Surgery For Women And Men

Surgery for women

Autologous fascial sling

Burch colposuspension

Injection of bulking agents

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Midurethral sling
Up until recent years a midurethral sling was the standard surgical treatment for treating stress incontinence in women. It involves inserting a mesh strap, called a sling, under the urethra to support it. The sling is made of synthetic material, and helps the urethra stand up to pressure when you do a sudden movement or action, such as a cough or sneeze. The sling material remains permanently inside your body and it is not absorbed over time.

When correctly placed, the sling supports the urethra like a hammock, helping to prevent the urethra from collapsing and leaking urine unexpectedly, as might usually happen with stress incontinence.

If this surgery is recommended for you, your doctor will discuss in detail how they would plan to insert the sling. However, there are now procedures which have less serious complications than those midurethral slings caused. Additionally, midurethral slings are not available in all countries, due to the nature of the complications sometimes associated with them. Some countries still offer them, but doctors are careful to assess the risks and discuss these thoroughly with their patients.

There are two different ways the operation can be carried out: a retropubic approach, sometimes called TVT, or a transobturator approach, which is sometimes called TO. A retropubic approach means the sling is inserted via the vagina behind the pubic bone, whereas the transobturator approach involves the sling being passed through the window of the pelvic bones.

The operations involve a surgeon inserting the sling through your vagina using special surgical tools and a guide to make sure that the sling is positioned correctly. Both types of midurethral sling operation are very effective.

Although midurethral slings are very successful in the treatment of stress urinary incontinence, complications can occur, which can make your urinary incontinence worse. This can require further operations to correct.

Your doctor will discuss thoroughly with you, the benefits and risks of this type of operation, the types of slings available in your country and alternative treatments available to you.

 

Autologous fascial sling


Your doctor may recommend an autologous fascial sling as surgical treatment for your stress incontinence. This type of operation may be suitable for you in any of the following circumstances:

  • If you have previously had surgery which wasn’t successful
  • If you are not able to have a midurethral sling procedure
  • If you do not wish to have any surgery which involves any synthetic (artificial) material being used in your body

This operation is similar to a midurethral sling operation. Both procedures use a sling to support the urethra, but an autologous fascial sling also supports the pelvic floor muscles. This strengthens the urethra against pressure in your abdomen when you do sudden movements such as coughing or sneezing. The urethra is supported and in turn prevents unexpected urinary leakage.

Where the autologous fascial sling operation differs from the midurethral sling operation is that in this operation, some of your own connective tissue, called fascia, is cut from your inside your lower abdomen or thigh, and is used by the surgeon to form the sling that is then moved into place underneath your urethra. The surgeon places the sling either at the mid-urethra, or nearer to the bladder.

This means that no synthetic (artificial) material is used in your body. This type of operation can have different complications. For instance, you may have difficulty emptying your bladder after the operation. However, these complications are likely to be more minor than those that sometimes occur in mid-urethral, synthetic slings. It is for this reason that this type of operation has gained popularity.

This type of surgery also means that you would have surgical wounds in two or three places rather than one place, because making the sling from your own body tissue means that the lower belly groin or thigh is also cut into, as well as the incisions that are made in for example, your abdomen and vagina, depending on how the sling is inserted.

 

Burch colposuspension



Burch colposuspension is an operation that involves repositioning the muscles that connect the bladder to the urethra. These muscles are called the bladder neck. The operations aims to improve the strength of the bladder neck so it does not leak urine unexpectedly when you do sudden movements, such as laugh or jump.

Burch colposuspension procedures were commonly used to treat stress incontinence before the invention of midurethral slings. These days, slings have largely replaced Burch colposuspension because it is more straightforward to insert a sling and is a smaller operation. If a midurethral sling is not an option for you, your doctor may suggest that you have a Burch colposuspension, as an alternative. It can also be offered to you if you have previously had a different type of surgery for your stress incontinence, that wasn’t successful.

During Burch colposuspension surgery, the surgeon attaches the side of the vagina to the ligament behind the pubic bone with stitches, so that the bladder neck lies in a hammock. This lifts and supports the bladder neck, strengthening it against collapse and resulting in less bouts of urinary leakage.

The surgery can be done in one of two ways:

  1. Open surgery, where the surgeon makes a larger incision (cut) into your lower abdomen to access the bladder; or
  2. Laparoscopic surgery, where the surgeon makes a number of small cuts to get to the abdomen. A small camera is then inserted into the area, so the surgeon has a high-quality view on a video monitor to guide them while they are carrying out the surgery.

Both surgical methods are equally effective, but laparoscopic surgery usually involves a shorter hospital stay because small wounds usually heal more quickly.

Fig. 2: In Burch colposuspension, supporting stitches lift the bladder neck.
Burch colposuspension
Fig. 3: For laparoscopic surgery the surgeon inserts the surgical instruments through small incisions in the abdomen.
Laparoscopic surgery
 

Injection of bulking agents



A bulking agent is a medical substance which can be injected into the outside edges of your urethra to help strengthen it. Bulking agents are usually synthetic (made of a manufactured medical substance) but sometimes collagen from cows is used. Bulking agents help the urethra stand up to pressure and prevent urine unexpectedly leaking when under pressure from an action such as a sneeze.

