Khullar_EU_Genito.qxp 31/7/07 12:21 Page 79
An Overview of the Management of Urodynamic Stress Incontinence
duloxetine to be superior to placebo for the treatment of severe stress Burch colposuspension; nor does it necessitate a large abdominal incision
incontinence in women with pure USI between the ages of 35 and 75 in the same manner as pubovaginal slings.
who were waiting for continence surgery. In this eight-week study, 22%
of women chose to abandon plans for surgery on the basis of the Tension-free Vaginal Tape
improvement of their symptoms. Duloxetine may have a role in patients The mainstay of mid-urethral surgery is the tension-free vaginal tape,
who are unsuitable or unwilling to undergo surgery, or are uncommitted which employs the technique of transvaginal introduction of the
to PFMT. It could also have a place alongside PFMT, although its long- synthetic tape, which passes retropubically and exits through the
term efficacy remains unknown. anterior abdominal wall.
Surgical The gynecare TVT system employs a monofilament, polypropylene mesh
with a pore size of 75–150 microns. The large pores encourage
Colposuspension incorporation into the patient’s own tissues; the mesh itself is elastic
The Burch colposuspension is still considered by many to be the gold and moves with the patient’s own movements and yet forms a
standard treatment for USI. The original colposuspension was devised to backstop to actions such as coughing, laughing and sneezing. The TVT
elevate the urethrovesical junction to the symphysis pubis. However, in attempts to reinforce dysfunctional pubourethral ligaments, enhance
1961 Burch chose to attach them to the Cooper’s ligament after finding connective tissue in the paraurethral area and create a solid support
the support to the pubic symphysis to be unreliable. Objective success beneath the urethra.
rates of colposuspension range from 70 to 95%, with five-year results
consistently at least 80%. This procedure was developed as an alternative to the Burch
colposuspension and has a shorter operative time and reduced morbidity
Laparoscopic colposuspension has also been reported. The possible associated with it. This procedure can also be performed under sedation
benefits of adopting a minimal access technique include reduction of with local anaesthesia or spinal anaesthesia, thereby reducing the
hospital stay and patient recovery time. Carey et al.
12
published a study anaesthetic risks to the patient.
of 200 women with USI who were randomised to open or laparoscopic
Burch colposuspension, and found no difference in subjective or The complications of this procedure are those inherent to all continence
objective cure rate at three-to-five-, six- and 24-year follow-up. This procedures and specific to the tape itself. These include:
study also reported longer operative time but reduced blood loss and
pain associated with the laparoscopic approach. Tan et al.
13
published a • bladder/urethral trauma;
systematic review of colposuspension in 2006. They concluded that • infection;
laparoscopic colposuspension results in a significant reduction in • voiding dysfunction and urinary retention;
hospital stay and earlier return to work, with a possible increased risk of • de novo urgency and overactive bladder symptoms;
bladder injury. When performed by appropriately experienced surgeons • tape infection; and
it may be a safe option with advantages for the patient, but further • migration or erosion leading to exposure in the bladder and vagina.
randomised, controlled trials should be undertaken to evaluate
continence after five years. Dean et al.
14
compared laparoscopic colposuspension with TVT and
reported higher objective cure rates with the TVT, with similar
The intra-operative complications of colposuspension include subjective cure rates, over an 18-month period. There is a large body of
haemorrhage and trauma to the urinary tract and other pelvic viscera. long-term evidence that supports the use of TVT with cure rates
Post-operatively, there are the complications of any open procedure such comparable to the open Burch colposuspension, without the
as thromboembolic event, post-operative ileus and infection; complications associated with open surgery.
complications relating to urinary function such as retention, de novo
urgency, overactive bladder symptoms; and long-term complications such Suprapubic Pubic Arch Sling Procedure
as chronic pain, dyspareunia and pelvic organ prolapse. This system is a minimally invasive sling procedure using a loosely
knitted self-fixating 4-0-propylene mesh, which is positioned at the
Mid-urethral Tapes mid-urethra by passing suspension needles through incisions in the
Introduced in 1994, these have grown in acceptance and the tension-free anterior abdominal skin, and emerges through a vaginal incision. The
vaginal tape (TVT) is now the most common procedure carried out for suprapubic pubic arch sling procedure (SPARC) can be performed under
incontinence in the UK. Polypropylene monofilament mesh is currently general, regional or local anaesthesia and care must be taken to avoid
considered the material of choice. The principle of the mid-urethral excessive tension applied to the sling intra-operatively. This system
approach is that incontinence results from weakening of the support contains a tensioning suture, which provides a restraint to sling
structures of the urethra, anterior vaginal wall to the mid-urethra and stretching that may occur during loosening of the sling during the
pubococcygeus, which inserts adjacent to the urethra; thus, by providing procedure. The literature supports further study of this system,
support to the mid-urethra, the tape restores continence. including more long-term data.
15–17
The mid-urethral approach is favoured because it involves minimal Transobturator Approach
vaginal dissection or alteration of vaginal architecture, and therefore The transobturator approach is a mid-urethral tape system where the
minimal effect on the mobility of the proximal urethra. It is a relatively technique for introduction of the tape is divided into two categories: the
easy procedure to master and has a lower operative morbidity than the ‘outside to in’ or ‘inside to out’ methods. This refers to the introduction
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