Curr Urol Rep (2014) 15:429 DOI 10.1007/s11934-014-0429-y
LOWER URINARY TRACT SYMPTOMS & VOIDING DYSFUNCTION (H GOLDMAN AND G BADLANI, SECTION EDITORS)
Management of Failed Stress Urinary Incontinence Surgery Lara S. MacLachlan & Eric S. Rovner
# Springer Science+Business Media New York 2014
Abstract With the increasing volume of surgery being performed for the treatment of female stress urinary incontinence (SUI), especially with the widespread use of midurethral slings (MUS), recurrent urinary incontinence is becoming an increasingly common condition. Various preoperative and intraoperative factors have been associated with failed SUI surgery. Treatment options for failed SUI surgery include conservative management and/or surgical management, which include pubovaginal sling, MUS, retropubic suspension, periurethral bulking agents, and artificial sphincters. The choice of treatment option will depend on the etiology of the patient’s failure, patient comorbidities, and patient preference. Keywords Recurrent stress urinary incontinence . Intrinsic sphincter deficiency . Retropubic suspension . Pubovaginal sling . Midurethral sling
States is 49.6 % and of those, 49.8 % have pure SUI and 34.3 % have mixed urinary incontinence [4]. Common treatments for both persistent and recurrent SUI following prior therapy include conservative management such as behavioral modification and pelvic floor muscle training (PFMT). Surgical interventions include retropubic suspensions, periurethral/transurethral injection of bulking agents, pubovaginal slings (PVS) and midurethral slings (MUS), as well as, in a few selected patients, placement of an artificial urinary sphincter (AUS). With the increasing volume of surgery being performed for the treatment of SUI, there is a corresponding increase in the number of failures after SUI surgery. Surgeons should be familiar with the assessment and treatment of these individuals. This paper will review how to recognize failed SUI surgery, evaluate these patients and discuss the different treatment options available. Current Surgical Treatments for SUI
Introduction Stress urinary incontinence (SUI) as a symptom is the complaint of involuntary leakage of urine on effort or exertion, or on sneezing or coughing [1]. Population based studies estimate the prevalence of SUI in women using the most inclusive definition of “any”, “current” or “ever” to range between 6 % and 63 % [2, 3]. The National Health and Nutrition Examination Survey (NHANES) found that in women older than 20 years, the overall prevalence of incontinence in the United This article is part of the Topical Collection on Lower Urinary Tract Symptoms & Voiding Dysfunction L. S. MacLachlan : E. S. Rovner (*) Department of Urology, Medical University of South Carolina, 96 Jonathan Lucas St., CSB 644, Charleston, SC 29425, USA e-mail: [email protected]
The intent of most, but not all surgical procedures to treat SUI is to improve the urethral closure mechanism during periods of increased intra-abdominal pressure [5]. Currently available therapies exert their favorable effects by either augmenting the anatomic support of the bladder neck and proximal urethra, or by improving intrinsic urethral function, or some combination thereof. There is a lack of consensus on the precise mechanism of continence in the asymptomatic female as well as a poor understanding of the exact factors that lead to urinary leakage in the stress incontinent female. This has led to the description of numerous surgical methods and approaches for the treatment of SUI, none of which are universally accepted or effective. Commonly used surgical treatments today include retropubic suspensions (open and laparoscopic), PVS, MUS, injection of periurethral bulking agents and AUS placement. The choice of surgical technique is often dependent on
429, Page 2 of 7
surgeon preference and training, patient preference (based on several factors including willingness to accept risks and costs of the procedure, convalescence, etc.), coexistent urologic problems, anatomic features, and other comorbidities related to the patient. Thus, the wide variety of surgical treatments for SUI may be indicative of a lack of consensus on which is the optimal procedure, but it may also be related to the heterogeneity of the condition and the patients who suffer from it. There are a variety of surgical treatments for primary and recurrent SUI. Retropubic bladder neck suspensions such as the Burch, or Marshall Marchetti Krantz (MMK), are performed within the space of Retzius and create support for, or otherwise prevent, the descent of the tissues near the bladder neck and proximal urethra by securing these structures onto a fixed anatomic point such as Coopers ligament or the symphysis pubis [6]. Such procedures are generally felt to be most effective in individuals with urethral hypermobility and less effective for those with significant intrinsic