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INTRODUCTION
Urinary stress incontinence
(USI) is a common problem among women. It was reported that the incidence of
urinary incontinence in women is about 25-45% [1]. It was thought that almost
30% of women after the age of 40 will develop urinary stress incontinence. It
is a bothersome symptom among women that affects their quality of life.
There have been several ways
to treat this condition beginning with the Kegel’s or pelvic floor exercises
that strengthens the pelvic floor which is the initial treatment advocated to
these women [2]. The pelvic floor exercises can be further improved with
biofeedback techniques [3]. There were vaginal pessaries designed for USI but
there was no major improvement on these. Surgical treatment has been the
mainstay option for those who did not improve with conservative treatments for
many years. Other complementary therapy has been advocated but it needs further
evidence before it can be incorporated into clinical practice [4].
Several methods of surgical
treatments have been tried such as Kelly’s fascial plication and pubo vaginal
needle suspension. However among the more popular and earlier successful
surgery was the Burch Colposuspension [5]. However this is a major surgery and
has higher risk of intraoperative bleeding as well as post-operative voiding
dysfunction.
Prof. Petros and Prof. Ulf
Ulmstein proposed in their intergral theory that the anatomical site of the
pathology is the defect at the mid urethra at the pubourethral ligament [6].
This ligament is weakened or damaged during childbirth particularly, causing
the urine leak during raised intra-abdominal pressure.
This led them to relook at
the pubovaginal slings. After extensive research the world saw the introduction
of the “Tensionless vaginal tape” (TVT) [7-9]. It was short procedure, safe and
showed great success rate. It was also easy to learn and took the world by
storm. It was embraced easily and further modifications were done to improve
the surgery. The transobturator approach and the mini slings were among there
variants [10,11]. But the placement at the mid urethra was the key to use of
these slings.
The common intraoperative
complication was bladder perforation which was easily managed. Rare incidences
of other organs perforations have been described. Post-operative problems of
voiding dysfunction are seen but rarely are a major problem. The transobturator
approach has the risk of thigh pain but again this rarely needs surgical
intervention. There is a 5% risk of mesh exposure through the vagina which
could be easily dealt with [10,11]. There were a variety of meshes used
initially but finally the use of monofilament Type 1 polypropylene mesh is the
mainstay of sling surgeries
The overall success rate of
the mid urethral slings was about 90% [7,8] and it was a great boon to the
women suffering from urinary stress incontinence. It was a minimally invasive
surgery, had minimal complications and good long term effectiveness.
The success of the TVT was
extrapolated to be used in vaginal prolapse repairs. The larger meshes were
implanted in the vagina. Even though the long term effectiveness of vaginal
meshes as opposed to native tissue repairs have been shown, unfortunately
complications of vaginal mesh began to present it. The problems of mesh
infection, exposure and chronic pain was debilitating to some women where the
mesh had to be excised. This unfortunately can present even at later stage
after several years. As more women presented with the problems, The FDA took
notice and issued alerts and warnings. This was followed by multiple legal
cases in the USA.
It made the physicians to take notice and became more cautious in the
use of vaginal mesh. Even though most of the complications involved the vaginal
meshes, unfortunately the mid urethral sling was also tainted in this issue.
The legal cases tend to include the slings as well in the mesh group even
though the sling use has been in practice for more than 20 years.
Recently in July 2018, the UK, the NHS, has
temporarily halted the use mid urethral sings pending further review. This is
very unfortunate as it deprives women from receiving appropriate treatment for
USI.
So where are we heading? [12] We hope that good
sense prevails and the use of mid urethral sling will be reinstated in the UK.
There are thousands of women who have benefitted with this surgery. Their
quality of life improved significantly. Unfortunately these benefits have been
drowned by small number of patients affected by complications of slings. There
is evidence to suggest very low risk of sling removal after many years of
insertion [13]. Losing this surgery is therefore a disservice to women
worldwide.
