"Long-Term results of colpocystourethropexy for persistent
or recurrent stress urinary incontinence".
NITAHARA, K.S.; ABOSEIF, S.; TANAGHO, E.A.
Department of Urology, University of California
Scholl of Medicine and Mount Zion Medical Center, San Francisco, California.
J.Urol, v.62, p.138-141, 1999.
Purpose: We review the long-term
outcome of colpocystourethropexy for persistent or recurrent stress urinary
incontinence after suspension procedure failure.
Materials and Methods: Medical records
and preoperative were reviewed of 60 patients (mean age 60.8 years) who
had undergone colpocystourethropexy after at least 1 suspension procedure
(range 1 to 8, mean 2.7). Patient responses to a standardized questionnaire
regarding overall health, degree of satisfaction with colpocystourethropexy,
presence or absence of leakage, and pattern and degree of leakage were
elicited by telephone or mail and compared with preoperative status. Results
were graded according to the degree of satisfaction and number of pads
used daily. Patients with persistent incontinence were reevaluated with
video urodynamic studies.
Results: Mean interval since colpocystourethropexy
was 6.9 years. Successful results (greater than 80% satisfaction and the
use of 1 or no pad daily) were reported by 41 patients (69%), who were
signicantly younger at the time of surgery than those with unsatisfactory
results. In the latter group significant urge incontinence was present
in 61% before the repair and in 63% postoperatively, suggesting na additional
nonanatomical cause, which was confirmed by postoperative video urodynamic
Conclusions: When colpocystourethropexy
was used for persistent urinary incontinence after previous surgical repair
two-thirds of the patients had excellent long-term results. In patients
with less satisfactory results a nonanatomical cause of urinary incontinence
was a major factor.
The authors discuss the surgical results of 60 patients
that were submitted to colpocystourethropexy by the technique described
and which consists in a Burch2
Technique modification 2. In this technique the author uses two pairs of
Dixon stitches No 1 which are given in the whole width of the anterior
vaginal wall and the Cooper ligament. The most distal point is found in
the medium urethra region and the most proximal point at the level of the
bladder neck. In the original description the author emphasizes the need
that the suture is situated very laterally to the urethrovesicle structures
to avoid the compression of the urethra against the Symphysis pubis.
We must emphasize that these were patients that
had already been submitted to earlier attempts of surgery for stress Urinary
Incontinence (SUI), so constituting an unfavorable group as to the expectation
of incontinent cure.
Of the 60 patients, 41 (69%) considered themselves
satisfied with the result of the surgery. Meanwhile, among those 41 patients
the authors also included patients that needed to use at least one pad
a day (there is no reference to the number of cases) which means that some
still presented a certain degree of Urinary Incontinence.
This is an important aspect in the evaluation of
the results of the treatment of SUI, this means, a clear definition of
the cure criteria. If we consider the absence of Urinary loss a cure criteria,
we would have to alter the 69% percentage of good results admitted by the
authors to less favorable values.
Another important aspect to be considered is surgical
treatment of SUI relapse is the technique choice to be indicated in each
case. In a last analysis we try to establish a propaedeutic protocol, the
most complete possible, to try to identify with precision which is the
residual anatomic defect which must be corrected. The non attendance of
this condition will certainly enlarge the percentile of failures in the
The authors report the most frequent cases that
lead to corrective surgery failures of SUI 1. In some cases the urethrovesicle
follow up is poorly or inappropriately, supported allowing that the initial
anatomical defect persist; 2) in other cases the urethrovesicle follow
up is initially well supported but yields again and becomes excessively
changeable; 3) Fibrosis and abnormal fixation of the urethra with persistence
or a new appearance of detrusor instability and lesion of the intrinsic
musculature of the sphincter.
In the cases where there is an abnormal fixation
of the urethra with a sphincterian musculature lesion leading to the opening
of the bladder neck the only adequate correction, in the opinion of the
authors, is the creation of a compression by a sling and an auto intermittent
catheterization. Meanwhile if the sphincterian musculature is working badly
due to fibrosis and the abnormal fixation of the urethra it would be a
possible solution to remove the fibrosis and the adequate mobilization
of the urethra with a correct repositioning of the urethrovesicle connection.
In these cases the retropubic approach would have na advantage over the
transvaginal, allowing an ample dissection of the anterior vagina wall
and exposing an inferior portion of the bladder and urethrovesicle connection,
making possible and adequate setting of the sutures to obtain correct positioning
of these structures. Another frequent problem in the postoperative of these
patients is the persistence or new appearance of urgency or Incontinence
The authors refer 16% of these cases mainly in patients
that had already presented these post operative symptoms. In literature
the amount varies between 6 and 27%. Those cases demand a careful urodynamic
evaluation in the pre operative, even though the physiopathology of those
symptoms have not been perfectly made clear. They may be caused by anatomical
enervation, disturbance of the bladder or by obstructive processes of the
urethra resulting from surgical techniques that were used.
A more profound consideration about this article
permits the verification that the frequency of failures in SUI surgeries
reveals numbers that are not low, putting into evidence the complexity
of this pathology and the difficulty in identifying the main causes of
Urinary incontinence in women. This reinforces the conviction that there
is a need to establish a rigorous propaedeutic protocol, using new technologies
to try to identify, in each case, which is the anatomical defect that must
be corrected and from this evidence indicate the most adequate surgical
technique to treat the respective case.
José Carlos Souza Trindade
1. Tanagho, E.A.:
Colpocystouretropexy; the way we do it. J Urol, 116:751-53, 1976.
2. Burch, J.: Urethrovaginal
fixation to Cooper’s ligament for correction of stress incontinence and
prolapse. AM. J. Obstet Gynecol 81:281-290, 1961.