Female Stress Urinary Incontinence (SUI)
Luis Lopez-Fando Lavalle
Pelvic organ prolapse(POP) and stress urinary incontinence(SUI) frequently coexist. Laparoscopic sacral colpopexy(LSC) is the gold standard surgery in apical POP. ICS and EAU guidelines recommend to offer simultaneous correction in women with POP and symtomatic SUI. However, 44% of women without initial TVT never require surgery(1) and severe complications are more common in combined surgery(2). Artificial urinary sphincter(AUS) implantation is an option in recurrent SUI or intrinsic sphincter deficiency(ISD), but in the described techniques of implantation there is a blind dissection of the dorsal side of the bladder neck, which increase the risk of erosion(3).
Combined LSC and AUS implantation (with a vesicovaginal approach to the dorsal side of the bladder neck) could be a safe option in selected cases of POP and complicated SUI.
Informed consent was obtained. We describe this technique in a 72 year-old woman, G4P4, who underwent sling implantation in 2014. She suffered sling extrusion requiring resection. Afterwards, she complained of SUI and POP that was treated with a pessary, but it had to be removed because of SUI worsening and anal discomfort. She showed stage III cystocele, stage II apical prolapse and no urethral hypermobility. Urodynamics suggested ISD and detrusor hypocontractility.
The patient is placed in a 30⁰ Trendelenburg position and surgery is performed using a transperitoneal approach. First, promontory is dissected and the rectovaginal space is created. Peritoneum is opened superficially to avoid damaging the right ureter. Endopelvic fascia is reached by blunt dissection and the dorsal mesh is sutured to the muscle, to both uterosacral ligaments and to the posterior side of the vagina. Secondly, vesicovaginal space is created. Then, the peritoneum is opened in its anterior part and the dissection is extended at both lateral sides of the bladder till the endopelvic fascia is reached. At this moment, we are able to perform the main step of the procedure, which is connecting the vesicovaginal space to the laterovesical spaces. The anterior side of the bladder neck is dissected and the bladder neck diameter is measured. The anterior mesh is fixed to the vaginal wall. It is important to fix the mesh before cuff implantation to avoid damaging it with the needles. A peritoneum window is created and the anterior mesh is passed through it. In a standard LSC the meshes are now fixed to the promontory, but in this technique they are fixed after cuff implantation to avoid pulling them during this step. After cuff and pressure-regulating balloon insertion, a left suprapubic incision is made and the tubes are externalised. A subcutaneous passage is created from this incision to the labia majora to place the pump. The balloon is inflated with 23 cc of saline and the components are connected. Finally, peritoneum is closed with a barbed suture. No drain is left.
Operative time was 180 minutes. No intraoperative complications occurred. Catheter was removed at 5th postoperative day. AUS was activated 6 weeks after surgery. After AUS activation the patient is pad-free, with no POP and satisfaction was 8/10.
Vesicovaginal dissection is a common step in this technique. This dissection let us place the cuff around the dorsal side of the bladder neck in a non-blind fashion, minimising the risk of erosion. AUS implantation should not be last option in SUI treatment. Bladder neck dissection could be more difficult after LSC, mainly in patients with previous antiincontinence surgeries. Since SUI evolution after POP correction is unpredictible, 44% of women could avoid surgery and the risk of complications with simultaneous surgery increases, we propose combined LSC and AUS implantation in selected cases of recurrent SUI or ISD.
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