Sayantika Dhar

Urinary IncontinenceSURGICAL MANAGEMENT

Sayantika Dhar

Before the surgery:

• accurate diagnosis• assessment by- incontinence specialist,

urologist or urogynecologist.• For pre-natal women or women planning to

bear a child, doctors recommend holding off the surgery- it may undo any surgical fixture.

Sayantika Dhar

Aim of surgical management:

• recreating urethral support allowing for the normal functioning of the urethra during increased abdominal pressures.

Sayantika Dhar

Approaches for Stress Incontinence

Abdominal approaches• Retropubic colpo-suspension

– Burch– Marshall-Marchetti-Krantz (MMK)

Contemporary• Pubo-vaginal sling• Tension free vaginal tape (TVT)• Trans-obturator tape (TOT)

Sayantika Dhar

Retropubic Colpo-suspension

• Retropubic suspension surgery is used to treat urinary incontinence by lifting the sagging bladder neck and urethra that have dropped abnormally low in the pelvic area.

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Retropubic Colpo-suspension

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Sayantika Dhar

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Pubo-vaginal Slings

• The procedure involves placing a band of sling material directly under the bladder neck (ie, proximal urethra) or mid-urethra, which acts as a physical support to prevent bladder neck and urethral descent during physical activity.

Sayantika Dhar

Sayantika Dhar

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Tension Free vaginal Taping (TVT):

• Through a small vaginal incision, permanent mesh-like material is placed underneath the urethra and anchored to the abdominal muscles above the pubic bone.

• The mesh-like material remains as a permanent sling under the urethra, preventing incontinence when straining or coughing.

• General anesthesia or local anesthesia is required.

Sayantika Dhar

Sayantika Dhar

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• Less invasive, Small incisions- Local anesthesia • Same day or overnight surgery stay• Return to work in 2 - 3 weeks

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Transobturator Sling (TOT)

• The transobturator sling (tot sling) is subfascial, ie the needle or the sling NEVER enters the retropubic space.

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Complications:

• Difficulty urinating and incomplete emptying of the bladder (urinary retention), although this is usually temporary

• Urinary tract infection• Difficult or painful intercourse

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Approach for Urge incontinence:

Augmentation Cystoplasty

Aim: increase bladder size

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• Augmentation cystoplasty is the most often performed surgical procedure for severe urge incontinence.

• In this surgery, a segment of the bowel is added to the bladder to increase bladder size and allow the bladder to store more urine.

Augmentation cystoplasty

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Augmentation cystoplasty

Contraindications• Patients who are unable or unwilling to perform life-

long intermittent catheterization should not undergo augmentation cystoplasty because of the high likelihood of ultimately requiring catheterization.

• In addition, patients with inflammatory bowel disease, bladder tumors, or severe renal insufficiency should not undergo augmentation cystoplasty.

• Patients with a short life expectancy - consider alternatives such as continued medical management.

Sayantika Dhar

Sayantika Dhar

Urethral Bulking

Indications:• Stress or Urge incontinence• Poor or no response to conservative

management

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Aim of bulking

• Build up the thickness of the wall of the urethra so it seals tightly when you hold back urine.

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• Performed under local anaesthesia• Collagen used as bulking agent • a skin test is done to check for allergies before

the procedure

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Risks:

• pain at the injection site• injury to the urethra, and • Migration/ dislodging of the bulking material

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THANK YOU