Treatment for Urinary Incontinence

September 9, 2006

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

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Professor Rudy De Wilde: “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?”

Dr. C.Y. Liu: “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.”

Professor Rudy De Wilde: “How does a patient know which type of incontinence she has?”

Dr. C.Y. Liu: “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.”

Professor Rudy De Wilde: “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?”

Dr. C.Y. Liu: “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.”

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

Dr. C.Y. Liu: “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.”

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

Dr. C.Y. Liu: “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.”

Professor Rudy De Wilde: “The third operation was the sling operation; in which case do you need the sling operation?”

Dr. C.Y. Liu: “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.”

Professor Rudy De Wilde: “So in the fourth sort of operation was the injection; what kind of injection do you perform?”

Dr. C.Y. Liu: “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.”

Professor Rudy De Wilde: “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.”

Dr. C.Y. Liu: “Thank you.”