Stress Incontinence Surgery Options For Female Stress Incontinence

There has recently been a lot of debate about the safety and durability of TVT mesh slings, widely used to treat women with stress incontinence.

We have are one of a small number of specialist centres with particular expertise in the pubovaginal sling with autograft. This means creating a sling using your own tissue (taken from your stomach area), rather than using synthetic TVT tape, which has a high complications rate.

The pubovaginal sling, using your own tissue, is a more complex procedure for the surgeon to undertake, but offers better durability which means it is more likely to work effectively and less likely to break down and cause serious complications.

There are several good, safe surgical treatments for female stress incontinence. We explain what they are and how they work in more detail below.

Urethral bulking agents

What does it involve and how do they work?

Under local anaesthetic, special bulking agents are injected into the urethral wall. By ‘bulking’ the tissue in this way, it helps the surrounding muscles to work better and more effectively control the flow of urine. We use the newer bulking agents which are much more durable and long-lasting than earlier treatments.

Advantages and disadvantages

This is the most minimally invasive of all the options and there is no need for a general anaesthetic. However, it is not a long term solution, with about 50 per cent still effective two years after the procedure. Nevertheless, urethral bulking agents can be a good solution for some women:

• For women who may want to have another child in the future.
• For older women who may not tolerate a more invasive approach.

Pubovaginal sling (with autograft)

What does it involve and how do they work?

This is based on the same principle as the vaginal sling using TVT tape, but with two key differences:

• The material which constitutes the sling is the patient’s own (usually a length of fascia taken from the stomach area).
• The sling is inserted via the abdomen and is a larger incision than the small one used for mid-urethral TVT tape. However, our approach is a minimally invasive one and therefore the incision used and subsequent recovery times are very much improved compared to traditional autograft sling surgery.

Advantages and disadvantages

Up until recently, the mid-urethral TVT was considered the gold standard procedure, offering a minimally invasive and effective option. However, concerns about the mesh becoming dislodged are important to consider. This has caused a great deal of pain for many women, often resulting in a need for corrective procedures. In Scotland, surgeons have been told to stop using mid-urethral TVT tape while further investigations are carried out.

There is no similar ban in England, but at BPC, our expertise is in the autologous pubovaginal skin (made from your own tissue) and we would continue to recommend that option over TVT tape. Our approach is highly personalised – we can provide all the different treatments for stress incontinence; many good options are available and the key is selecting the right treatment for each individual patient.

Traditionally, patients were told that a TVT offered a very short post-operative recovery time and an autologous sling would be more invasive. However because we use a minimally invasive to the autologous sling, recovery times are often exactly the same as for TVT. In many cases, after an autologous sling is implanted, the patient may go home on the same day or day after. There may be a little soreness in the area of the abdomen from which tissue was taken, but this is normally manageable and quickly passes.

Bladder neck suspension by colposuspension

What does it involve and how do they work?

The entrance of the bladder (or bladder neck) is lifted, so that it is better supported and able to stop urine from leaking under pressure. The top of the vagina is lifted and fixed with permanent stitches into the space behind your pubic bone. The stitches are attached to the cartilage behind the pubic bone, forming a cradle to support your bladder neck. The operation can be undertaken as laparoscopic, or keyhole surgery, with the surgeon working through two or three small cuts in your lower abdomen.

Advantages and disadvantages

Colposuspension involves a longer time in surgery and subsequent recovery. The operation takes one to two hours and you will stay in hospital for three to five days after surgery. Bleeding is minimal and compares with a light period. You will probably have a catheter to pass urine for up to 48 hours after the operation.

Because it is a more invasive approach than the sling procedures, colposuspension is considered if other approaches have not worked, or your condition is at the severe end of the spectrum. However, this is a very effective procedure, with reports showing long term cure rates of 85-90 per cent. The introduction of minimally-invasive keyhole techniques has reduced the recovery time following the procedure.

For women with the most severe degree of stress incontinence, or previous failures of mid-urethral slings, the following approach is normally recommended:

Artificial urinary sphincter

What does it involve and how do they work?

The artificial urinary sphincter (AUS) is a small device implanted under the skin that keeps pressure on the urethra until there is a decision to urinate, at which point a pump allows the urethra to open and so that the patient can pass urine.

Advantages and disadvantages

The AUS is only considered if you have tried other approaches and they have not been effective for you. The effectiveness and durability of the AUS is good, but it does require substantial lifestyle modifications. However, patients who have been living with severe incontinence and have struggled to find effective solutions often report the impact of having an AUS device is worthwhile, compared with their previous symptoms.

More information

Click here for more information about our TVT mesh removal treatment.