Surgery For Urinary Incontinence: Pros And Cons, Indications

2024 Author: Josephine Shorter | [email protected]. Last modified: 2023-12-16 21:43

Surgery for urinary incontinence: the pros and cons

Surgery for urinary incontinence is a major surgical procedure. When a doctor directs a woman to such a procedure, he is obliged to inform her about all possible complications of the procedure, as well as that there is a possibility of a recurrence of the existing problem.

To relieve a woman of stress urinary incontinence, modern surgery offers more than 250 types of different operations. Their goal is either to completely compensate or correct the cause that led to the impossibility of holding back urine. As for the effectiveness of such interventions, the rates vary within 70-95%.

For urinary incontinence, the following types of surgery can be performed:

• Sling operations (suspension operations);
• Vaginal plastic surgery;
• Installation of an artificial sphincter;
• Introduction of injections of bulking agents into the periurethral zone.

Content:

• Indications for surgery
• Female urinary incontinence sling (TVT)
• Anterior colporrhaphy
• Laparoscopic colposuspension according to Burch
• Artificial bladder sphincter implantation
• Periurethral injection of bulking agents
• Operation cost
• Reviews

Indications for surgery

The indications for surgical intervention for urinary incontinence are as follows:

• Acquired stress incontinence.
• Mixed incontinence of urine with a predominance of the stress component.
• Rapid progression of pathology.
• The ineffectiveness of conservative therapy in patients with the second and third degree of incontinence.

Female urinary incontinence sling (TVT)

Sling surgeries (TVT and TVT-O) are an effective and safe method of treating stress urinary incontinence. They belong to minimally invasive techniques, which are carried out under the control of modern equipment. The essence of the intervention is that a loop is introduced under the middle part of the urethra, which is designed to support the urethra and prevent urine from flowing out under tension. The loop is made of synthetic material and is placed in the space between the urethra and the anterior vaginal wall. As a result, the angle between the bladder and the urethra is restored and no urine flows out.

Sling surgery is performed for stress urinary incontinence, as well as when stress incontinence is combined with urgent urinary incontinence. That is, in cases where the uncontrolled output of urine is accompanied by an increase in intra-abdominal pressure (this happens when sneezing, laughing, coughing, etc.).

Contraindications for this type of surgical intervention are:

• The period of bearing a child.
• Pregnancy planning stage.
• Infectious and inflammatory diseases of the genitourinary system.
• Taking medicines that thin the blood less than 10 days before the start of the surgery.

A sling operation can be carried out even if the previous surgical treatment has not been successful.

Before the patient is referred for surgery, she must undergo a comprehensive urodynamic examination.

As for an alternative to sling surgery, special exercises can help with mild urinary incontinence. However, when conservative therapy turns out to be ineffective, it will not be possible to get rid of the existing problem in other ways. It is also possible to install mini-loops (miniTVT), transobturator loops (TOT) and needleless loops (needleless).

When a woman has other pathologies in parallel, for example, a prolapse of the pelvic floor, then it is possible to install a mesh, and not a small loop implant. If urinary incontinence is of a mixed nature, then drug correction is carried out in parallel. That is, the imperative cause is eliminated with medication, and stress incontinence with surgery.

Preparation for the operation takes place in several stages:

• Specialist consultation: urologist, therapist, anesthesiologist, gynecologist. If there are any inflammatory processes, then they are subject to treatment.
• Hospitalization in a hospital on the eve of surgery, tests and assessment of the patient's condition.
• Examination by an anesthesiologist, premedication appointment.
• Setting an enema before surgery, or taking laxatives to cleanse the intestines.
• Shaving the pubic area and external genitalia.
• Refuse food and any liquid on the eve of the operation.

The course of the surgical intervention:

• The patient is injected with spinal anesthesia, in which consciousness remains, but the sensitivity of the body below the waist disappears.
• An incision is made on the front wall of the vagina and tunnels are formed for passage and installation of the chant.
• A loop is drawn through the tunnels, its lateral ends are brought out. The center of the loop will be located under the urethra.
• The surgeon pulls the loop until the canal touches the bladder.
• Normal urinary retention is checked by filling the bladder.
• The side parts of the loop are removed.
• The incision over the vagina is sutured.
• A catheter is placed in the bladder.
• A tampon is placed in the vagina.

As a rule, complications after surgery are extremely rare. Perforation of the bladder is possible during the procedure. In this case, the lesion is sutured, and the catheter is inserted for 5 to 10 days. Sometimes in the early postoperative period there is an increase in body temperature and slight pain in the incision area.

As for the long-term postoperative period, it is possible that urinary incontinence cannot be fully eliminated, or urination may be difficult.

