Surgical Management of Urinary Incontinence

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.

Sayantika Dhar

Retropubic Colpo-suspension

Sayantika Dhar

Sayantika Dhar

Sayantika Dhar

Sayantika Dhar

Sayantika Dhar

Sayantika Dhar

Sayantika Dhar

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

Sayantika Dhar

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

Sayantika Dhar

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

Sayantika Dhar

Transobturator Sling (TOT)

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

Sayantika Dhar

Complications:

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

• Urinary tract infection• Difficult or painful intercourse

Sayantika Dhar

Approach for Urge incontinence:

Augmentation Cystoplasty

Aim: increase bladder size

Sayantika Dhar

• 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

Sayantika Dhar

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

Sayantika Dhar

Aim of bulking

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

Sayantika Dhar

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

the procedure

Sayantika Dhar

Risks:

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

Sayantika Dhar

THANK YOU