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Thakkarwad and Mundlod: A retrospective comparison of various stress urinary incontinence surgery with there outcome in a tertiary care teaching institute


Introduction

Stress urinary incontinence is defined as the involuntary loss of urine through the intact urethra caused by a sudden increase in intraabdominal pressure on coughing, walking and in some cases during turning in bed.1 It is the most common type of urinary incontinence in woman and when it is of sufficient quantity causes a great embarrassment which was frequently underreported.

UI is a multifactorial syndrome produced by a combination of genitourinary pathology, age-related changes, and co morbid conditions that impair normal micturation or the functional ability to toilet oneself, or both.

Stress incontinence was first introduced by sir Eardlye Holland in 1928. However, the condition was first recognized in the 19th century, when special procedure for its cure first come to force.

Until more than 2 to 3decades ago, the diagnosis of urinary incontinence in the female was for the most part made casually, primarily on the basis of history given by the patient. The underlying anatomic abnormality was not precisely understood. Jeffcoate & Roberts [1952]1 were the first to call attention to the importance of the anatomic configuration of the urethrovesical junction and proximal urethra to the continence mechanism on the basis of their extensive studies using urethrocystography.1

UI is not associated with increased mortality. UI impairs quality of life, affecting the older person's emotional well-being, social function, and general health. Incontinent persons often manage to maintain their activities, but with an increased burden of coping, embarrassment, and poor self-perception. Caregiver burden is higher with incontinent older persons.

Surgical procedures to remedy stress incontinence generally aims to lift and support the urethra-vesical junction, although there is disagreement about the precise mechanism by which continence is achieved.

More than 100 surgical procedures2 have been described for correction of stress incontinence - vaginal, abdominal, combined, Endoscopic, laproscopic3 and prosthetic;3 just to name a few approaches and this abundance of approaches. Signifies the fact that no single approach can claim to benefit all cases of SUI and an accurate selection of cases combined with a meticulous surgical technique and attention to the lower tract female pubic anatomy is a must to ensure success both technical and symptomatic.4

Aims & Objective

To compare the various procedures in relation to complications and failure rate.

Materials and Methods

This was a hospital Based retrospective study conducted in In the gynecology department k. e. m. hospital Mumbai with complaint of urinary incontinence were studied. A total 50 patient were included in following study.

The study design

This was a hospital based retrospective study

Study setting & duration

Study was conducted in the department of gynecolog, KEM Hospital Mumbai India.

Total duration of study from enrollment to completion was 2 yeas Each patient was followed for 6 month

Working Definitions

Case: Women with complaint of involuntary loss of urine on coughing or on increase in abdominal pressure.

Failure: was defined as presence of urinary incontinence after a period of 6 months following SUI surgery.

Post operative urinary retention: It was defined as a persistence of high more than 100 ml post –void residual urine or 20% of voided volume.5

Complications

Intra operative complication: Bladder perforation, urethral injury, bowel injury

Post operative complication: Urinary retention, erosion, infection, hematoma .

History

Age, occupation, severity, duration and frequency of SUI, other menstrual history, urinary symptoms, detail obstetric history, parity, gynecological procedure, pelvic floor trauma, previous urinary tract infection, previous surgeries. trauma in childhood, any spinal surgery, or drugs

Examination

A focused physical examination should be performed. The examination is tailored somewhat in each case, based on the specifics of the patient's incontinence complaint and pertinent medical and surgical history, local and per vaginal examination Each patient should have height, weight, blood pressure, and pulse recorded. Obesity is an important contributor to stress incontinence, and the presence of obesity may influence management decisions. Lastly stress incontinence was clinically confirmed by “ Bonneys test “

Also there are certain urinary symptoms that can mimic stress incontinence and there are certain neurological causes of stress incontinence which need to be distinguished from the true anatomical stress incontinence. The clinical evaluation is therefore aimed at.

  1. Establishing the diagnosis of stress incontinence.

  2. Establishing the etiology of stress incontinence and once the diagnosis of anatomical stress incontinence is established

  3. The degree of anatomical change producing stress incontinence

Bonneys test6 : Patient is examined in lithotomy position with full bladder, stress incontinence is demonstrated by asking the patient to cough. The severity of the problem is assessed, if patient doesn’t lose urine in lithotomy position she is than tilted to 45 degree upright position and asked to cough. This raised the resting bladder pressure by adding the weight of some of the abdominal content. About 80% of patient with surgically curable incontinence lose urine in lithotomy position with coughing. Another 10% required tilting to 45 degree position. The rest 10% demonstrated loss of urine related to coughing only when examined in the standing position

After stress urinary incontinence is demonstrated bonneys test is carried out by elevating the paraurethral tissue near the bladder neck with two finger and asking the patient to cough. The ability to control the stress incontinence is studied which usually indicate that bladder neck elevation is going to cure the patient. Care is taken not to compress the urethra directly. Next, voided volume and residual urine are checked this may give a clue to neurogenic bladder. Presence of cystocele or rectocele is determined.