sphincter deficiency (ISD). Open retropubic suspensions have an estimated cured/dry rate of 82 % at 12 to 23 months and this rate decreases to 73 % at 48 months or longer [7]. Laparoscopic suspensions using the same principles have a short-term cured/dry rate of 69 %, and there is long-term data at 24 to 47 months which demonstrate a cured/dry rate of 74 % [7]. Pubovaginal slings are placed at the bladder neck and proximal one third of the urethra generally through a combined vaginal and retropubic approach. Such procedures are applicable to patients with and without urethral hypermobility and are also effective in those with intrinsic sphincter deficiency (ISD) with or without associated urethral hypermobility. Estimated cured/dry rates following autologous pubovaginal slings range between 90 % at 12 to 23 months and 82 % at 48 months or longer [7]. Midurethral slings using either a retropubic or transobturator approach came into widespread use in the late 1990s as they provided surgeons with a minimally invasive approach to SUI surgery. For such slings, the estimated cured/ dry rates range from 81 % to 84 %. This is comparable to the medium-term results for the open retropubic suspensions and autologous pubovaginal slings [7]. For the past three decades, injectable urethral bulking agents have been used in the treatment of SUI in women. Bovine gluteraldehyde cross-linked collagen has historically been the most widely used bulking agent largely due to its ease of administration, efficacy, and wide safety margin. Periurethral injection of collagen has an efficacy that declines over time, from 48 % at 12 to 23 months to 32 % at 24 to 47 months [7]. Importantly, this agent is no longer commercially available, but other bulking agents have been approved for clinical use in the US and elsewhere. Data on the use of AUS in the female patient with stress incontinence is limited. It is occasionally used in a patient with severe ISD who has failed other surgical procedures or in
Curr Urol Rep (2014) 15:429
patients with significant SUI and poor bladder contractility such as those with diabetes or back injury. One recent study reported long-term results of AUS for women with SUI due to ISD and demonstrated a fully continent (no leakage) rate of 85.6 % with an additional 8.8 % with social incontinence (some drops of leakage but not requiring use of pads) [8]. The 3-year, 5-year, and 10-year device survival rates were 92.0 %, 88.6 %, and 69.2 %, respectively [8]. For all of the procedures noted above, the success rates quoted in these studies often encompass a wide range of patients including primary cases as well as those who may have failed prior procedures. It is, therefore, difficult to accurately assess the effectiveness of some of these procedures in the treatment of individuals who have failed prior SUI surgery as the breakdown of surgical success rates in primary and recurrent cases is lacking in the literature in many individual case series.
Definition of Failure Success and failure for SUI surgery are often difficult to define resulting in a wide range of values for each procedure. Factors such as length of follow-up, data collection methodology (prospective/retrospective, chart review, direct patient questioning, postal questionnaire, etc.), perspective of success (surgeons vs. patients, etc.), and variation in clinical parameters (severity of leakage, complications related to surgery, concomitant surgery, redo surgery, vaginal prolapse, inclusion of patients with mixed incontinence, etc.) can all significantly affect success and failure rates as reported in the literature [9–12]. For example, recurrent SUI after a midurethral sling (MUS) procedure is reported to be between 2 % to 23 % [13, 14]. Strict criteria for success often results in a lower success rate and, depending on the criteria utilized, success rates for MUS have been reported to be as low 48 % when composite outcomes are utilized [9]. Failure can be defined in many different ways, but for purposes of this review, failure will be defined as recurrent or persistent SUI following previous surgical treatment for incontinence for which additional treatment is being sought. An important concept in assessing and evaluating failure of SUI surgery is timing. SUI that is unchanged following attempted surgical treatment should be termed persistent SUI. SUI that occurs postoperatively at some interval from the initial surgery should be termed recurrent SUI. Nevertheless both are “failures”. Overall, failures can be immediate (no improvement or worsening of SUI symptoms), short- term failures (weeks to months) or long-term failures (months to years). It is likely that immediate failures are most often due to poor surgical technique, inappropriate choice of procedure for
Curr Urol Rep (2014) 15:429
