR 7.12, 95% CI 2.53 to 20.07); this study concluded that anterior colporrhaphy seemed less effective than open abdominal retropubic suspension, and suggested that use of the former approach should be restricted to women deemed unsuitable for alternative treatment.²⁴

The laparoscopic Burch RPU is a relatively new procedure with purported advantages over the open tech nique, and was introduced in 1991 by Vancaille.²⁵ These two approaches for the Burch RPU have been reviewed in an analysis of the literature.²⁵ Five randomized or quasi-randomized trials compared laparoscopic with open Burch RPU in a combined total of approximately 250 subjects per group. Follow-up ranged from 6 to 18 months, with one study reporting long-term 5-year data. Surgical methods used for laparoscopic Burch RPU vary, with most attempting to reproduce the open method utilizing two sutures as mentioned above. A trend toward increased complications and operative times and decreased pain and estimated blood loss was found with laparoscopic Burch RPU. No differences were noted between the two routes with regard to subjective cure rates (RR 1, 95% CI 0.95 to 1.06). However, objective cure rates were significantly lower in the laparoscopic Burch RPU group, as noted by increased positive cough stress testing (RR 2.3, 95% CI 1.06 to 4.99) and poorer urodynamic results (RR 0.89, 95% CI 0.82 to 0.98).

CONCLUSION

Surgical treatment of GSUI in the presence of a hypermobile urethra with normal pressure has been reviewed with regard to two of the most common surgical procedures: anterior colporrhaphy and Burch RPU. Randomized, controlled trials have demonstrated superior GSUI cure rates with Burch RPU compared with anterior colporrhaphy. In addition, laparoscopic Burch RPU may yield poorer results than the open procedure, although data and follow-up are limited. The concluding article of this series will discuss suburethral sling procedures (including tension-free tape) and urethral injections for the treatment of GSUI.

Dorothy N. Kammerer-Doak, MD, is associate clinical professor, Department of Obstetrics and Gynecology, University of New Mexico, and urogynecologist, Lovelace Health Systems, Albuquerque, NM. Rebecca G. Rogers, MD, is director, Division of Urogynecology, and assistant professor of obstetrics and gynecology at the University of New Mexico, Albuquerque.

REFERENCES

1. Nygaard IE, Kreder KJ. Complications of incontinence surgery. Int J Urogyn. 1994;5:353-360.
2. Enhorning GE. Simultaneous recordings of intravesical and intra-urethral pressure. Acta Chir Scand. 1961;276(suppl):1-68.
3. Enhorning GE. A concept of urinary continence. Urol Int. 1976;31:3-5.
4. DeLancey JO. Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. Am J Obstet Gynecol. 1994;170:1713-1720.
5. Horbach NS, Ostergard DR. Predicting intrinsic urethral sphincter dysfunction in women with stress urinary incontinence. Obstet Gynecol. 1994;84:188-192.
6. Klarskov P, Belving D, Bischoff N, et al. Pelvic floor exercise versus surgery for female stress urinary incontinence. Urol Int. 1986;41:129-132.
7. Hurt WG. Genuine stress urinary incontinence: traditional surgical management. In: Brubaker LT, Saclarides TJ, eds. The Female Pelvic Floor. Philadelphia: FA Davis; 1996:165-181.
8. Cullen PK, Welch JS. Ten year results of the Kelly and Kennedy types of procedure in urinary stress incontinence. Surg Gynecol Obstet. 1961;113:85-90.
9. Harris RL, Yancey CA, Wiser WL, et al. Comparison of anterior colporrhaphy and retropubic urethropexy for patients with genuine stress urinary incontinence. Am J Obstet Gynecol. 1995;173:1671-1674.
10. Beck RP, McCormick S, Nordstrom L. A 25-year experience with 519 anterior colporrhaphy procedures. Obstet Gynecol. 1991;78:1011-1018.
11. Colombo M, Maggioni A, Scalambrino S, et al. Surgery for genitourinary prolapse and stress incontinence: a randomized trial of posterior pubourethral ligament plication and Pereyra suspension. Am J Obstet Gynecol. 1997;176:337-343.
12. Bergman A, Elia G. Three surgical procedures for genuine stress incontinence: five-year follow-up of a prospective randomized study. Am J Obstet Gynecol. 1995;173:66-71.
13. Nichols DH. Cystocele. In: Nichols DH, ed. Gynecologic and Obstetric Surgery. St Louis: Mosby-Year Book; 1993: 334-362.
14. Stanton SL, Cardozo LD. A LMO comparison of vaginal and suprapubic surgery in the correction of incontinence due to urethral sphincter incompetence. Br J Urol. 1979;51: 497-499.
15. Burch JC. Urethrovaginal fixation to Cooper's ligament for the correction of stress incontinence, cystocele, rectocele, and prolapse. Am J Obstet Gynecol. 1961;82:281.
16. Tanago EA. Colpocystourethropexy: the way we do it. J Urol. 1976:116:751-753.
17. Persson J, Wolner-Hanssen P. Laparoscopic Burch colposuspension for stress urinary incontinence: a randomized comparison of one or two sutures on each side of the urethra. Obstet Gynecol. 2000;95:151-155.
18. Feyereisl J, Dreher E, Haenggi W, et al. Long-term results after Burch colposuspension. Am J Obstet Gynecol. 1994; 171:647-652.
19. Gillon G, Stanton SL. Long-term follow-up of surgery for urinary incontinence in elderly women. Br J Urol. 1984;56: 478-481.
20. van Geelen JM, Theeuwes AGM, Eskes TK, Martin CB, Jr. The clinical and urodynamic effects of anterior vaginal repair and Burch colposuspension. Am J Obstet Gynecol. 1988; 159:137-144.
21. Kammerer-Doak DN, Dorin MH, Rogers RG, Cousin MO. A randomized trial of Burch retropubic urethropexy and anterior colporrhaphy for stress urinary incontinence. Obstet Gynecol. 1999;93:75-78.
22. Lalos O, Berglund AL, Bjerle P. Urodynamics in women with stress incontinence before and after surgery. Eur J Obstet Gynecol Reprod Biol. 1993;48:197-205.
23. Liapis AE, Asimiadis V, Loghis CD, et al. A randomized prospective study of three operative methods for the genuine stress incontinence. J Gynecol Surg. 1996;12:7-14.
24. Glazener CM, Cooper K. Anterior vaginal repair for urinary incontinence in women (Cochrane Review). In: The Cochrane Library. Oxford: Update Software; 2002;1.
25. Moehrer B, Cllis G, Carey M, Wilson PD. Laparoscopic colposuspension for urinary incontinence in women (Cochrane Review). In: The Cochrane Library. Oxford: Update Software; 2002;1.

back to top