Rudy De Wilde, MD

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   “Hello, my name is Rudy Leon De Wilde; I’m working as a Professor of  Obstetrics and Gynecology in the Northern part of Germany, and I’m very  honored that Dr. John Miklos out of Atlanta is here.  He has worked in  recent years in the field of the tension free vaginal tape.  The tension  free vaginal tape is a therapy for women with urinary incontinence, and  I think the expert should say something about that.”
       
       

  “Thank you,  Rudy, I appreciate the invitation to speak on TVT.  Dr. Ulmsten  introduced TVT in 1995 in Sweden; I had the pleasure of going to Sweden  in 1998 to learn the operation.  It is an outstanding minimally invasive  operation for the treatment of stress urinary incontinence with great  effectiveness, minimal pain and discomfort, and small incisions of no  more than about one-third of an inch.  The operation has now been  performed worldwide with 150,000 cases with 35,000 cases in the United  States.  I utilize this operation; I’ve performed approximately 250 of  these procedures since 1998 and find it to be an outstanding operation  for the treatment of stress urinary incontinence patients in select  individuals.”
       
       

  “First, a little help, what is stress urinary incontinence?”
       
       

   “Essentially, stress urinary incontinence is urinary leakage when a  patient exerts pressure on her abdominal region and her pelvic floor so  when one coughs, sneezes, or strains urine leakage occurs at the opening  of the urethra and it creates a hygienic problem for the patient.” 
       
       

  “A word about the operation, do you excise any tissue or is this a minimal invasive operation without excision of tissue?”
       
       

  “The  operation is so minimally invasive that we excise no tissue.  The actual  surgical procedure entails only two incisions on the very lowest part  of the abdomen right above the pubic hairline.  The two incisions are  only one-third of an inch and then a single incision in the midline of  the vagina right underneath the urethra approximately 2.5 cm or 1 inch.”
       
       

  “Then afterwards you bring in some kind of tissue.”
       
       

  “Yes, first  let me emphasize that the TVT is a sling procedure.  If you review the  literature there are two outstanding operations for the treatment of  stress incontinence.  Those two operations are the Burch and the sling  operation, make no mistake about it, a TVT is a sling operation but we  have been able over the last ten years with the help of our colleagues  in Sweden to develop a technique that is so minimally invasive using a  Prolene mesh tape that functions as a sling procedure and that literally  wraps around the urethra and supports it from the bottom up to the  anterior abdominal wall.”
       
       

 “So you have to suture it to the abdominal wall?”
       
       

  “No,  actually the tape is delivered by using long needles from the vagina up  to the belly wall and it literally anchors in by almost a Velcro  technique.  The incisions that are made in the passage of the needle;  the needles are only .5 centimeters, roughly 5 mm, the tape is 1.1 cm so  as the tape passes through the tissue, the needle makes a small passage  and as the tape comes through it spreads out, and grabs the tissue  making it secure and does not need any suturing into place.”
       
       

 “This really seems minimally invasive.  Does the patient need general anesthesia for it?”
       
       

  “No, Rudy,  as a matter of fact, I have been taught by the doctors who invented the  operation and I highly encourage other physicians to stay to protocol,  and that is attempt to do the operation either under local anesthesia or  regional anesthesia.  In other words, the patient must be awake during  the operation to get the full effect of the surgical protocol.  The  patient’s bladder is filled with a certain amount of fluid, they cough,  they leak, and you gently adjust the tape so that they no longer have  stress urinary incontinence.  Over-adjustment obviously allows for  possible retention and difficulty in urinating and that’s one of the  problems that we see with the standard sling procedure.  The TVT has  taken away the voiding dysfunction that is often associated with a  suburethral sling procedure.”
       
       

 “This  really seems minimally invasive; you don’t need any general surgery,  and you have very small incisions.  It seems very good.  Have you got  any complications?”
       
