Surgical Alternatives

Surgical approaches are useful in patients who have more severe forms of stress incontinence, or who have failed or are not satisfied/compliant with more conservative measures. There are many different procedures done to correct stress incontinence, the goal of each is to re-support the bladder neck to prevent its downward rotation with stress. The selection of which operation is done is usually based on the patients symptoms, medical condition, ongoing risk factors for failure (obesity, chronic cough, heavy lifting) and the skill/training of the surgeon. It is very important that at the time of the surgery, other problems such as rectoceles, enteroceles, vaginal, and/or uterine prolapse are corrected. Otherwise, there is a great chance that the patient will no longer be incontinent, but will be just as miserable with worsening of another problem.

Recent reports in the literature show that the classic anterior vaginal repair (bladder tuck) has only about a 30% long term cure rate after 5 years. It has the highest failure rate, but is also the easiest to do and quickest to recover from and allows simultaneous repair of other vaginal defects. It is useful in patients with minimal stress incontinence.

The retropubic procedures (Burch and MMK) are the best with a 5 year cure rate of 85%, however they are also the hardest to perform, take longer to recover from and require a "staged" operation to repair other vaginal defects. With this procedure a bikini-cut incision is made and the neck of the bladder is reattached to the back of the pubic bone with permanent suture. It is rare that this will ever give way in the future, but failures can still occur due to the sutures pulling out from the bladder neck. A variant of this operation is the "Paravaginal Repair". It is done through a similar incision.

The needle suspension operations are done by making small incisions on the abdomen and passing sutures down into the vagina on either side of the bladder neck. The sutures are then elevated and tied to the abdominal wall tissue thereby suspending the bladder. There are several variations of these operations each done a little differently. Unfortunately, the long term cure rate with there operations is not as good as with the larger retropubic procedures. However, they can be done as outpatient procedures and recovery from them is usually quick.

The Vesica procedure is a recent combination of the retropubic procedures and the needle suspensions. In this operation, small screws are attached to the pubic bone. The suspension sutures are later attached to these screws. There are not yet 5 and 10 year studies with this new operation so it is difficult to predict if this surgery will be as successful as the Burch and MMK.