Bulking agents are an option if you are unable, or do not wish, to have other surgical treatments, or if you need, or wish, to postpone having surgery. Bulking agents are not a permanent solution and cannot cure stress incontinence because the bulking agent gradually and harmlessly dissolves over time, so the benefit is short-term.

During the operation, a surgeon uses a narrow, flexible, surgical telescope (called an endoscope) to insert a needle into, or next to, the wall of the urethra. Once inside, bulking agent is injected into the outside edges of the urethra. There are no incisions or stitches involved with this procedure.

Fig. 1: Bulking agents are injected into the urethral wall.
During and after bulking agent surgery
 

Surgery for men

Artificial urinary sphincter implantation

Injection of bulking agents



Sling implant
A sling implant is the standard surgical treatment for treating stress incontinence in men. The procedure involves inserting a mesh strap, called a sling, under the urethra to support it. The sling is made of synthetic material and helps the urethra stand up to pressure when you do a sudden movement or action, such as a cough or sneeze. The sling material remains permanently inside your body, so it is not absorbed over time.

When correctly placed, the sling lightly compresses the urethra to slightly close it, helping to prevent the urethra from leaking urine unexpectedly, as can happen with stress incontinence.

Your doctor will discuss in detail how they would plan to insert the sling. This involves having an incision between your scrotum and anus. There are different types of slings and different ways the operation can be carried out. The diagrams below show the different types of slings.

In two-arm slings, the ends of the sling are put in position on both sides of the urethra, shaping the sling like a hammock. Then, the ends of the sling are attached to tissue either just above the pubic bone, or around the groin.

In four-arm slings, the ends of the sling are put in position on both sides of the urethra, shaping the sling like a hammock. Then, two ends of the sling are attached to the groin, while the other two are attached to tissue around the pubic bone.

Fig. 1: A common type of retropubic two-armed sling.
Two-arm sling
Fig. 2: A common type of four-armed sling.
Four arm sling

Artificial urinary sphincter implantation



An artificial urinary sphincter implant, or AUS, is the standard treatment for moderate to severe stress urinary incontinence in men. It may be offered to you if you have previously had a sling implant for your stress incontinence, but it didn’t work.

Alternatively, your doctor may recommend this operation if other treatment options have a low chance of success.

Your doctor will inform you and discuss the risk of complications, mechanical failure, and the potential need for removal.

Before being offered this operation, your doctor will need to work out whether it will be effective. You may be asked to do a urodynamic test so your doctor can check how your lower urinary tract is working.

An artificial urinary sphincter implant operation involves putting a cuff around the urethra. An incision is made between the scrotum and the anus, and another one in the lower abdomen. A water-filled balloon, called a reservoir, is inserted under the lower abdominal muscles above the bladder. This inflates the cuff via a hand-controlled pump. The pump is placed beneath the skin, inside the scrotum, so it is accessible. The pump is hand-operated so that you can control it yourself in your everyday life.

Fig. 1: AUS implantation in the male lower urinary tract.
Artificial urinary sphincter implant operation
 

Injection of bulking agents



A bulking agent is a medical substance which can be injected into the outside edges of your urethra to help strengthen it. Bulking agents are usually synthetic (made of a manufactured medical substance) but sometimes collagen from cows is used.

Bulking agents help the urethra stand up to pressure and prevent urine unexpectedly leaking when under pressure from an action such as a sneeze.

Bulking agents may be an option if you are unable, or do not wish, to have other surgical treatments, or if you need, or wish, to postpone having surgery. Bulking agents are not a permanent solution and cannot cure stress incontinence because the bulking agent gradually and harmlessly dissolves over time, so the benefit is short-term.

During the operation, a surgeon uses a narrow, flexible, surgical telescope (called an endoscope) to insert a needle into, or next to, the wall of the urethra. Once inside, bulking agent is injected into the outside edges of the urethra. There are no incisions or stitches involved with this procedure.

Fig. 1: Bulking agents are injected into the urethral wall.
During and after bulking agent surgery
 

Electrical stimulation


Our bodies are made up of trillions of nerves which send signals between your brain, spinal cord, and the rest of your body. Each of your muscles has thousands of nerve endings that activate the muscles, either by tightening or relaxing when your brain commands. Sometimes the brain struggles to activate or deactivate a muscle, and this is where electrical stimulation can be helpful.

Electrical stimulation involves having a device called an electrode placed near a nerve so it can send an electric current to artificially activate the muscle. As with all treatments, electrical stimulation may not be suitable for everyone, but your doctor will be able to discuss this with you.

Electrical stimulation can feel a little uncomfortable at first, but it is not painful. The treatment usually starts with a low level of intensity which may be increased, but only up to a certain point where you still feel comfortable.

