Stress Urinary Incontinence Treatments

Artificial Urinary Sphincter

Cuff placement

  1. Place patient in low lithotomy, ensure far enough down on bed for full perineal access, shave, prep, drape, give vancomycin + gentamicin or alternative, place capped catheter
  2. Optional - cystoscopy prior to ensure no bladder neck contracture
  3. Make midline perineal incision down to bulbospongiosus, place lone star retractor with hooks for retraction (use larger circle inferior)
  4. Divide bulbospongiosus, then free up urethra using sharp dissection, ensure enough length proximal and distal, dissect until able to safely get right-angle clamp around urethra
  5. Bring vessel loop around urethra to maintain access
  6. Measure urethra to assess size, do not overly tighten
  7. Bring right-angle behind urethra from same side as PRB placement, grasp cuff and pull through
  8. Use rubbershod clamps to put cuff together without introducing air

Pressure regulating balloon (PRB) placement

  1. Choose suprapubic location within lateral portion of rectus, make transverse incision and cut down to anterior rectus fascia
  2. Tag fascia with superior and inferior PDS stitches, then make transverse fascial incision between them
  3. Develop submuscular space through this window, then place balloon and inflate with 20mL

Pump placement

  1. Place spongestick through PRB incision aiming inferiorly and laterally down to scrotum, once inside ipsilateral scrotum open and spread to create a space
  2. Bring pump down into scrotum, ensure it does not retract

Connecting and finishing

  1. Develop space through PRB incision down to perineal incision, should be able to palpate small amount of tissue between fingers in both incisions
  2. Use blunt needle passer to pass cuff tubing up to PRB incision site
  3. Once tubing passed, start closing perineal incision - spongiosum, subcutaneous, then skin
  4. Use connecting device to connect tubing together, trim redundant tubing prior if needed
  5. Close PRB incision with subcutaneous and skin stitches
  6. Apply dressing, leave foley x24hr

Retropubic Synthetic Sling

Technique

  1. Place patient in high lithotomy, bed in trendelenburg
  2. Make longitudinal incision at least 1cm proximal to urethra
  3. Using lone star, retract lateral tissue
  4. Dissect down towards urethra
  5. Once deep enough, dissect space lateral to urethra to open potential space
  6. Tip: should be able to feel under pubic tubercle
  7. Make incision 2cm lateral to midline just superior to pubic tubercle
  8. Start with trocar perpendicular to skin, but torque towards head and pass along edge of bone
  9. After popping through fascia, should move smoothly through tissue
  10. Once trocars placed, perform cystoscopy to assess for bladder/urethral injury
  11. Attach sling to trocars and retract sling through skin
  12. Use instrument to create space between sling and urethra
  13. After removing plastic sheath, cut sling at skin and pull up edges to bury sling
  14. Close incision w/ 2-0 monocryl then 4-0 monocryl
  15. Void trial then discharge

Pubovaginal Sling

Fascia lata harvest

  1. Choose side that patient does not sleep on (if she has preference)
  2. Drape in a way to provide access to lateral thigh (usually sticky drapes, can staple extras as needed)
  3. Make 3cm transverse incision over lateral distal thigh, 3-5cm proximal to knee
  4. Expose fascia, make transverse incision using cut, tag corners with prolene, then track proximally to create 2cm x 5-8cm strip
  5. Place penrose drain and stitch in place with nylon
  6. Close subQ with 3-0 vicryl, then close skin with 4-0 nylon sutures (no need to close fascia)
  7. Mark both ends with #1 prolene stitch, mark midline with a pen, place in moistened gauze

Sling placement

  1. Place lone star retractor and vaginal speculum
  2. Make u-flap incision at midurethra (don't go past bladder neck) and create flaps
  3. Create transverse suprapubic incision 1-2cm above pubic symphysis, expose fascia
  4. Expand the periurethral space using sharp/blunt dissection until the posterior pubic bone can be palpated, protect urethra with narrow malleable, should be able to feel fingers connect behind pubic bone with fascia between
  5. Place double-pronged ligature carrier (Raz-Pereyra) from suprapubic to retropubic, aim lateral to avoid bladder/urethra, attach prolene stitches and bring out through suprapubic incision, perform on both sides
  6. Align fascial sling at midline, secure to urethra with 4-0 vicryl x6
  7. Cystoscopy (30 and 70 deg lenses) to confirm no bladder/urethral injury, assess efflux from ureteral orifices
  8. Close vaginal incision with 3-0 vicryl, pack with antibiotic gauze
  9. Rubbershod prolene 2cm above fascia, then tie and release on each side
  10. Close incision with 3-0 vicryl and steristrips

Male sling

Surgical steps

  1. Position patient in dorsal lithotomy, prep/drape perineum and medial thigh crease, give antibiotics (cefazolin +/- gentamicin), place foley for urethral identification
  2. Make midline perineal incision, ensure posterior enough to access central perineal tendon
  3. Identify adductor longus inferior margin, make stab incision 1 fingerbreadth inferior within crease
  4. Divide perineal layers, place lone star retractor, incise bulbospongiosus with metzenbaum scissors
  5. Free urethra (do not need to free dorsal surface), ensure freed from central tendon
  6. Place sling trocar through stab incision with handle at 45deg angle, feel two pops, then drop hand so handle is at 15deg, rotate and try to guide tip into perineal field as high as possible behind pubic bone (should rotate through obturator foramen and pass behind inferior pubic ramus)
  7. Attach sling with blue stripes facing outwards, then guide sling out through incision, repeat on other side
  8. Gently tension sling so it sits on proximal bulbar urethra (do not place on curve or distal urethra)
  9. Stitch corners to urethra with 4-0 vicryl x4
  10. Gently tension sling then cut off plastic sleeves
  11. Optional: bring tonsil clamp from perineal incision under skin out through stab incision, grab sling and pull backwards into perineal incision then trim excess sling
  12. Close bulbospongiosus with 2-0 monocryl, (can place fibrillar/surgicel), close Colles fascia with 2-0 monocryl, then close skin with 4-0 monocryl, place bacitracin and dressing, dermabond stab incisions

Bulking agents

Macroplastique

  1. Find lateral portion of urethra, position needle out and insert into midurethra at 45 degrees
  2. Inject and visualize submucosal wheal, should not see extravasation, should see good coaptation
  3. Repeat on contralateral side
  4. Test of success: red rubber catheter placed in urethra does not fall out spontaneously

Bulkamid

  1. Place bulkamid cystoscope into bladder and exam urethra
  2. Identify point of urethra where needle can be inserted to black line without buttonholing urethra into bladder
  3. Pick a clock point (130, 430, 730, or 1030) and move entire cystoscope to insert needle - move as a unit to keep needle at same submucosal level, torquing scope will drive needle deeper into tissue (not desired)
  4. Inject bulkamid agent, should see coaptation of mucosa
  5. Repeat up to 4x total, should see coaptation completely
  6. Tip: do not place catheter as this will mold the Bulkamid (undesired)

Sacral neuromodulation (Interstim)

Insterstim placement (1-stage)

  1. Position patient prone, use either general anesthesia without paralysis, or with patient awake and local anesthesia