The medical professionals of course are trying
their best to continue to help women with USI. A relook at Burch
colposuspension is possible but a lot of surgeons are not trained in this and
will need retraining. The fascial sling can be used as an alternative to the
polypropylene tapes. However we need to relook the reasons why we moved from
fascial slings to synthetic one in the first place.
There are intra urethral injections of bulking
agents that seems increasingly to be an option [14]. If this option is found to
be useful and economical, then it can be used widely. We are hopeful that new
research will provide better implant material that may avert potential
complications associated with the current mesh and make this surgical option a
better one.
In conclusion, as the medical profession
continues to find a long term solution to identify the best option in treating
USI, let’s hope that the sling operation is not sent to oblivion ignoring the
many women who have benefitted from this surgery.
1. Buckley BS, Lapitan MC (2010) Prevalence of urinary
incontinence in men, women and children - Current evidence: Findings of the
Fourth International Consultation on Incontinence. Urology 76: 265-270.
2. Cacciari LP, Dumoulin C, Hay-Smith EJ (2019) Pelvic
floor muscle training versus no treatment, or inactive control treatments, for
urinary incontinence in women: A Cochrane systematic review abridged
republication. Braz J Phys Ther 23: 93-107.
3. Nunes EFC, Sampaio LMM, Biasotto-Gonzalez DA, Nagano
RCDR, Lucareli PRG, et al. (2019) Biofeedback for pelvic floor muscle training
in women with stress urinary incontinence: A systematic review with meta-analysis.
Physiotherapy 105: 10-23.
4. Gažová A, Valášková S, Žufková V, Castejon AM,
Kyselovič J (2018) Clinical study of effectiveness and safety of CELcomplex®
containing Cucurbita pepo seed extract and flax and casuarina on stress urinary
incontinence in women. J Tradit Complement Med 9: 138-142.
5. Burch JC (1968) Cooper's ligament urethrovesical
suspension for stress incontinence. Nine years' experience - Results,
complications, technique. Am J Obstet Gynecol 100: 764-774.
6. Petros PE, Ulmsten U (1990) An integral theory of
female urinary incontinence. Experimental and clinical considerations. Acta
Obstet Gynecol Scand Suppl 153: 7-31.
7. Ulmsten U, Henriksson L, Johnson P, Varhos G (1996) An
ambulatory surgical procedure under local anesthesia for treatment of female
urinary incontinence. Int Urogynecol J Pelvic Floor Dysfunct 7: 81-86.
8. Svenningsen R, Staff AC, Schiøtz HA, Western K,
Kulseng-Hanssen S (2013) Long-term follow-up of the retropubic tension-free
vaginal tape procedure. Int Urogynecol J 24: 1271-1278.
9. Bakas P, Papadakis E, Karachalios C, Liapis I,
Panagopoulos N, et al. (2019) Assessment of the long-term outcome of TVT
procedure for stress urinary incontinence in a female population: Results at 17
years' follow-up. Int Urogynecol J 30: 265-269.
10. Karmakar D, Mostafa A, Abdel-Fattah M (2017) Long-term
outcomes of transobturator tapes in women with stress urinary incontinence:
E-TOT randomised controlled trial. BJOG 124: 973-981.
11. Stavros C, Ioannis V, Vasileios S, Gkotsi ACh,
Georgios S, et al. (2012) Comparison of TVT, TVT-O/TOT and mini slings for the
treatment of female stress urinary incontinence: 30 months follow up in 531
patients. Arch Ital Urol Androl 84: 129-136.
12. Haylen BT, Lee JKS, Sivagnanam V, Cross A (2018) What
if there were no tapes? Neurourol Urodyn 37: 2026-2034.
13. Gurol-Urganci I, Geary RS, Mamza JB, Duckett J,
El-Hamamsy D, et al. (2018) Long-term rate of mesh sling removal following
midurethral mesh sling insertion among women with stress urinary incontinence.
JAMA 320: 1659-1669.
14. Siddiqui ZA, Abboudi H, Crawford R, Shah S (2017)
Intraurethral bulking agents for the management of female stress urinary
incontinence: A systematic review. Int Urogynecol J 28: 1275-1284.
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