a given patient, or improper patient selection (wrong diagnosis). Such issues will be discussed below. There are many factors that contribute to the failure of SUI surgery besides recurrent or persistent SUI. Between 5 % to 8 % of patients will experience de novo urge incontinence following surgical treatment for SUI [7]. Postoperative voiding dysfunction can occur in up to 9 % of patients and urinary retention can be seen in 0 % to 8 % of patients following SUI surgery [7]. Other complications of SUI surgery that could be considered a failure of treatment include postoperative pain, sexual dysfunction, and vaginal extrusion of mesh products or erosion of mesh into the urinary tract. Patient dissatisfaction following any SUI surgery can also be considered a failure of treatment. Therefore, when evaluating a patient for recurrent SUI following SUI surgery, it is important to ensure that the patient’s incontinence is due to stress incontinence and nothing else. Cofactors such as prolapse, foreign bodies, pain, and obstruction should be considered in the patient with apparent recurrent SUI. In addition, many other conditions can appear to be recurrent or persistent postoperative SUI but are not (Table 1). Recurrent or persistent SUI is suggested by a careful history and confirmed by demonstrable SUI on physical exam or during urodynamic studies without confounding conditions.
Reasons for Failure Various factors have been associated with failure of surgery for SUI, which can be subdivided into preoperative factors and intraoperative factors. Preoperative factors that can affect SUI surgery outcomes include obesity, patient age, preoperative urgency incontinence and concomitant vaginal prolapse [15–19]. Studies have shown that obese patients have lower cure rates following SUI surgery [15, 17, 18]. For patients who underwent Burch colposuspension, preoperative weight greater than 80 kg was shown to adversely affect cure rates [15]. Cure rates following transobturator (TOT) sling are also significantly lower in the obese population (BMI>30) when compared to normal controls with BMI
LOWER URINARY TRACT SYMPTOMS & VOIDING DYSFUNCTION (H GOLDMAN AND G BADLANI, SECTION EDITORS)
Management of Failed Stress Urinary Incontinence Surgery Lara S. MacLachlan & Eric S. Rovner
# Springer Science+Business Media New York 2014
Abstract With the increasing volume of surgery being performed for the treatment of female stress urinary incontinence (SUI), especially with the widespread use of midurethral slings (MUS), recurrent urinary incontinence is becoming an increasingly common condition. Various preoperative and intraoperative factors have been associated with failed SUI surgery. Treatment options for failed SUI surgery include conservative management and/or surgical management, which include pubovaginal sling, MUS, retropubic suspension, periurethral bulking agents, and artificial sphincters. The choice of treatment option will depend on the etiology of the patient’s failure, patient comorbidities, and patient preference. Keywords Recurrent stress urinary incontinence . Intrinsic sphincter deficiency . Retropubic suspension . Pubovaginal sling . Midurethral sling
States is 49.6 % and of those, 49.8 % have pure SUI and 34.3 % have mixed urinary incontinence [4]. Common treatments for both persistent and recurrent SUI following prior therapy include conservative management such as behavioral modification and pelvic floor muscle training (PFMT). Surgical interventions include retropubic suspensions, periurethral/transurethral injection of bulking agents, pubovaginal slings (PVS) and midurethral slings (MUS), as well as, in a few selected patients, placement of an artificial urinary sphincter (AUS). With the increasing volume of surgery being performed for the treatment of SUI, there is a corresponding increase in the number of failures after SUI surgery. Surgeons should be familiar with the assessment and treatment of these individuals. This paper will review how to recognize failed SUI surgery, evaluate these patients and discuss the different treatment options available. Current Surgical Treatments for SUI
Introduction Stress urinary incontinence (SUI) as a symptom is the complaint of involuntary leakage of urine on effort or exertion, or on sneezing or coughing [1]. Population based studies estimate the prevalence of SUI in women using the most inclusive definition of “any”, “current” or “ever” to range between 6 % and 63 % [2, 3]. The National Health and Nutrition Examination Survey (NHANES) found that in women older than 20 years, the overall prevalence of incontinence in the United This article is part of the Topical Collection on Lower Urinary Tract Symptoms & Voiding Dysfunction L. S. MacLachlan : E. S. Rovner (*) Department of Urology, Medical University of South Carolina, 96 Jonathan Lucas St., CSB 644, Charleston, SC 29425, USA e-mail: [email protected]
