Female Stress Urinary Incontinence (SUI)
We considered if there could be a solution to treat a stress urinary incontinence in a patient with multiple surgeries and contraindication of new mesh placement. We rescue the old surgical techniques that we show in the video
The patient was 46 years old, a smoker of 40 cigarettes per day, with stress urinary incontinence from the first pregnancy. She had Chronic Obstructive Pulmonary Disease.
In February 2014 she had a vaginal hysterectomy with anterior colpoplasty, and ajustable single-incision suburethral mini-sling (Ajust®).
In January 2016 a new suburethral sling to treat stress incontinence relapse was indicated, but intraoperatively an endourethral extrusion of Ajust® was detected by cystoscopy, and subsequently the urethro-vaginal communication was repaired.
Because of stress urinary incontinence persistence she had undergone in May 2016 a MiniArc® suburethral sling.
In February 2018 an Altis® suburethral sling for stress urinary incontinence relapse was added.
Two weeks later a respiratory syndrome and septic thrombosis attributed to the sling occurred and the Intensive Care Unit doctors indicated the removal of the suburethral sling. At the time of repair we made an urethro-vaginal hole that was fixed. She was hospitalized for 2 months. Afterwards, she was diagnosed of antiphospholipid antibody syndrome.
Months later, the patient presented severe mixed urinary incontinence symptoms with very poor quality of life.
An urethro-vaginal fistula was detected in the level of the middle third of the urethra.
Because of prior deliveries and several surgeries, the periurethral anatomy has been compromised. Based on the DeLancey hypothesis (1) we suspect the loss of support of the pubocervical fascia. Loss of this support would compromise equal transmission of intra-abdominal pressure
We could no longer use any mesh for the treatment of incontinence, nor was it advisable to use the abdominal route because of multiple prior surgeries.
We reviewed old vaginal surgical techniques for correcting the stress urinary incontinence.
We believed that Kelly's technique (2), described in 1913, could provide a solution in this case.
Although numerous long-term failures of this technique have been described. We expected that the operation would be satisfactory by means of a mechanical restoration of the sphincter area at the vesical neck.
In November 2018 we decided to perform a fistulectomy. Also, at the level of the bladder neck, we applied two Kelly sutures with silk as it was originally described by Kelly: the first suture, taking in about 1.5 cm of tissue, is tied at once and may be used as a tractor; the succeeding one is applied on the outside of this, further contracting and bringing together the tissues at the neck. This was the essential part of the operation. Next, the puborectalis muscle bundles could be brought in the median line above the Kelly sutures. We proceeded to partial colpectomy and the closure of it.
We repaired the urethro-vaginal fistula.
With the Kelly sutures we repaired the torn and relaxed tissues at the neck of the bladder re-uniting the sphincter muscle. We restored anatomically, the vesicourethral angle. Thereby a backboard is created for compression of the proximal urethra during increased intra-abdominal pressure.
The puckered puborectalis muscles stitch support the vesical area operated upon to avoid any dead space between bladder and vagina.
Four months later the patient had neither stress incontinence nor nocturia, just minimal persistence of initial urgency that was successfully treated with solifenacin
Despite being a complicated case it was possible to find a solution to restore urinary continence in this woman without using meshes.
We cannot rule out the use of old surgical techniques to treat urinary stress incontinence for certain patients as long as we strictly follow the original technique