Surgical Treatment of Urinary Incontinence

Question 1

Candidates for surgery for stress incont

Answer 1

failed conservative therapy

No future childbearing

Question 2

Burch Urethropexy

Answer 2

Endopelvic fascia to Cooper’s
ligament

limit the mobility of the pubocervical fascia

5 year cure rate 70%
- stabilized and suspend anterior vaginal wall and compresses urethra

complications:
Bladder perforation
Detrusor overactivity (too tight)
Ostetitis Pubis and Osteomylitis

Question 3

Bladder Neck Sling

Answer 3

Rectus Fascia Sling
Sling is more successful tha Burch

Sling had higher rate of UTI, voiding dysfuction, and postop urge incontinence, erosion, revision

Question 4

TVT

Answer 4

Bladder empty 
Pass 1st needle through
suprapubic incisions (hug pubic bone) 
 Introduce 2nd needle and place
in a similar fashion
 Remove introducer from needles

release any tension on the urethra

 Cystoscopy to check for bladder
perforation (~ 10 & 2 o’clock)

Equally effective to Burch

fewer
perioperative complications, less postoperative voiding
dysfunction, shorter operative time, and a shorter
hospital stay but significantly more bladder perforations.

Management of Bladder perf
- remove intraop, replace,and drain for >24 hours

Management of retention, downward traction, or with prolonged urinary retention sling lysis (may pull down in 1st month)

Void vs PVR is normal 2x they can stop cath (PVR>200)

Question 5

TOT

Answer 5

slightly lower cure rate

Advantages of TOT: ↓ bladder perforation, ↓ EBL, &
↓ voiding dysfunction

 Disadvantages of TOT: ↑ risk of neurologic symptoms

Question 6

ISD

Answer 6

Do not do Burch

TVT is good :)

Question 7

urethral bulking agents

Answer 7

Indications:
– Intrinsic sphincter deficiency and nonmobile bladder neck
– Older, more debilitated patient
– Second-line therapy after failure of 1st surgery
cure ~ 40%, improved ~ 70%

Question 8

Retropubic space of retzus anatomic concerns

Answer 8

obturators are lateral medial there are perivesicular plexus

Question 9

Presacral space for abdominal sacrocopopexy

Answer 9

left common iliac vein
find middle sacral vessels
stay high to avoid venous plexus

Question 10

TVT bleeding

Answer 10

Paraurethral venous plexus of Santorini
or obturator

Pressure
- overdistend the bladder, inflate the foley
bulb to 30 cc and apply downward traction,
inject hemostatic agent (Flowseal)
LAST resort – open up the retropubic
space for direct visualization and control

Question 11

urinary incontinence after TVT

Answer 11

Relaxation of the tape,
Primary failure,
UTI,
Tape perforation of the bladder,
Overcorrection resulting in urethral
obstruction with resulting bladder
instability and/or overflow incontinence,
Retropubic hematoma impinging on the
bladder causing bladder instability,
Fistula

Evaluation
\+SST and HMU would suggest primary
failure
UA C&S would rule out UTI
UA with XS RBCs, PE with vaginal leakage
of urine, cystoscopy to R/O tape
perforation
PE with placement of urethral dilator, and
elevated PVR suggest tape too tight
PE for ecchymosis, palpable hematoma,
and imaging (ultrasound, CT, MRI) to
detect retropubic hematoma
Tampon test to R/O fistula