Complications of anesthesia are: headaches, nausea. These negative phenomena go away on their own in 5-7 days.

Anterior colporrhaphy

Anterior colporrhaphy is a surgical procedure aimed at eliminating urinary incontinence in women. During the operation, the anterior wall of the vagina is dissected, the bladder and urethra are isolated, then the vagina is sutured again. At the same time, its walls, as it were, tighten, which allows to stabilize the urethra and the bladder neck. The vagina itself is also strengthened.

This operation carries the risk of fibrosis of the vaginal tissues. In addition, the effect of its implementation can hardly be called stable, and the frequency of unsuccessful outcomes of the intervention is quite high.

Colporrhaphy is not recommended for women who suffer only from stress urinary incontinence, in the absence of other pathologies.

Laparoscopic colposuspension according to Burch

Colposuspension according to Birch is reduced to the suspension of the tissues that surround the urethra. They are suspended from the inguinal ligaments, which are located on the anterior abdominal wall and are very strong.

Access is obtained through an incision in the abdomen. The operation can be open and closed. The latter is performed using laparoscopic equipment.

For many years, Birch colposuspension has been used to treat stress urinary incontinence in women in the vast majority of cases. The effectiveness of this procedure was up to 70-80%.

As for the disadvantages of the technique, among them we can single out: the need for the introduction of general anesthesia, the connection of the patient to a ventilator. In addition, for the procedure to be successful, it had to be performed by a highly qualified surgeon. It should be noted that sling surgeries at this point in time have practically supplanted Birch colposuspension, as they are safer and more effective methods of treating urinary incontinence in women.

Artificial bladder sphincter implantation

Urinary incontinence has a negative impact on the quality of life of any person, as its involuntary leakage always causes a lot of inconvenience. From 5 to 10% of the world's population suffer from various forms of urinary incontinence, and 70% of them are women.

Urinary incontinence can be urgent or neurogenic. In this case, a person has an increased contractility of the bladder, and the mechanism for retaining fluid in it is impaired. This can occur due to the failure of the sphincter of the bladder.

Separately, stress urinary incontinence is distinguished, which is associated with true sphincter insufficiency. It is classified as the third type of stress urinary incontinence (classification by the International Society for Urinary Continence).

It is known that no more than 50% of people apply for a problem they have for qualified medical help. This is often due to a false sense of shame, or a false belief that therapy is not possible. As a rule, from the moment when a person first experienced urinary incontinence and until he goes to a specialist, an average of 5 years pass. Meanwhile, modern medicine has effective methods of treating incontinence and is able to help almost everyone with this problem.

Urgent urinary incontinence is most often treated with medication, but type 3 stress urinary incontinence always requires surgery. One of the leading methods of surgical intervention is the implantation of an artificial bladder sphincter.

What is an Artificial Bladder Sphincter? An artificial sphincter is a prosthesis that is implanted into the human body. It is necessary for maintaining urine in the event that its own sphincter cannot cope with this task.

When and why was it created? The first prototype of a modern device was developed back in 47 of the last century by the scientist and urologist FB Foley. It looked like a cuff that was placed around the human urethra. This cuff was connected to a syringe pump, which was stored in a pocket of underwear. The idea was very innovative and medically correct. However, the level of surgery at that time did not allow to completely remove the implant into the human body, so its installation was often complicated by purulent processes.

In 72 of the last century, the device was improved by the urologist FB Scott. It was this American doctor who created the prototype of the modern artificial sphincter. It consisted of three elements: a cuff that wrapped and compressed the urethra, two pumps that inflated and deflated it, and a reservoir for collecting fluid. The success of surgical intervention for the installation of the first three-component sphincter at that time reached 60%.

Later, the device was improved by American Medical System, which happened back in 83. Until now, doctors have successfully used AMS artificial sphincters, which have undergone only minor improvements.

The efficiency of the operation. The success rate of installing a modern artificial bladder sphincter is equal to 75%. Moreover, 90% of people who use these devices are absolutely satisfied with their work. In no more than 20% of cases, a second operation is required, which is carried out in order to eliminate defects in the operation of the device.

Indications and contraindications. Indications for placing an artificial bladder sphincter vary. An absolute indication is irreversible disturbances in the work of one's own sphincter, against the background of normal functioning of the bladder. In this case, the patient should not have a urinary tract infection and impaired urethral patency.

In men and women, various indications for the operation can be distinguished, which are presented in the table.

