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Surgery for stress incontinence: Which technique for which patient?

When conservative treatments fail, operative therapy may offer better success—and an increasing number of methods are available. Our experts consider the full range of surgical options and offer guidance on tailoring treatment to the patient’s underlying problem, activity level, and desires.


 

References

PANELISTS
  • Peter K. Sand, MD, moderator, is professor of obstetrics and gynecology, Feinberg School of Medicine, Northwestern University, Evanston, Ill.
  • G. Willy Davila, MD, is chairman, department of gynecology, Cleveland Clinic Florida, Weston, Fla.
  • Karl Luber, MD, is assistant clinical professor, division of female pelvic medicine and reconstructive surgery, University of California School of Medicine, San Diego, and director of the female continence program at Kaiser Permanente, San Diego.

  • Deborah L. Myers, MD, is associate professor of obstetrics and gynecology, Brown University School of Medicine, Providence, RI.

Choosing appropriate surgical interventions is the focus of the second of our 2-part panel on stress urinary incontinence (SUI). The panelists discuss:

  • how to weigh the factors that influence choice of technique, including Burch retropubic urethropexy and the various sling operations;
  • the challenges of treating “mixed” stress and urge incontinence; and
  • when to use bulking agents for intrinsic sphincteric deficiency.

The panelists also share tips on:

  • how to help patients accurately describe their symptoms, and
  • what issues to review with patients as they consider their options.

Part 1 covered medical therapies such as pelvic floor muscle rehabilitation, occlusive devices, and drugs. (Stress urinary incontinence: A closer look at nonsurgical therapies. OBG Management. 2003;15(9):40-51.)

Review surgical options with the patient

SAND: How do you counsel patients about surgical treatments for stress urinary incontinence?

MYERS: After the initial evaluation and diagnosis, I review the conservative options, and I also offer surgery. At this time, I discuss whether an operation is appropriate.

I work with the patient, going over her diagnosis as well as the different types of operations that are performed. Some patients are fairly well educated about their options, having looked up information on the Internet.

Next I explore whether other types of procedures need to be done concomitantly. For instance, does the patient need abdominal hysterectomy for some other reason? That would prompt me to offer an abdominal approach to the SUI. Do other types of vaginal surgery need to be done? Then I would probably opt for a vaginal approach.

I also look at the patient’s health status. Is she healthy and physically active? Or is she sedentary with comorbidities? In a woman who is a poor surgical candidate, I would consider less invasive procedures or procedures with less operative risk, such as urethral injections or the newer tape slings.

LUBER: When it comes to surgery for urinary incontinence, I like to reinforce the reconstructive nature of the repair, since patients tend to view surgical procedures as definitive. For example, when the uterus and ovaries are removed, they never bother that patient again. Incontinence procedures are different. Their effect is potentially time-limited, so it’s important to reinforce the patient’s understanding of their reconstructive and fallible nature.

At the first surgical consultation, I basically go through an informed consent. I do so again preoperatively, but I think it is a very important initial step for a patient who is considering surgery.

SAND: What if a patient isn’t sure she wants surgery?

LUBER: When a patient asks, “What should I do, Dr. Luber? Should I have an operation?” I like to use the example of standing in front of the refrigerator and asking, “Gee, am I hungry?” If you have to ask, you probably aren’t.

Potential surgical patients should feel extremely comfortable that they have exhausted all the nonsurgical options. Even if they have decided against nonsurgical therapy, they should feel very comfortable with that choice. Then I am confident we can work through any potential problems of surgery.

As for the operation itself, history has demonstrated the irresistible impulse to innovate during surgery for female stress incontinence. Literally hundreds of operations have been described, and dozens are currently in use; this reinforces the supposition that our techniques are imperfect, and the importance of basing what we do upon the available data. The 1997 American Urological Association guidelines are an excellent example. Looking forward, the National Institutes of Health are sponsoring studies comparing, for example, the goldstandard Burch to the goldstandard sling operation. In the next few years, we should have better evidence-based guidance.

Consider patient characteristics when choosing treatment

SAND: How do you select a surgical procedure for a particular patient?

MYERS: Because of all the different variables, I use various treatment arms. Since my institution does a large number of sling procedures, I am very comfortable performing those operations. I still do retropubic urethropexy. I also do the newer vaginal-tape procedures, and I use bulking agents for patients who have a demonstrated sphincter deficiency with no obvious support problems. Basically, I try to tailor my procedure to the patient.

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