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Urinary incontinence surgery is a major surgical procedure. When a doctor refers a woman to such a procedure, he is obliged to inform her of all possible complications of the procedure, as well as that there is a possibility of a recurrence of the existing problem.
To save a woman from stress urinary incontinence, modern surgery offers more than 250 types of different operations. Their goal is to either completely compensate or correct the cause that led to the impossibility of urinary retention. As for the effectiveness of such interventions, the indicators vary between 70-95%.
Urinary incontinence can be treated with the following types of surgery:
Sling operations (suspension operations);
Vaginoplasty;
Installation of an artificial sphincter;
The introduction of injections of volume-forming substances into the periurethral zone.
Indications for operation
Indications for surgical intervention for urinary incontinence can be called the following:
Acquired stress incontinence.
Mixed incontinence of urine with a predominance of the stress component.
Rapid progression of pathology.
Ineffectiveness of conservative therapy in patients with second and third degree of incontinence.
Sling surgery for female urinary incontinence (TVT)
Sling surgeries (TVT and TVT-O) are an effective and safe treatment for stress urinary incontinence. They belong to minimally invasive techniques that are carried out under the control of modern equipment. The essence of the intervention is that a loop is inserted under the middle part of the urethra, which is designed to support the urethra and prevent urine from flowing out when stressed. The loop is made of synthetic material and is placed in the space between the urethra and the anterior vaginal wall. As a result, the angle of inclination between the bladder and the urethra is restored, and urine does not flow out.
Sling surgery is performed for stress urinary incontinence, as well as for a combination of stress incontinence with urge incontinence. That is, in cases where uncontrolled urine output is accompanied by an increase in intra-abdominal pressure (this happens when sneezing, laughing, coughing, etc.).
Contraindications for this type of surgery are:
Childbearing period.
Stage of pregnancy planning.
Infectious and inflammatory diseases of the genitourinary system.
Taking medications that thin the blood less than 10 days before the start of surgery.
A sling operation can be implemented even if previous surgical treatment has not been successful.
Before the patient is referred for surgery, she must undergo a comprehensive urodynamic examination.
As an alternative to sling surgery, specific exercises can help with mild urinary incontinence. However, when conservative therapy is ineffective, then it will not be possible to get rid of the existing problem in other ways. It is also possible to install mini loops (miniTVT), transobturator loops (TOT) and needleless loops (needleless).
When a woman has other pathologies in parallel, for example, prolapse of the pelvic floor, it is possible to install a mesh, rather than a small loop implant. If urinary incontinence is of a mixed nature, then medical correction is carried out in parallel. That is, the imperative cause is eliminated with the help of drugs, and stress incontinence with the help of surgery.
Preparation for the operation takes place in several stages:
Consultation of specialists: urologist, therapist, anesthesiologist, gynecologist. If there are any inflammatory processes, then they are subject to treatment.
Hospitalization in the hospital on the eve of surgery, testing and assessment of the patient’s condition.
Examination by an anesthesiologist, appointment of premedication.
Setting an enema before surgery, or taking laxatives to cleanse the intestines.
Shaving the pubic area and external genitalia.
Refuse to eat and any liquid should be on the eve of the operation.
The course of surgery:
The patient is given spinal anesthesia, in which consciousness is preserved, but the sensitivity of the body below the waist disappears.
An incision is made on the front wall of the vagina and tunnels are formed for the passage and installation of the sing.
A loop is passed through the tunnels, its lateral ends are brought out. The central part of the loop will be located under the urethra.
The surgeon pulls the loop until the channel comes into contact with the bladder.
By filling the bladder check the normal degree of urinary retention.
The side parts of the loop are removed.
The incision above the vagina is sutured.
A catheter is placed in the bladder.
A tampon is placed in the vagina.
As a rule, complications after the surgery are extremely rare. Possibly during its carrying out perforation of a bladder. In this case, the damage is sutured, and the catheter is placed for a period of 5 to 10 days. Sometimes in the early postoperative period there is an increase in body temperature and there are minor pains in the incision area.
As for the late postoperative period, it is possible that it will not be possible to fully get rid of urinary incontinence, or urination may be difficult.
Complications of anesthesia are: headaches, nausea. These negative phenomena disappear on their own in 5-7 days.
