Incontinence - Surgery

Surgical Options for Incontinence

There are many operations for incontinence but dramatic changes in our understanding of the causes of incontinence have led to exciting developments in surgery.

This journey is best summarised chronologically to enable you to understand how each type of operation has developed. The most critical factor in determining the best option for treatment of your problem is making the correct diagnosis so that the operation is targeting the actual problem. This is where the issues become clouded as doctors have argued about this for many years. However, there is now a general consensus on how surgical treatment should be offered to help treat incontinence.

Basic Anatomy and Physiology

The bladder (B) empties through the urethra (U). The bladder rests on the vagina (V) and is supported anteriorly by the pubourethral ligaments (PUL) and posteriorly by the uterosacral ligaments(USL). Traditionally surgery has targeted the anterior support mechanisms and tried to tighten or elevate the bladder neck (BN).

Anterior Repair

This procedure involves tightening the vaginal wall to support the bladder and urethra above. It has lost favour as an incontinence procedure as it was successful in only about 30% after 5 years.

Needle Suspension

A suture passed with a needle is used to elevate the bladder neck on either side and attach it to the abdominal muscle. This procedure has lost favour due to very poor results when the sutures tended to pull out.

Colposuspension

This is an abdominal procedure where the vagina and urethra are pulled forward and attached to the ligaments adjacent to the symphasis. The procedure was the gold standard for many years because of consistent results and a long term success rate of 70-80%

The problems with this procedure were as follows:

it was a significant operation with 10-12 days in hospital,
significant postoperative retention and long term voiding difficulties
need for suprapubic catheterisation
secondary prolapse and loss of posterior support

Laparoscopic Colposuspension

Key hole surgery enables a colposuspension to be done as a minimally invasive procedure but these procedures are increasingly replaced by sling procedures.

Fascial Slings

Still popular with some surgeons the fascial slings are effective operations but require a second procedure to harvest the fascia to use for making the sling.

Bulking Agents

These treatments are really a type of filler or "no more gaps" injection which are placed around the urethra to support it. As a primary treatment these agents are not very successful but they are safe and simple to perform. They have been increasingly helpful in recent years as a secondary treatment for patients with persistent incontinence due to a poor urethra following a sling.

Sub urethral slings

Now the acknowledged gold standard the tension free suburethral sling acts by rebuilding the support provided by the Pubo-urethral or Mid urethral ligament. These slings have taken over the management of stress incontinence and many variations are available.

Rapid changes have occurred in the way these slings are implanted over the last 10 years. Originally the first generation slings such as TVT, and IVS are placed from the vagina through to the abdominal suprapubic skin while the SPARC is the same but placed in the reverse direction.

Second generation slings emerge through the obturator fossa into the thigh and reduce the risk of bladder and bowel damage.

Click here for Sub Urethral Sling Patient Information Sheet

The latest development in sling technology is the TVT Secur which uses a soft tissue attachment to avoid having to pass through the body at all. The risk of bladder, bowel or vascular injury is drastically reduced but data is not yet available as to the long term success of the procedure.