The intent of most, but not all surgical procedures to treat SUI is to improve the urethral closure mechanism during periods of increased intra-abdominal pressure [5]. Currently available therapies exert their favorable effects by either augmenting the anatomic support of the bladder neck and proximal urethra, or by improving intrinsic urethral function, or some combination thereof. There is a lack of consensus on the precise mechanism of continence in the asymptomatic female as well as a poor understanding of the exact factors that lead to urinary leakage in the stress incontinent female. This has led to the description of numerous surgical methods and approaches for the treatment of SUI, none of which are universally accepted or effective. Commonly used surgical treatments today include retropubic suspensions (open and laparoscopic), PVS, MUS, injection of periurethral bulking agents and AUS placement. The choice of surgical technique is often dependent on
429, Page 2 of 7
surgeon preference and training, patient preference (based on several factors including willingness to accept risks and costs of the procedure, convalescence, etc.), coexistent urologic problems, anatomic features, and other comorbidities related to the patient. Thus, the wide variety of surgical treatments for SUI may be indicative of a lack of consensus on which is the optimal procedure, but it may also be related to the heterogeneity of the condition and the patients who suffer from it. There are a variety of surgical treatments for primary and recurrent SUI. Retropubic bladder neck suspensions such as the Burch, or Marshall Marchetti Krantz (MMK), are performed within the space of Retzius and create support for, or otherwise prevent, the descent of the tissues near the bladder neck and proximal urethra by securing these structures onto a fixed anatomic point such as Coopers ligament or the symphysis pubis [6]. Such procedures are generally felt to be most effective in individuals with urethral hypermobility and less effective for those with significant intrinsic sphincter deficiency (ISD). Open retropubic suspensions have an estimated cured/dry rate of 82 % at 12 to 23 months and this rate decreases to 73 % at 48 months or longer [7]. Laparoscopic suspensions using the same principles have a short-term cured/dry rate of 69 %, and there is long-term data at 24 to 47 months which demonstrate a cured/dry rate of 74 % [7]. Pubovaginal slings are placed at the bladder neck and proximal one third of the urethra generally through a combined vaginal and retropubic approach. Such procedures are applicable to patients with and without urethral hypermobility and are also effective in those with intrinsic sphincter deficiency (ISD) with or without associated urethral hypermobility. Estimated cured/dry rates following autologous pubovaginal slings range between 90 % at 12 to 23 months and 82 % at 48 months or longer [7]. Midurethral slings using either a retropubic or transobturator approach came into widespread use in the late 1990s as they provided surgeons with a minimally invasive approach to SUI surgery. For such slings, the estimated cured/ dry rates range from 81 % to 84 %. This is comparable to the medium-term results for the open retropubic suspensions and autologous pubovaginal slings [7]. For the past three decades, injectable urethral bulking agents have been used in the treatment of SUI in women. Bovine gluteraldehyde cross-linked collagen has historically been the most widely used bulking agent largely due to its ease of administration, efficacy, and wide safety margin. Periurethral injection of collagen has an efficacy that declines over time, from 48 % at 12 to 23 months to 32 % at 24 to 47 months [7]. Importantly, this agent is no longer commercially available, but other bulking agents have been approved for clinical use in the US and elsewhere. Data on the use of AUS in the female patient with stress incontinence is limited. It is occasionally used in a patient with severe ISD who has failed other surgical procedures or in
Curr Urol Rep (2014) 15:429
patients with significant SUI and poor bladder contractility such as those with diabetes or back injury. One recent study reported long-term results of AUS for women with SUI due to ISD and demonstrated a fully continent (no leakage) rate of 85.6 % with an additional 8.8 % with social incontinence (some drops of leakage but not requiring use of pads) [8]. The 3-year, 5-year, and 10-year device survival rates were 92.0 %, 88.6 %, and 69.2 %, respectively [8]. For all of the procedures noted above, the success rates quoted in these studies often encompass a wide range of patients including primary cases as well as those who may have failed prior procedures. It is, therefore, difficult to accurately assess the effectiveness of some of these procedures in the treatment of individuals who have failed prior SUI surgery as the breakdown of surgical success rates in primary and recurrent cases is lacking in the literature in many individual case series.
