I. The main indications for surgical treatment include.
1, patients who have poor results or cannot adhere to non-surgical treatment, cannot tolerate it, and have poor expected results.
2, patients with moderate to severe stress urinary incontinence, which seriously affects the quality of life.
3, patients with high quality-of-life requirements.
4, accompanied by pelvic organ prolapse and other pelvic floor functional lesions requiring pelvic floor reconstruction, should be performed at the same time anti-stress incontinence surgery.
II. Surgical methods.
1.Tension-free midurethral sling surgery
DeLancey proposed the new hypothesis of mid-urethral hammock theory in 1994, suggesting that the rise in mid-urethral closure pressure caused by an increase in abdominal pressure is one of the main mechanisms of urinary control. Accordingly, Ulmsten (1996) and others applied tension-free vaginal tape (TVT) to treat stress urinary incontinence, which brought a new revolution in the treatment of stress urinary incontinence.
It is highly recommended as the initial and reoperative procedure for urinary incontinence because of its stable efficacy and low complications, with the advantages of TVT-O or TOT being more obvious due to less trauma, shorter hospital stay and fewer complications.
2.Burch vaginal wall suspension
Principle: The vaginal wall on both sides of the bladder base, bladder neck and proximal urethra are suspended by sutures via the posterior pubic bone to Cooper’s ligament to lift the bladder neck and proximal urethra, thus reducing the mobility of the bladder neck. It has also been suggested that this procedure has an effect on the position of the pelvic floor support tissues (MRI findings show a significant correlation between the degree of shortening of the distance between the anal levator muscle and the bladder neck and the success rate of the procedure).
3.Bladder neck sling (Sling) procedure
Principle: The bladder neck is suspended and anchored from below the bladder neck and proximal urethra in a suprapubic direction and fixed to the anterior rectus abdominis sheath to change the angle of the vesicourethra, fix the bladder neck and proximal urethra, and produce a slight compressive effect on the urethra. The sling material is mainly its own material, but it can also be a homograft, allograft or xenograft and synthetic material.
Efficacy: more positive. The mean urinary control rate for the initial surgery was 82% to 85%, and Meta-analysis showed that the objective urinary control rate was 83% to 85% and the subjective urinary control rate was 82% to 84%; when used for reoperation patients, the success rate was 64% to 100%, and the mean cure rate was 86%. The rate of urinary control at 10 years of long-term follow-up was not significantly different from that at 1 year. It can be applied to patients with all types of stress urinary incontinence, especially type II and type III stress urinary incontinence with better efficacy.
4.Artificial urethral sphincter
The cuff of the artificial urethral sphincter is placed in the proximal urethra, thus creating a circular compression of the urethra. The application in the treatment of female stress urinary incontinence has been reported relatively rarely and is mainly used in patients with type III stress urinary incontinence. Patients with significant pelvic fibrosis, such as multiple surgeries, urinary extravasation, and pelvic radiation therapy are not suitable for this procedure.
The advantages are the definite efficacy in type III stress urinary incontinence and the long-term urinary control that can be obtained. The main disadvantage is that it is expensive and has a high complication rate. Common complications include mechanical failure, infection, urethral erosion, urinary retention, recurrence of urinary incontinence and, if necessary, removal of the artificial urethral sphincter.
5.Anterior vaginal wall repair
It is a repair of the anterior vaginal wall to strengthen the supporting tissue of the bladder base and proximal urethra, to reposition the bladder and urethra, and to reduce their movement.
III. Follow-up of surgical treatment.
1. Time
At least one follow-up visit should be conducted within 6 weeks after surgery, mainly to understand the recent complications, and after 6 weeks, mainly to understand the long-term complications and the efficacy of surgery.
2.Content and index