Anterior colporrhaphy
Anterior colporrhaphy is a surgical intervention that is aimed at eliminating urinary incontinence in women. During the operation, the anterior wall of the vagina is dissected, the bladder and urethra are isolated, then the vagina is sutured again. At the same time, its walls seem to tighten, which allows you to stabilize the urethra and the neck of the bladder. The vagina itself is also strengthened.
This operation is associated with the risk of fibrosis of the tissues of the vagina. In addition, the effect of its implementation can hardly be called stable, and the frequency of unsuccessful outcomes of the intervention is quite high.
Colporrhaphy is not recommended for women who suffer only from stress urinary incontinence, in the absence of other pathologies.
Burch laparoscopic colposuspension
Birch’s colposuspension consists of suspending the tissues that surround the urethra. They are suspended from the inguinal ligaments, which are located on the anterior abdominal wall and are very strong.
Access is obtained through an incision in the abdomen. The operation can be open or closed. The latter is performed using laparoscopic equipment.
For many years, Birch’s colposuspension has been used to treat stress urinary incontinence in women in the vast majority of cases. The effectiveness of this procedure was up to 70-80%.
As for the shortcomings of the technique, among them we can single out: the need for the introduction of general anesthesia, the connection of the patient to a ventilator. In addition, for the procedure to be successful, it had to be carried out by a highly qualified surgeon. It is worth noting that sling surgeries have almost supplanted Birch colposuspension at this point in time, as they are safer and more effective methods for treating urinary incontinence in women.
Implantation of an artificial bladder sphincter
Urinary incontinence negatively affects the quality of life of any person, since its involuntary leakage always causes a lot of inconvenience. From 5 to 10% of the world’s population suffers from various forms of urinary incontinence, and 70% of them are women.
Urinary incontinence may be urgency or neurogenic. In this case, a person has an increased contractility of the bladder, and the mechanism for retaining fluid in it is broken. This may occur due to insufficiency of the sphincter of the bladder.
Separately, stress urinary incontinence is distinguished, which is associated with true sphincter insufficiency. It is classified as the third type of stress urinary incontinence (classification of the International Society for urinary retention).
It is known that no more than 50% of people seek qualified medical help about their problem. Often this is due to a false sense of shame, or because of the wrong belief about the impossibility of therapy. As a rule, from the moment when a person first experienced urinary incontinence and before his visit to a specialist, an average of 5 years pass. Meanwhile, modern medicine has effective methods of treating incontinence and is able to help almost every person with this problem.
Urge incontinence is most commonly treated with medication, but type XNUMX stress incontinence always requires surgery. One of the leading methods of surgical intervention is the implantation of an artificial bladder sphincter.
What is an artificial bladder sphincter? An artificial sphincter is a prosthesis that is implanted into the human body. It is necessary to retain urine in the case when its own sphincter does not cope with this task.
When and why was it created? The first prototype of a modern device was developed back in 47 of the last century by the scientist and urologist FB Foley. It looked like a cuff, which was placed around the human urethra. This cuff was connected to a syringe pump, which was stored in an underwear pocket. The idea was very innovative and correct from a medical point of view. However, the level of surgery of that time did not allow the implant to be completely removed from the human body, so its installation was often complicated by purulent processes.
In 72 of the last century, the device was improved by the urologist FB Scott. It was this American doctor who created the prototype of the modern artificial sphincter. It consisted of three elements: a cuff that wrapped around and squeezed the urethra, two pumps that inflated and deflated it, and a reservoir to collect fluid. The success of surgery to install the first three-component sphincter in those days reached 60%.
Later, the device was improved by the American Medical System, which happened back in 83. So far, doctors have successfully used artificial AMS sphincters, which have undergone only minor improvements.
Operation efficiency. The success of the installation of a modern artificial bladder sphincter is equal to 75%. Moreover, 90% of people who use these devices are absolutely satisfied with their work. In no more than 20% of cases, a second operation is required, which is carried out in order to eliminate the shortcomings in the operation of the device.
Indications and contraindications. Indications for the installation of an artificial bladder sphincter vary. An absolute indication is an irreversible disturbance in the work of one’s own sphincter, against the background of the normal functioning of the bladder. In this case, the patient should not have a urinary tract infection, and urethral obstruction.
In men and women, there are various indications for the operation, which are presented in the table.