To help relieve urinary incontinence, your doctor may offer you different types of electrical stimulation including sacral nerve stimulation, tibial nerve stimulation, or pelvic floor stimulation.

Sacral nerve stimulation
You have a network of nerves (called a plexus) in the lower half of your body, near the base of your spine. This particular network is called the sacral plexus. Your sacral nerves are found in the thigh, most of the lower leg and foot, and part of the pelvis.

If your doctor recommends trying sacral nerve stimulation, you will need to have a thin wire (called an electrode) and a control unit inserted under your skin. The procedure is done under a local or general anaesthetic.

The control unit is about the size of a mobile phone and is used to change and control the frequency of electrical signals delivered to the electrode, which stimulates the sacral nerves.

Tibial nerve stimulation
Your sciatic nerve is the largest nerve in your body. It extends from the lower end of your spine, down the back of your thigh, and divides into two branches above the knee. Your tibial nerves are one of these two branches of nerves. Your tibial nerves extend through your leg and foot muscles.

Tibial nerve stimulation involves having a tiny needle inserted into your foot which is used to send electrical pulses to the nerves around your pelvis, which can be helpful if the brain is struggling to activate the muscles necessary for holding urine in the bladder.

Fig. 2: Sacral nerve stimulation.
Sacral nerve stimulation
Fig. 1: Tibial nerve stimulation.
Tibial nerve stimulation.

Pelvic floor stimulation
Your pelvic floor muscles are a sheet of muscle at the bottom (floor) of the pelvis. The muscles help you to control when you release urine from the bladder. Pelvic floor stimulation can help both women and men contract and strengthen their pelvic floor muscles to address the cause of their urinary incontinence symptoms. Pelvic floor stimulation involves passing a small electrical current through your pelvic floor muscles. The probe is placed in the vagina for women or in the anus for men.

 

Botulinum toxin injections


Botulinum toxin works by paralysing nerve endings. You may have heard this substance being referred to as Botox®. While most of us think of botulinum toxin as a cosmetic procedure to reduce the visible signs of ageing, botulinum toxin injections do have several medical purposes including treating muscle and nerve-related health problems.

Your doctor may suggest treating your urinary incontinence with botulinum toxin injected into the wall (lining) of your bladder. This treatment is often used in people who have been diagnosed with an overactive bladder, but it is also used to help treat urge incontinence. Botulinum toxin helps the muscles relax, which will give you more time to get to the bathroom when you feel the need to urinate.

The procedure involves filling your bladder with an anaesthetic liquid to numb it. A thin tube with a tiny camera on the end, called a cystoscope, is then inserted up your urethra and into your bladder. Your doctor will then pass a special needle through the tube and begin injecting botulinum toxin into the wall of your bladder.

Your doctor will be able to advise you if botulinum toxin is a treatment option for you and discuss potential side effects, such as the risk of urinary tract infections, urinary retention and the need for repeated botulinum toxin injections as this is a temporary treatment and the effects will wear off over time.

The injections are done under a local anaesthetic.

Fig. 1: Botulinum toxin is injected into the bladder wall.
Botulinum toxin is injected into the bladder wall.
 

Cystoplasty


In cases where all other treatment options have been unsuccessful in helping a person to manage their urinary incontinence, a cystoplasty (bladder enlargement) may be considered. Otherwise known as a bladder augmentation, this involves removing strips of tissue from the bowel, and adding it to the tissue of the bladder to enlarge it. This has 2 intended results: increasing the bladder volume to hold more urine and reducing the amount of bladder tissue that can contract, which will lower the pressure in the bladder during urination.

The risks of this surgery are that the bladder won’t completely empty, and you may need to insert a catheter to drain the remaining urine. Also, blockage of the bladder due to scar tissue where the bowel tissue has been attached.

Fig. 3: Bladder surgery to increase the size of the bladder.
Bladder surgery to increase the size of the bladder.

Urinary diversion
This should be considered only when all other treatments are not an option. Urinary diversion is a surgical procedure involves removing the bladder through an incision in the abdomen. Part of the intestines are then used to either create a new urethra or to create a new bladder. If a new urethra tube is created, it exits the body via a new opening in the abdomen called a stoma. A small urine disposal bag is placed over the stoma. The bag fits under your clothes and your doctor will teach you how to take care of and empty it as you will need to use urine disposal bags permanently afterwards.

If a new bladder is created, urine will pass out of the body as it did before, but it will feel different, and you will require a catheter and to wear pads in your underwear while you re-learn how to hold in urine and how to go to the toilet.

It is carried out under general anaesthetic as open surgery with an incision, or by laparoscopic or robotic-assisted surgery at specialist centres that offer this facility.

These types of surgery are considerably more invasive and are carried out by doctors with a lot of experience in this type of surgery. Should this type of surgery be recommended for you, there are potential long-term complications associated with having this type of operation, that your doctor will discuss with you in detail, should this type of surgery be recommended for you. Having an operation of this nature can also involve the life-long use of a catheter or urine disposal bags afterwards.