TREATMENT OF STRESS URINARY INCONTINENCE: PRESENT AND POSSIBLE FUTURE
Gian Franco Puggioni, Antonio Campiglio, Antonio Onorato Succu
UOC Ostetricia e Ginecologia, Dipartimento Cure chirurgiche, Ospedale San Martino, Azienda sanitaria di Oristano, via Rockfeler, 09170 Oristano
Topic: SUI surgery
Stress urinary incontinence (SUI) affects 35% of adult women and severity and prevalence increase with age. In 1994 de Lancey formulated the hammock theory and in 1998 Petros proposed the theory of the middle urethra. In the year 2001 de Lorme published his first series using the out-in transobturator tape. Single-incision mini-slings (SIMS) have been developed to reduce procedure-related discomfort without negatively affecting the benefit. To date midurethral slings are the preferred treatment option for SUI. We focused on minisling, particularly on the surgical treatment of SUI with monoincision technique, but with a look to the future on the suggestions of cell therapy and regenerative medicine.
We conducted an extensive search of the scientific literature by consulting the main nternationally bibliographies, especially PubMed, Ovid, Embase, and others. We then made use of a powerful bibliographic search tool born about 1 year ago in the Sardinia region and promoted and implemented by Sardinia research and made available to researchers and clinicians working in the Island. This is the advanced search tool called Discovery that has allowed us to make a detailed and comprehensive search and find any scientific article interesting for our purposes. The key words used were: stress urinary incontinence (SUI), treatment of SUI, SUI and surgery, sling or mesh for SUI. In the literature review and exposition of the results we have considered largely our clinical and surgical experience in the surgical treatment of genital prolapse, following the historical evolution of the recent acquisitions in terms of pathophysiology, functional anatomy, and also, in close relationship with recent prosthesis and with the new devices, a research in our group of a rigorous planning for the treatment of stress urinary incontinence. We describe the surgical pocedure of MiniArc that represents the current procedure of choice for us. We value our series in comparison with other published studies.
MiniArc is introduced through a single 1.5-cm incision at the level of the midurethra, after bilateral periurethral dissection with Metzenbaum scissors to the posterior portion of the ischiopubic ramus (about 1–1.5 cm). The needle is trackedalongthe posterior surface of the ischiopubic ramus until the midline mark on the mesh is approximately at the midline internus fascia, the needle is removed. The same procedure is repeated on the contralateral side. The sling is pillowing with gently tension on the midurethra. The incision is closed using a delayed absorbable suture. The complication rate is very low and the cure rate of this procedure is high: 85% in our experience.
This treatment results in a cure rate of over 80% based on both subjective and objective evaluations. However despite the high success rates, 10–20% of women remain incontinent. This is also why we wanted to look at possible future therapies, in combination or as an alternative to surgery. With monoincision sling for the surgical treatment of SUI we seem to have reached a more than good result. In fact, the patient discomfort is minimal as well as operative time and complications. However, there remains a certain share of relapses and no cure. In these cases might eventually open up a promising avenue with regenerative medicine and cell therapy with resident or perhaps even placental stem cells.