Men | Women |
If urinary incontinence develops against the background of a radical prostatectomy due to prostate cancer. After transvesical adenectomy or retropubic prostatectomy, intraurethral resection of the prostate due to benign prostatic hyperplasia. | Urinary incontinence of a neurogenic nature against the background of trauma, disease of the brain or spinal cord, myelomeningocele, sacral genesis, peripheral neuropathy. |
Postponed trauma of the pelvis, reconstruction of the stricture of the urethra, carried out by surgery. | Stress urinary incontinence of the third type, which could not be eliminated with less invasive procedures. |
Malformations of the neck of the urethra and the bladder of a congenital nature. |
|
Neurogenic dysfunction of the sphincter of the bladder on the background of a brain injury or due to congenital malformations. |
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Absolute contraindications to the operation are:
Stricture disease of the urethra.
Stricture recurrence.
Urinary tract infections.
Diverticula of the urethra.
An unstable or overactive bladder.
Shriveled bladder.
Low bladder volume.
Relative contraindications include:
Vesicoureteral reflux of the second stage and above.
Urolithiasis, bladder cancer and other conditions that require surgical treatment.
Bladder neck stenosis, its contracture.
If it is possible to eliminate relative contraindications, then the installation of an artificial sphincter becomes possible. It is important that a person has the necessary mental and physical abilities that would allow him to control the operation of the pump. Before the operation, a detailed consultation with a doctor about all the nuances of working with the sphincter is required.
What tests should be done before the bladder sphincter implant surgery? First, the patient discusses with the doctor all the nuances of the upcoming intervention. Secondly, he undergoes a physical examination, which is aimed at identifying indications and contraindications for surgery.
It is mandatory to pass a general urinalysis, urine culture, blood tests, and possibly an ECG.
In some cases, cystography, urethrography, ureteroscopy, cystoscopy and other highly specialized tests are required. The better the patient is examined, the higher the chance that the operation will be successful.
Operation progress. The operation can be performed through the angle of the penis and scrotum (penoscrotal approach), or through a perineal incision (performed under the scrotum). If the access is penoscrotal, then one incision is enough to install the implant. If the access is perineal, then an additional incision is required to install the reservoir. The patient in this case spends in the hospital from 1 to 3 days. The urethral catheter will be removed the next day after the operation.
Activate the sphincter after its installation after 6 weeks. This time is necessary for it to take root. Under the supervision of a urologist, a person is trained to work with the device. Further visits to the doctor will be required once a year.
Periurethral injections of bulking agents
Periurethral injections are carried out by introducing various biological and synthetic preparations into the space around the urethra. As a result, an additional external sphincter is created, as it were, which narrows the urinary canal and prevents urine from flowing out. This procedure is the least traumatic for the patient.
The indication for injection is insufficiency of the sphincter. The procedure is carried out under local anesthesia. Most often, it is prescribed to those women who refuse surgery with more invasive methods.
The main disadvantage of the procedure is the recurrence of urinary incontinence, which occurs after 1-2 years. After the introduction of the substance at the injection site, there is a noticeable soreness. In addition, urinary retention and disturbances in the emptying of the bladder are possible.
The European Association of Urology recognizes periurethral injections as an effective method for eliminating urinary incontinence in women, but experts note the temporary effect of the procedure. In some cases, it can last no more than 3 months. Therefore, the injection will need to be administered again. Sling surgery is more effective than this method of treatment.
Cost of operation
Some operations may be carried out under government quotas. To receive them, you need to apply and wait in line.
The following are subject to quotas:
Sling operations.
Abdominal and laparoscopic operations.
Installation of sphincter prostheses for men (it is possible that you will have to pay for the prosthesis yourself).
If a person does not want to wait in line, then he can go to a private clinic and pay for the procedure he needs on his own.
Installing a sling costs an average of 80-000 rubles. If the last generation sling is used for the operation, then the price may increase several times.
Vaginoplasty costs women 50-000 rubles.
Colposuspension using the laparoscopic method costs about 150 rubles.
Bladder sphincter implantation can cost about 500 rubles.
Reviews
Although the problem of urinary incontinence is quite common, many people hesitate to seek help from a specialist. This is especially true for older women. They use gaskets, but they stubbornly refuse to raise this topic. This affects socialization and self-esteem of a person not in the best way.
All patients who underwent surgery to eliminate urinary incontinence note a significant improvement in their quality of life in their reviews. They are almost unanimous in their opinion that it is better to survive a few months of rehabilitation than to continue to suffer from an existing problem for the rest of your life.
It is important to understand that the sooner the patient turns to the urologist with his problem, the easier it is to cure him. Therefore, do not hesitate to talk about urinary incontinence with a specialist.