Anal sphincter tone ad sensation at s2,3,4 dermatomes are checked to rule out any neurological lesion.

Investigation   

Following investigation are helpful in evaluating patient of SUI

  1. Urinary microscopy and culture sensitivity: Although urinary tract infection is mentioned in literature as a cause of urinary incontinence, a and patient with acute cystitis often have urge incontinence. A patient of urinary incontinence was not helped by clearing the bacteria

  2. All routine hematological and other investigation required for anaesthesia fitness were done.

Treatment of stress urinary incontinnce

Before discussing different option in the treatment of SUI an important question should be addressed –who should be treated and why?

After underlying causes are ruled out or treated, most women with incontinence will have symptoms suggesting the stress or the mixed type. Management falls into these general categories:

  1. Behavioral

  2. Mechanical

  3. Pharmacologic

  4. Surgical

Pharmacologic

Table 1
Topical or vaginal estrogen Conjugated estrogen Vaginal atrophy
Anticholinergic agents Tolterodine Urge incontinence (overactive bladder)
Oxybutynin
Propantheline
Darifenacin
Solifenacin
Tricyclic antidepressants Imipramine * Mixed and stress urinary incontinence
Alpha-adrenergic agonists Pseudoephedrine * Stress urinary incontinence
Selective serotonin and norepinephrine reuptake inhibitor

Results

The result of the current study with respect to various criteria are presented as far as possible in a table form for easy and simplicity.the total number of patient with SUI in this study is 50

Table 2
S. No Age grouping year No. of patient Percentage
1 Less than 30 0 00
2 30-39 15 30
3 40-49 16 32
4 50-59 10 20
5 60-69 09 18

Agewisw classifcation

Thus majority of the patients fall in the range of 30-50 yrs.

The following table depict the duration of symptomatology of these patients

Table 3
S. No Duration of symptoms No. of patient Percentage
1 Less than 6 mths 22 44
2 6-12mths 10 20
3 1-2 yrs 15 30
4 3-5yrs 02 04
5 More than 5 yrs 01 02

Duration of symptoms

Among various associated factors responsible for SUI, the following were evaluated in details

Table 4
S. No Parity No. of patient Percentage
1 Nulliparous 0 00
2 P1 02 04
3 P2 15 30
4 P3 07 14
5 P4 12 24
6 P5 or more 14 28

Parity of the patient

The above table depict the parity of the patient majority of patient have more than two parity.

Table 5
S. No Menstrual history No. of patient Percentage
1 Normal mences 20 40
2 Menorrhagia 10 20
3 Menopausal 20 40

Depict menstrual history

Table 6
S. No Associated disease No. of patient Percentage
1 Hypertension 11 22
2 Bronchial asthma 05 10
3 Diabetes mellitus 03 06
4 Epilepsy 01 02
5 Heart disease 01 02
6 Hypothyroidism 02 04
7 No disease 27 54

Depict accidental associated disease

Table 7
S. No Previous surgery No. of patient Percentage
1 Tubal ligation 12 24
2 LSCS 03 06
3 Vaginal hysterectomy 05 10
4 Abdominal hysterectomy 00 00
5 No previous surgery 30 60

Depict history of previous surgery

Bonneys test was performed in all cases and positive bonneys test was considered to be a prime requisite for patient under go sui surgery

Table 8
S. No Associated disease No. of patient Percentage
1 No growth 40 80
2 Growth of organisms 10 20

Depict report of urine culture

The above table depict 20% of the patient has growth of E coli and Klebsiella. they have been treated with nitrofurontoin and norfloxacine and some with cephalosporin.