       

  “With  approximately 240 patients that I have operated on, I have had 2  patients that went into retention.  Six weeks later we simply cut the  tape in a second minor operation of only seven minutes, their ten  minutes long, and we literally cut the tape, closed this vaginal skin  back up with an incision, once again, of only three-fourths of an inch.   The patient could void without problem and both patients remain  completely continent, meaning they no longer leaked but they could  completely empty their bladder immediately following the release of the  tape.  I have personally had very few other complications, some minor  urge incontinence afterwards and on occasion a bladder perforation but a  small hole in the bladder with a removable needle will heal on its own  without any complications at all.”
       
       

 “So  to end, a minimal invasive technique for stress urinary incontinence  with no major complications.  Thank you very much Dr. Miklos out of  Atlanta.”
       
       

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OBGYN.net Conference CoverageFrom ISGE 2001 Congress - Chicago, Illinois, 2001

TVT – Tension Free Vaginal Tape

   “Hello, my name is Rudy Leon De Wilde, I am a Professor of Obstetrics  and Gynecology working in Oldemburg in Germany.  I’m very proud that Dr.  Liu, is here today; he’s one of the most famous gynecological  laparoscopists.  I have a few questions for Dr. Liu, and one of my first  questions is how do we treat urinary incontinence?”
       
       

  “Thank you,  Rudy, it’s my pleasure to be here with you.  I think before we talk  about treatment of stress urinary incontinence we have to ask ourselves a  question - what type of a stress urinary incontinence does this patient  have before you do any kind of a surgical intervention or even  conservative treatment.  There are basically two types of stress urinary  incontinence: the first type we call the “hypermobile” type of stress  urinary incontinence which means the anterior vaginal wall is poorly  supported and whenever a patient has an increase in intraabdominal  pressure, the anterior vaginal wall will descend down and they’ll be  loss of support of the proximal paraurethra and the bladder.  With that  kind of stress urinary incontinence, I think the gold standard of the  surgical treatment is what we call the “Burch colposuspension” or  sometimes associated with paravaginal repair to repair the cystocele and  then with Burch to maintain and support the proximal part of the  urethra and the UV junction.  The second type of stress urinary  incontinence we call “intrinsic sphincteric deficiency” and, again,  intrinsic sphincteric deficiency can coexist with hypermobile of the  anterior vaginal wall and also with a well-supported anterior vaginal  wall.  So with a patient with an intrinsic sphincteric deficiency and  hypermobile anterior vaginal wall, the treatment choice is a suburethral  sling procedure.  Now if a patient had intrinsic sphincteric deficiency  and with a well supported anterior vaginal wall, the first treatment  would be periurethral collagen injection.  Basically, there are three  things you can do after you decide what type of incontinence the patient  has.  In summary, if a patient has a hypermobile anterior vaginal wall  but it was intact intrinsic sphincter mechanism now that treatment would  be a Burch or the first combined with a paravaginal.  Now if a patient  has intrinsic sphincteric deficiency with a hypermobile anterior vaginal  wall, the treatment choice would be a suburethral sling.  If it were a  patient with intrinsic sphincteric deficiency with a supported anterior  vaginal wall, then it would be a periurethral collagen injection.  It’s  kind of a complicated answer.”
       
       

 “How does a patient know which type of incontinence she has?”
       
       

  “That would be  the physician’s job.  Based on the patient’s history, physical  examination, and urodynamic study usually you can tell what type of  incontinence the patient has.  When you examine the patient in the  examining room you definitely can identify whether the anterior vaginal  wall is supported or not.  Which by physical examination you can clearly  diagnose that and, I suppose with intrinsic sphincteric deficiency, you  will have to have a high suspicion.  For example, if a patient empties  her bladder before you examine her and comes back and gets on the  examination table and you ask her to cough and all of a sudden a large  amount of urine just sprints out, in that case more or less you know  this patient probably has intrinsic sphincter deficiency.  Intrinsic  sphincteric deficiency, to me, is the patient’s internal sphincter of  the urethra is opening for whatever reason and so there’s always a small  amount of urine that stays in that proximal part of the urethra.  When  the patient has an increase in intraabdominal pressure, this small  amount of urine works as an urge and just drives and ties the urethra  opening.  Of course, a large amount of urine would just follow out so  you can use an urodynamic study, as pressure is a true test.  One is the  abdominal leak point pressure and another one is the urethra closure  pressure and based on these two indices or the lab test result in a  plus, clinical high suspicion, then you can have a pretty good  diagnosis.”
       