Men	Women
If urinary incontinence develops against the background of a radical prostatectomy due to prostate cancer. After undergoing transvesical adenoectomy or retropubic prostatectomy, intrasurethral resection of the prostate due to benign prostatic hyperplasia.	Neurogenic urinary incontinence on the background of trauma, diseases of the brain or spinal cord, myelomeningocele, sacral genesis, peripheral neuropathy.
Postponed pelvic trauma, reconstruction of the urethral stricture, carried out by surgery.	Type 3 stress urinary incontinence, which has not been managed with less invasive procedures.
Congenital malformations of the urethral neck and bladder.
Neurogenic dysfunction of the bladder sphincter in the presence of a brain injury or due to congenital malformations.

Absolute contraindications for the operation are:

• Urethral stricture disease.
• Recurrent stricture.
• Urinary tract infections.
• Urethral diverticula.
• An unstable or overactive bladder.
• Shrunken bladder.
• Low bladder volume.

Relative contraindications include:

• Vesicoureteral casting of the second stage and higher.
• Urolithiasis, bladder cancer and other conditions that require surgical treatment.
• Stenosis of the bladder neck, its contracture.

If it is possible to eliminate the relative contraindications, then the installation of an artificial sphincter becomes possible. It is important that the person has the necessary mental and physical abilities to control the pump. Before the operation, a detailed consultation with a doctor is required about all the nuances of working with the sphincter.

What examinations need to be done before the operation of the bladder sphincter implantation? First, the patient discusses with the doctor all the nuances of the upcoming intervention. Secondly, he undergoes a physical examination, which is aimed at identifying indications and contraindications for surgery.

It is imperative to pass a general urine test, urine culture, blood tests, and possibly an ECG.

In some cases, it is required to undergo cystography, urethrography, urethroscopy, cystoscopy and other highly specialized tests. The better the patient is examined, the higher the chance that the operation will be successful.

Operation progress. The operation can be performed through the angle of the penis and scrotum (penoscrotal approach), or through a perineal incision (performed under the scrotum). If the access is penoscrotal, then one incision is enough to install the implant. If the access is perineal, then an additional incision is required to install the reservoir. In this case, the patient spends 1 to 3 days in the hospital. The catheter from the urethra will be removed the next day after the operation.

The sphincter is activated after its installation after 6 weeks. This time is necessary for it to take root. Under the supervision of a urologist, a person is trained to work with the device. You will need to see a doctor in the future once a year.

Periurethral injection of bulking agents

Periurethral injections are carried out by introducing various biological and synthetic drugs into the space around the urethra. As a result, an additional external sphincter is created, which narrows the urinary canal and prevents urine from flowing out. This procedure is the least traumatic for the patient.

The indication for injection is sphincter insufficiency. The procedure is performed under local anesthesia. Most often, it is prescribed to those women who refuse to undergo surgery with more invasive methods.

The main disadvantage of the procedure is the recurrence of urinary incontinence, which occurs after 1-2 years. After the injection of the substance, palpable soreness occurs at the injection site. In addition, urinary retention and impaired bladder emptying are possible.

The European Association of Urology recognizes periurethral injections as an effective method for eliminating urinary incontinence in women, but experts note the temporary effect of the procedure. In some cases, it can last no more than 3 months. Therefore, the injection will need to be administered again. Sling surgery is more effective than this method of treatment.

Operation cost

Some transactions can be carried out under government quotas. To receive them, you need to submit an application and wait in line.

Quotas include:

• Sling operations.
• Cavity abdominal and laparoscopic operations.
• Installation of sphincter prostheses for men (it is possible that you will have to pay for the prosthesis yourself).

If a person does not want to wait in line, then he can go to a private clinic and independently pay for the procedure he needs.

• Installation of a sling costs 80,000-100,000 rubles on average. If the last generation sling is used for the operation, the price can increase several times.
• Vaginal plastic surgery costs 50,000-200,000 rubles for women.
• Colposuspension using the laparoscopic method costs about 150,000 rubles.
• Bladder sphincter implantation can cost about 500,00 rubles.

Reviews

Although the problem of urinary incontinence is quite common, many people hesitate to seek help from a specialist. This is especially true for older women. They use pads, but stubbornly refuse to raise this topic. This affects socialization and self-esteem of a person not in the best way.

All patients who have undergone surgery to eliminate urinary incontinence in their reviews note a significant improvement in the quality of life. They are almost unanimous in the opinion that it is better to survive several months of rehabilitation than to continue to suffer from the existing problem for the rest of their lives.

It is important to understand that the sooner the patient addresses his problem to the urologist, the easier it is to cure him. Therefore, do not hesitate to talk about urinary incontinence with a specialist.

Author of the article: Lebedev Andrey Sergeevich | Urologist

Education: Diploma in the specialty "Andrology" received after completing residency at the Department of Endoscopic Urology of the Russian Medical Academy of Postgraduate Education in the urological center of the Central Clinical Hospital No. 1 of JSC Russian Railways (2007). Postgraduate studies were completed here by 2010.