Table 9
S. No Associated disease No. of patient Percentage
1 Fibroid 03 06
2 Prolapse 02 04
3 Adenomyosis 04 08
4 DUB 03 06
5 Cystorectocele 04 08
6 SUI 03 06
7 Prolapse with CR 31 62

Depict sui associated disease

Table 10
S. No Surgery No. of patient Percentage
1 Vaginal hyst with AP with SUI repair 31 62
2 Vaginal hyst with SUI repair 12 24
3 AP repair with SUI repair 04 08
4 SUI repair 03 06

Depict siu repair along with other procedure

Table 11
S. No Complication No. of patient Percentage
1 Bladder perforation 01 02
2 Bowel injury 00 00
3 Urethral injury 00 00
4 Hematoma 00 00
5 No complication 49 98

Depict the intraoperative coplication

Table 12
S. No Complication No. of patient Percentage
1 Urinary retention 09 18
2 Infection 00 00
3 Erosion 00 00
4 No complication 41 82

Depict the post operative comlication

Table 13
S. No Procedure Bladder perforation No of patient
1 Kellys placation 00 20
2 Stameys repair 00 05
3 TVT 01 10
4 TOT 00 15

Intra operative comlication of individual procedure

The above table depict the intra operative complication of individual procedure only TVT has single bladder perforation

Table 14
S. No Procedure Urinary retation No of patient Percentage
1 Kellys placation 06 20 30
2 Stameys repair 01 05 20
3 TVT 02 10 20
4 TOT 00 15 00

Post operative comlication of individual procedure

The above table depict the post operative Urinary retention majority of patient belong to kellys AP repair and no retention in TOT

Table 15
S. No Procedure No of patient n=40 Percentage
1 Kellys placation 18
2 Stameys repair 02
3 TVT 08
4 TOT 12

No of patient who come for follow up at 6 month

The following table depict total number of patient who come for follow up out of 50 patient only 40 came for follow up

Table 16
S. No Procedure No of patient n=40 Recurrence of SUI Percentage
1 Kellys placation 18 06 33
2 Stameys repair 02 00 00
3 TVT 08 01 12.5
4 TOT 12 01 8.3

Recurrence of sui in followup cases

The above table depict recurrence of SUI in follow up patient. However only kellys plication has more recurrence of sui in about 33 % of patient. As in stameys the number of follow up patient was only two and none of them had recurrence of sui.

Discussion

Stress urinary incontinence is a major problem among women unfortunately it is frequently ignored in spite of it being a treatable condition

SUI is classified in two group3, 27

  1. Anatomical incontinence7, 3, 2 caused by malposition or hyper mobility of intact urethra secondary to poor support

  2. Intrinsic sphincteric dysfunction –when with or without an accompanying anatomical abnormality, the urethra and bladder neck does not adequately function as a sphincteric unit.

The age group commonly affected by this disorder is usually between 40-60 yrs of age. In our study too, 62% of cases of SUI fall in age group of 30-50with 20 % of cases between the age of 50-59yrs of age also affected

Table 17
S. No No of patient Mean age
1 Ulmsten et al8 131 53(35-88)
2 Levin et al9 70 57(32-65)
3 Current studies 66 58(40-80)

The incidence of stress urinary incontinence is believed to increase directly with parity7, 10, 3 in our study not a single patient was nulliparous 100% of the patient were multiparous who delivers one or more time

Table 18
S. No Parity Average
1 Ulmsten et al8 0-12 2.84
2 Porena m11 2-3 2
3 Current studies 0-5 2

According to various studies parity varies from 0-5 and average is two.

In this study, 40% patient had normal mences, 20% had menorrhagia and 40% had menopause

Out of fifty patient, three patient had only SUI complaints and forty seven patient were along with fibroid,adenomyosis,prolapse with cystorectocele, DUB, prolapse, cystorectocele. In our study 62% of patient had SUI along with prolapse cystorectocele,3% with fibroid, 3% with DUB,2% prolapse,4% with adenomyosis,4% with cystorectocele. The majority of patient had SUI along with prolapse cystorectocele.

In this study not only SUI repair but also SUI repair along with other surgeries included. Out of fifty SUI surgeries thirty one patient had vaginal hysterectomy with anterior colporrhaphy and posterior colpo perineorrhaphy with SUI repair, twelve with vaginal hysterectomy with SUI repair, four with AP with SUI repair, only three patient had SUI surgeries.

Out of fifty, eighty percent patients urine culture was suggestive of no growth and twenty percent had growth of organisms, were treated with sensitive antibiotics.

Intra operative complication like bladder perforation, bowel and urethral injury, hemorrhage has been included in this study. only single case had complication of bladder perforation, that was in TVT. In this study bladder perforation was seen in 10 % with TVT procedure as compared to 5%, and 9.7% in Barber et al and de Tayarac et al 2004 studies respectively in TVT procedure. No bladder perforation seen in TOT in both above mentioned studies.

Table 19
S. No TOT TVT
1 Barber et al11 2006 0% 5%
2 de Tayarac et al12 2004 0% 9.7%
3 Current studies 0% 6%

Bladder perforation

Post operative complication like urinary retention, infection, vaginal erosion, and hematoma has been included in this study. Out of fifty, nine patients had urinary retention, of that six patients were of Kellys plication and two patient of TVT and one patient of stameys. No urinary retention seen in TOT and other complication like infection and erosion was not found in any cases.