       

  “We’ve already discussed four different types of possible therapies as a  sort of gynecological operation.  You said one of them is the Burch  operation.  Could you tell us something more?”
       
       

  “Yes, the Burch  colposuspension was actually started in 1968 by John Burch.  Basically,  he put the stitches around the proximal part of the urethra and the UV  junction and then suspended that area of the paravaginal tissue to the  Cooper’s ligament.  It kind of stabilized and aided the proximal urethra  by giving a very good support of the proximal part of the urethra so  when a patient has an increase in intraabdominal pressure like a cough,  sneeze, or laugh the proximal part of the urethra will not drop down too  low.  That maintains continence, which means the Burch procedure  actually has provided a very steady and firm backstop for the proximal  part of the urethra.  So when a patient has an increase in  intraabdominal pressure that part of the urethra can be compressed,  closed, anterior posterior without obstructing there.”
       
       

  “Burch discussed his operation technique with a laparotomy, that means  he opened the abdomen very broadly, nowadays we have new techniques.”
       
       

  “Yes, we are  using laparoscopic surgery to do Burch now.  Of course, when John Burch  did his procedure there was no laparoscopic surgery but now with  advances in video we can really get into the retropubic space and we can  have a very clear view of the retropubic anatomy.  Actually, through  the very sophisticated video camera we can magnify that area onto the TV  monitor so we can see the anatomy very well and we can suture  laparoscopically without making a large incision, and we can achieve the  same goal as Burch.”
       
       

 “So  this kind of operation can be performed minimally invasive.  You also  talked about paravaginal repair, what does that mean?”
       
       

  “Paravaginal  repair is a repair of a defect in the paravaginal area which means  there’s an endopelvic fascia we call it a pubocervical fascia which is  the fascia of the anterior vaginal wall.  Normally this anterior vaginal  wall will attach to a structure, we call it white line - arcus  tendineus fascia of the pelvis, and when this pubocervical fascia  detaches from this white line then we call it the paravaginal defect.   As a result of a paravaginal defect, clinically, you will see a  cystocele and so if you repair this defect, then the cystocele can be  repaired.”
       
       

 “The third operation was the sling operation; in which case do you need the sling operation?”
       
       

  “As I mentioned  earlier, the first indication if the patient has intrinsic sphincteric  deficiency with a hypermobile anterior vaginal wall, the first choice is  really a paravaginal repair plus suburethral sling procedure.  There  are basically three materials that you can use as a sling graft; one is a  gift from the patient’s own fascia, from the thigh, another one is what  we call the donor fascia which is basically from a cadaver, and the  third one is a synthetic material like Prolene, Gortex, Mersilene, these  kind of things.”
       
       

 “So in the fourth sort of operation was the injection; what kind of injection do you perform?”
       
       

  “That we call  the periurethral collagen injection and the indication for that in my  practice is a patient with ISD - intrinsic sphincteric deficiency with a  well supported anterior vaginal wall.  The first thing I do is a  periurethral collagen injection and what it does is, as I mentioned, the  intrinsic sphincteric deficiency is the internal os of the urethra,  internal sphincter of the urethra is open so if we inject collagen under  the submucosa around that area you can swell up the mucosa and then the  proximal part of the urethra can be coaptated and be closed.  So they  won’t have any urine stay in that proximal part of the urethra and  that’s what helps their incontinence.  The only problem with the  periurethral collagen injection is the collagen can be absorbed by the  body and then you have to repeat it.”
       
       

“We  would like to try and thank Dr. Liu for this very educational and  scientific talk, which will open new perspectives in the therapy of  urinary incontinence.  Thank you very much, Dr. Liu.”
       
       

Author | Rudy De Wilde, MD

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