Definition of Failure Success and failure for SUI surgery are often difficult to define resulting in a wide range of values for each procedure. Factors such as length of follow-up, data collection methodology (prospective/retrospective, chart review, direct patient questioning, postal questionnaire, etc.), perspective of success (surgeons vs. patients, etc.), and variation in clinical parameters (severity of leakage, complications related to surgery, concomitant surgery, redo surgery, vaginal prolapse, inclusion of patients with mixed incontinence, etc.) can all significantly affect success and failure rates as reported in the literature [9–12]. For example, recurrent SUI after a midurethral sling (MUS) procedure is reported to be between 2 % to 23 % [13, 14]. Strict criteria for success often results in a lower success rate and, depending on the criteria utilized, success rates for MUS have been reported to be as low 48 % when composite outcomes are utilized [9]. Failure can be defined in many different ways, but for purposes of this review, failure will be defined as recurrent or persistent SUI following previous surgical treatment for incontinence for which additional treatment is being sought. An important concept in assessing and evaluating failure of SUI surgery is timing. SUI that is unchanged following attempted surgical treatment should be termed persistent SUI. SUI that occurs postoperatively at some interval from the initial surgery should be termed recurrent SUI. Nevertheless both are “failures”. Overall, failures can be immediate (no improvement or worsening of SUI symptoms), short- term failures (weeks to months) or long-term failures (months to years). It is likely that immediate failures are most often due to poor surgical technique, inappropriate choice of procedure for
Curr Urol Rep (2014) 15:429
a given patient, or improper patient selection (wrong diagnosis). Such issues will be discussed below. There are many factors that contribute to the failure of SUI surgery besides recurrent or persistent SUI. Between 5 % to 8 % of patients will experience de novo urge incontinence following surgical treatment for SUI [7]. Postoperative voiding dysfunction can occur in up to 9 % of patients and urinary retention can be seen in 0 % to 8 % of patients following SUI surgery [7]. Other complications of SUI surgery that could be considered a failure of treatment include postoperative pain, sexual dysfunction, and vaginal extrusion of mesh products or erosion of mesh into the urinary tract. Patient dissatisfaction following any SUI surgery can also be considered a failure of treatment. Therefore, when evaluating a patient for recurrent SUI following SUI surgery, it is important to ensure that the patient’s incontinence is due to stress incontinence and nothing else. Cofactors such as prolapse, foreign bodies, pain, and obstruction should be considered in the patient with apparent recurrent SUI. In addition, many other conditions can appear to be recurrent or persistent postoperative SUI but are not (Table 1). Recurrent or persistent SUI is suggested by a careful history and confirmed by demonstrable SUI on physical exam or during urodynamic studies without confounding conditions.
Reasons for Failure Various factors have been associated with failure of surgery for SUI, which can be subdivided into preoperative factors and intraoperative factors. Preoperative factors that can affect SUI surgery outcomes include obesity, patient age, preoperative urgency incontinence and concomitant vaginal prolapse [15–19]. Studies have shown that obese patients have lower cure rates following SUI surgery [15, 17, 18]. For patients who underwent Burch colposuspension, preoperative weight greater than 80 kg was shown to adversely affect cure rates [15]. Cure rates following transobturator (TOT) sling are also significantly lower in the obese population (BMI>30) when compared to normal controls with BMI
