Surgical treatment of urinary incontinence in women -stress and urge incontinence

Jaeger W1

Research Type

Clinical

Abstract Category

Overactive Bladder

Abstract 746
Non Discussion Abstract
Scientific Non Discussion Abstract Session 37
Mixed Urinary Incontinence Urgency Urinary Incontinence Surgery
1.Dept Urogyne university of Cologne
Links

Abstract

Hypothesis / aims of study
Urinary incontinence (UI) is the unintended loss of urine. That is caused by an uncontrolled opening of the bladder into the urethra via the urethral-vesical opening/junction (UVJ). In women the bladder is fixed at the lower anterior abdominal wall and at the upper cervix. The urethra and the bladder base are otherwise stabilized only by the upper vaginal wall. Any lowering of the anatomical position of the cervix will lead to a change of the tension of the vagina. Since the upper vagina is adherent to the bladder base and the urethra, any descensus of the cervix changes the vaginal support of the UVJ. Patients with urge urinary incontinence (UUI) do not lose urine in horizontal body position but only in the upright body position. We therefore hypothesized that UUI is also caused by the stress on the bladder base or – or precisely – on the area of the UVJ.. 
The position of the vagina is stabilized by the pubo-urethral ligaments (PUL) and the utero-cervical ligaments (USL) according to the Integral Theory). We therefore hypothesized that UI is caused by defect functions of the USL or PUL.
For the replacement of the USL we developed the bilateral cervico- or vagino-sacropexy (CESA or VASA). The PUL were replaced by alloplastic tapes (TVT or TOT). 
According to our hypothesis we treated patients with UUI or mixed urinary incontinence (MUI) by CESA/VASA and TOT.
Study design, materials and methods
The diagnosis of UUI or MUI were based on the standard questionnaires. (Urodynamic testing (UT) did not provide any further important information for our treatment schedule so that we omitted UT since 2010 in our institution). Patients with classical urgency symptoms (UUI) reported that they lose urine when rising to an upright body position. Therefore, we summarized these patients with UUI to the group of MUI.  
CESA and VASA operations were performed as laparotomy or lapascopically (laCESA and laVASA). The technique is standardized for all women and has been described in detail (www.cesa-vasa.com).
Clinical outcome was assessed 4 months after surgery. In case of incontinence after CESA or VASA a TOT 8/4 was performed. All treatments were agreed by the Ethical Committee.
Results
284 patients with MUI were evaluated. 119 patients (42%) were immediately continent after CESA or VASA. 71 of the CESA patients (52%) and 48 of the VASA patients (33%). The remaining incontinent patients received a TOT. With the TOT 48 % of the CESA patients became continent and 50% of the VASA patients. Therefore, the overall continence rates were 76% in the CESA group and 65% in the VASA group. According to further analysis patients age at surgery was a prognostic factor with a significantly better continence rate in patients younger than 60 years (73%) compared to the older ones (57%).
Interpretation of results
The fixation of the USL and PUL can restore continence in between 65% and 76% of patients urgency or mixed urinary incontinence. All these patients would otherwise have been treated by several neurological treatments ranging from oral medication via botox injections to neurological bladder stimulation. However, the continence rates after these treatment modalities are disappointing indicating that they do not address the correct problem.
We therefore agree with others who stated that UI is caused by an anatomical relaxation of the upper vagina. That could be repaired by a specific kind of surgery. Some patients only need an apical fixation which was achieved with the CESA or VASA and others needed an anterior support with an additional TOT. 
(Interestingly did the primary placement of the TOT not lead to continence in patients with MUI – only when they were placed after CESA or VASA!)
The continence rates in that study were dependent on patients age indicating that UI increases with increasing age. UI seems to be a pathophysiological continuum starting with loss of urine only after increased pressure on the UVJ after coughing to urine loss already after getting up from a chair.
Concluding message
We therefore believe that urinary incontinence (stress and urge) in women is caused by an anatomical relaxation of the upper vaginal wall. In younger age a high pressure on the UVJ is needed to open the urethra (coughing) while in elderly patients that pressure can be light to cause the same effect (sitting up). We hypothesize that stress- and urge urinary incontinence are not caused by different etiologies but they are a pathophysiological continuum.  We hypothesize that continence can be reestablished in all patients when beside the anterior and the posterior part of the upper vagina also the part of the vagina in the area of the UVL can be “repaired”.
Disclosures
Funding no sources or funding Clinical Trial Yes Public Registry No RCT No Subjects Human Ethics Committee Ethical Committee of the University of Cologne/Germany Helsinki Yes Informed Consent Yes