Surgery for stress incontinence (Injection therapy, Retropubic suspension)

1- Injection therapy 

Injection of bulking material into bladder neck and periurethral muscles 


Indication: 

Female stress incontinence secondary to ISD with normal bladder function 
There is evidence of benefit in urethral hypermobility


Contraindications 

• UTI
• Untreated OAB
• Bladder neck stenosis

Success rates (50-80%). Repeat treatments are often required. Therefore bulking agents are not commonly used as a first-line intervention. 

Complications: 

• Temporary retention (2-15%)
• De novo UI (6-12%) 
• UTI (5%) 
• Haematuria (5%)
• Distant migration of particles (granuloma formation) 

2- Retropubic suspension


Indication

• Urethral hypermobility 
• Lower chance of benefit in patients with significant ISD. 

Types of Surgery

• Burch colposuspension 
• Vagino-obturator shelf/ paravaginal repair 
• Marshall-Marchetti-Krantz procedure (MMK)

Burch colposuspension

• Most widely used technique
• Vaginal wall is elevated and attached to lateral pelvic wall
• It is an option for patients with concurrent SUI and anterior vaginal wall prolapse. 
• Approximating the paravignal fascia to the iliopectineal ligament of Cooper’s 
• Success rates (90%) at 1y and 970%) at 5 y. 
• Complications 
• Posterior compartment prolpase (10-25%) 
• De novo urgency incontinence (15%) 
• Voiding dysfunction (10%)

                                      “Burch Colposuspension” 

Vagino-Obturator shelf/paravaginal repair 

• In some cases a cystocele develops because the front vaginal wall tears away from its lateral attachment to the pelvic sidewalls, resulting in a paravaginal defect. When this happens, a simple anterior repair is not appropriate, as it won't correct the problem
• Variant of the Burch procedure 
• Sutures from the paravaginal fascia are passed through the obturator fascia to attach to the arcus tendoneus fascia
• The aim is to dispense the tension on the paravesical tissues laterally to reduce the risk of prolapse. 
• Success rate 85%

Marshall-Marchetti-Krantz (MMK) Procedure 

• Sutures are placed on either side of the urethra at the bladder neck level and tied to the hyaline cartilage of the pubic sympysis.
• Short term succes 90% (declines over time)
• Complications: 3% risk of osteitis pubis. (analgesia, bed rest, steroids)