In this study urinary retention of 30%was seen in Kellys plication, 20% with stameys, 10% with TVT, 0% with TOT.

de Tayarac et al 2004 reported risk of urinary retention in 13.3% patient with TOT and 25.8% patient with TVT surgery

Hilton et al 1991 reported risk of urinary retention in 17.3% patient with stameys repair,

Harris et al 1995 reported risk of urinary retention in 38% patient with Kellys plication.

Table 20
S. No TOT TVT
1 Laurence M D et al 200413 10 % 22.8%
2 de Tayarac et al12 2004 13.3% 25.8%
3 Current studies 8 % 18 %

Urinary retention

Table 21
S. No Kellys plication
1 Beck et al 199114 40%
2 Harris et al 14 1995 38%
3 Current studies 38%

Urinary retention

According to this study failure rate of 33.3% was seen with Kellys plication, 12.5% with TVT, 8.3% with TOT and failure rate was not reported in stameys operation. According to various studies done failure rate varies from 5.7-10.6 % in case of TVT operation and 4.8-6.6% with TOT operation.

Failure rate with Kelly’s plication varies from 31 – 48 % in various studies

Failure rate with stameys operation varies from 18-26 % in various studies

Table 22
S. No TOT TVT
1 Tomsaz et al 25 2002 6.6 % 8.2 %
2 de Tayarac et 22 al 2004 6.5% 8.8%
3 Porena M et al 2004 4.8 % 10.6 %
4 Current studies 5.4% 5.7%

Failure rate

Table 23
S. No Kellys plication
1 Beck et al 199114 35%
2 Harris et al14 1995 46%
3 de Tayarac et al12 2004 47%
4 Current studies 31%

Failure rate

Table 24
S. No Stameys operation
1 Hilton et al15 1991 26%
2 Ashken et al16 1993 18%
3 Current studies 22%

A comprehensive analysis of all studies done. Comparing various SUI surgeries suggest that there is less chances of complication like bladder perforation, urinary retention and failure rate with TOT operation as compared to other SUI surgeries.

Conclusion

In the general hospital major bulk of patient come with other complaint in gynaecology OPD. From detail history of every patient, it is concluded since the symptoms of SUI are not life threatening and most of the female are less health conscious the medical help is not sought for longer duration.

In the study TOT procedure was found superior with respect long term failure rate and also intra and post operative complication

Source of funding

None.

Conflict of interest

None.

References

1 

N Jeffcoate Sir 4th edn Principles of gynecology1975456

2 

Kelly Dumm stress urinary incontinence in women without manifest injury to the bladderSurg Gyne Obste1914136444

3 

S. Raj Female UrologyIst edn. 1982

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S. Raj Female Urology2nd edn. 1996

5 

Telinde’s Text book of operative gynecology6th edn

6 

T Stamey A: urinary incontinence in the female :the stamey Endoscopic suspension of vesical neck for stress incontinence Combell’s urology, vol I philadlphiaW.B. suunders C.O199228292850

7 

Camp bells text book of urology1998341349

8 

U Ulmsten L Henriksson P Johnson G Varhos An ambulatory surgical procedure under local anesthesia for treatment of female urinary incontinenceInt Urogynecol J Pelvic Floor Dysfunct199678186

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I Levin A Groutz R Gold D Pauzner J B Lessing D Gordon Surgicalcomplications and medium-termoutcome results of tension-free vaginaltape: a prospective study of 313 consecutive patientsNeurourol Urodyn20042379

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A J Pereyra T B Lebherz W A Growdon J Powan Pubourethral support in perspective modified pereyra procedure for stress urinary incontinenceGyne Obste198259643648

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12 

R De Tayrac X Deffieux S Droupy A Chauveaud-Lambling L Calvanese- Benamour H Fernandez A prospective randomized trial comparing tension-free vaginal and transobturator suburethral tape for surgical treatment of stress urinary incontinenceAm J Obstet Gynecol2004190602608

13 

Laurence Md De Tayrac M D Renaud Stephane Md B Chauveaud-LamblingAm J Obstet Gynecol20041903602608

14 

Dieter Becker Wolf Gang Zubeka Ella Retzlow Diethlm wallwineer Long term result of SUI urinary and Fecal Incontinence: An Interdisciplinary Approach - Google Books Result2005498

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C J Hilton Mayne stameys Endoscopic bladder neck suspensionBr J Obstet Gynecol1991

16 

Handly Ashken Follow up result with stameys operation for SuiBr J Urol2002345



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