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Surgical Options for Treating Urinary Incontinence (SUI)

Surgery is often indicated for the treatment of urinary incontinence occurs with physical activity such as coughing, sneezing, walking and exercise and is due to a weakness in urethral closure. This is known as Stress Urinary Incontinence. It is important to distinguish this from leakage of urine with urgency, or at nighttime, which typically is known as Overactive Bladder syndrome, or urgency incontinence.

Stress urinary incontinence, or SUI, is a common condition that affects more than 19 million women in the United States alone. SUI is caused by a weakness in the support of the urethra, which leads to leakage with exertion and physical activity.

Traditionally, stress incontinence was treated surgically by making a large abdominal incision and placing either sutures next to the urethra (eg MMK or Burch urethropex) or by fashioning a sling of tissue from the abdominal wall (eg traditional fascial sling). While effective, either of these approaches required hospitalization and a lengthy recovery. Other techniques, known collectively as needle suspensions or ‘bladder neck slings’ did not demonstrate long term effectiveness, in many clinical trials.

NEW SURGICAL TECHNIQUES

Significant advances have occurred in the management of stress urinary incontinence for women. In 1996, a Swedish gynecologist developed a minimally invasive synthetic mid urethral sling that has revolutionized the surgical management of SUI in women. This procedure, known as the TVT sling, (stands for tension free vaginal tape) was introduced in the United States in 1998, and in early 1999, Dr. Marc Toglia became the first surgeon to perform this procedure in Philadelphia. Since that time, over 2 million TVT slings have been performed worldwide, and Drs Toglia and Fagan have performed well over 2000 of these in their practice, making them one of the most experienced physician group on the East Coast.

Minimally Invasive Mid Urethral Slings for SUI (TVT, TVT-O)

The TVT tension-free support system is an innovative, surgical device and technique for the treatment of female stress urinary incontinence. Clinical studies over the past 10 years have demonstrated that 85% of women experience resolution of their incontinence, with an additional 11% reporting significant improvement. Overall, patient satisfaction has been extremely high. Currently, Bonnie Blair, the five time Olympic gold medal speed skater, is the national spokesperson for the TVT technique.

The TVT sling utilizes a safe, and well studied mesh material, known as polypropylene. The mesh is inserted beneath the mid-portion of the urethra, through a small vaginal incision. The sling is then passed behind the pubic bone, next to the urethra and bladder, so that the mesh cradles and supports the urethra. The ends of the mesh exit the skin above the pubic bone so that tension can be adjusted on the sling, and the ends are trimmed and buried beneath the skin.

The unique properties of the sling material and technique allow for it to be placed under low tension, without traditional anchoring. This allows the urethra to relax during normal urination, but allows the urethra to remain supported and closed during exertion or exercise.

The TVT sling is typically performed in the operating room under heavy sedation and local analgesia, without the need for general anesthesia. The procedure itself takes 30 to 40 minutes, and most patients are discharged home after a brief recovery of 1- 3 hours. The vast majority of patients are discharged home without the need for a foley catheter. Postoperative pain is typically minimal, and most women can drive a car the next day, and resume working within 2 days. It is recommended that you abstain from exercise for one week, on average, and from sex for 3 weeks.

The TVT sling has revolutionized the treatment of SUI in women worldwide. The procedure itself was carefully designed, and well studied both in terms of safety and effectiveness. Hundreds of clinical studies have supported the efficacy of the procedure. Long term followup studies (as long as 12 years) have been published, supporting the long term success of mid urethral slings.

Patients are sometimes confused when they hear about some of the current concerns regarding vaginal mesh kits and serious complications, as well as the recent FDA safety update on this topic. It is important to understand that synthetic mesh used in the form of mid urethral slings for the treatment of SUI have been well studied and have an excellent track record, and currently represent the standard of care in the treatment of female SUI. Below is the essential information that a woman should know when seeking surgical treatment for SUI, and is interested in a minimally invasive technique such as the TVT or TVTO sling.

How does a mid urethral sling such as the TVT correct stress urinary incontinence?

Female stress urinary incontinence is believed to be the result of a poorly functioning urethra, not an intrinsic problem of the bladder. In a young, healthy woman, the urethra is supported from within and the outside by fibromuscular connective tissue which maintain a seal along the length of the urethra to prevent involuntary urine loss. Normal voiding involves a process by which the muscular walls of the urethra relaxes and the bladder contracts to allow drainage of urine. As a women ages, the connective tissues of the urethra and pelvic floor oftentimes weaken, and as a result, the urethra cannot maintain its tight seal to periods of exercise or exertion, and urine escapes.

The TVT tension support system combines a traditional operation known as a pubovaginal sling with polypropylene mesh material that has been specifically designed for the application of treating female SUI. The sling material is inserted through a small incision in the vagina and positioned underneath the mid portion of the urethra to create a supportive sling. This unique tape material is capable of providing support to the urethra during physical activity, without interfering with normal voiding function. The unique properties of this mesh allows for the tension-free placement of this material within the pelvic floor, reducing the incidence of post operative voiding difficulties, or urinary retention.

What are the Key Benefits to the TVT System?
  • Short operative time – The TVT procedure is typically completed within 30 minutes, under local anesthesia and heavy intravenous sedation.
  • Outpatient procedure – The TVT system is performed through several small (1/4 inch) incisions which allows patients to be discharged home from the hospital 3 to 4 hours after surgery
  • Short Recovery with Minimal Pain – Most patients can drive a car the next day and return to work in 2 – 3 days.
  • No traditional anchoring – the tape is held in place initially by surface tension (e.g. like Velcro) as it is sandwiched between several layers of tissue. Over time, in-growth of connective tissue through the mesh locks the tape into place
  • Low risk of postoperative voiding dysfunction – The tape is “adjusted” by the surgeon intraoperatively utilizing a cough test which improves the likelihood of the mesh being tight enough to prevent leakage, but not overly tight, making it difficult to void. In addition, the positioning of the tape at the level of the mid-urethra provided unique support, reducing the need for postoperative catheterization. In our experience, approximately 90% of patients are discharged from the hospital without a catheter. The remaining patients typically have an indwelling catheter overnight only.
What are the risks of this type of surgery?

All surgical procedures present risks. As the patient, you must decide whether the anticipated benefits of a particular operation override the inherent but fortunately uncommon risks.

TVT type sling procedures are associated with a small but recognizable risk of bleeding, injury to surrounding structures such as the bladder, urethra, vagina, bowel, blood vessels and nerves. A small percentage of patients continue to have significant leakage of urine following their surgery, or difficulty emptying their bladders. Some may experience erosion or exposure of the mesh material which may need to be removed. A very small percentage of patients may experience long-term pain or discomfort within the surgical field, or even muscle weakness from nerve injury.

Based upon our experience in over 2,000 mid urethral sling procedures (mostly the TVT sling) Drs Toglia and Fagan have noted the following:

  • Bladder injury occurs in a minority of patients (< 5%), and occurs with the placement of one of the thin cannulas. When recognized, the cannula is withdrawn and placed slightly more laterally, leaving a small (4 mm) puncture hole in the bladder which heals quickly and completely. In most cases, no direct treatment is needed.
  • Bleeding can occur in a small number of cases ( In some cases ( Vaginal mesh exposure or erosion has been very uncommon in our experience, occurring in less than 0.5% of cases we perform. This is typically the result of a breakdown or opening of the vaginal incision after surgery. In most cases, the vagina can be reclosed over the mesh, however in some cases, the exposed portion of mesh is excised and the vaginal tissue closed. This is also usually performed as an outpatient under local analgesia and light sedation.