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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 1996  |  Volume : 7  |  Issue : 4  |  Page : 387-390
Endoscopic Suspension of Bladder Neck for Treatment of Female Stress Urinary Incontinence


1 Department of Gynecology, King Hussein Medical Center, Amman, Jordan
2 Department of Urology, King Hussein Medical Center, Amman, Jordan

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   Abstract 

Between the years 1984 and 1993, a total of 72 female patients underwent endoscopic suspension of bladder neck for treatment of stress urinary incontinence at the King Hussein Medical Center and Hamad General Hospital, Amman, Jordan. The age of the study patients ranged between 32 and 75 years (mean: 46.5 years). Fifteen (20.8%) had history of previous operations for incontinence. The overall success rate achieved was 93.1%. Post­operative complications were encountered in seven (9.8%) patients within follow-up period of 4 to 43 months. Treatment failure occurred in five patients (6.9%). Our experience further confirms that endoscopic suspension of the bladder neck is a simple and reliable procedure in the treatment of female stress urinary incontinence.

Keywords: Endoscopic suspension, Bladder neck, Female, Stress urinary incontinence.

How to cite this article:
Al-Tayyeb G, Al-Jader K, Al-Ajlouni S, Budair Z, Musa F, Al-Kadi H. Endoscopic Suspension of Bladder Neck for Treatment of Female Stress Urinary Incontinence. Saudi J Kidney Dis Transpl 1996;7:387-90

How to cite this URL:
Al-Tayyeb G, Al-Jader K, Al-Ajlouni S, Budair Z, Musa F, Al-Kadi H. Endoscopic Suspension of Bladder Neck for Treatment of Female Stress Urinary Incontinence. Saudi J Kidney Dis Transpl [serial online] 1996 [cited 2020 Aug 9];7:387-90. Available from: http://www.sjkdt.org/text.asp?1996/7/4/387/39409

   Introduction Top


Stress urinary incontinence constitutes almost 75% of all cases of female urinary incontinence [1] . It is generally caused by a change in the position of the bladder neck and surgical intervention is needed to restore the vesicourethral anatomy. Various procedures including anterior colporrhaphy [2] , suprapubic vesicourethral suspension [3] , combined urethrovesical suspension and vaginourethroplasty [4] , pubovaginal slings [5] and endoscopic bladder neck suspension [6] have all been reported as being successful in the treatment of female stress incontinence. Our preference has been the use of endoscopic bladder suspension (Stamey procedure) because of its high success rate, ease of performance, patient satisfaction and short hopital stay [7],[8],[9] . In this report, we review our experience with this technique and compare our results with those available in literature.


   Materials and Methods Top


Between March 1984 and March 1993, 72 female patients underwent endoscopic bladder neck suspension for the treatment of stress urinary incontinence at the King Hussein Medical Center and Hamad General Hospital, Amman, Jordan. The age of the patients ranged between 32 and 75 years with a mean of 46.5 years. The duration of urinary incontinence ranged between 1 and 20 years with a mean of six years. Of the study patients, 15 had previous attempts at surgical repair of whom 12 had one operation (9 vaginal repair and 3 endoscopic suspension), while a history of more than one repair was obtained in three patients (two patients had vaginal and abdominal repair, once each, and one had three attempts at vaginal repair). A history of .2 to 11 deliveries was available in the study patients with a mean of 6.6 deliveries. All patients underwent full clinical examination, Bonney test, urine microscopic examination and culture and sensitivity, intravenous pyelography and ascending urethrocystography. Urodynamic study, in addition, was performed in 37 patients.


   Technique Top


In all cases, classical Stamey procedure was used. Antibiotics were given 24 hours before surgery. Under general anesthesia, the patient was put in dorsal lithotomy position and cystoscopy was performed to evaluate the bladder. A Foley's catheter was inserted into the bladder, balloon was inflated and the catheter pulled slightly to ensure that the balloon was at the bladder neck. A clamp was placed over the catheter, flush with the external urethral orifice, following which the catheter was removed and the urethral length measured (between the base of the balloon and the clamp). The pre-operative length of the urethra ranged between 0.8 and 3.0 cms. The catheter was then re-inserted, and the balloon was used as a marker for the urethrovesical junction. A T-shaped incision was made on the anterior vaginal wall after injection of 5-10 ml of saline to facilitate tissue disection. The vaginal mucosa was subject to blunt disection till the catheter balloon placed at the urethrovesical junction could be palpated with a finger passed through the vaginal incision. A one cm stab wound was made one cm above the pubic bone on each side and dissected bluntly down to the rectus sheath. The Stamey needle was introduced at the medial and then at the lateral edge of each stab wound and directed into the periurethral tissues at the urethrovesical junction under guidance of the finger in the vaginal wound. Following this, No. 2 polypropylene sutures were placed on either side. The cystoscope was then re­inserted and both sutures were tightened under cytoscopic guidance reducing the bladder neck diameter by 60 to 70%. A suprapubic catheter was inserted and a vaginal pack left for 24 hours. Copious irrigation of the vaginal wound with gentamycin solution was done several times during procedure. A buried silicon buttress was used in 28 cases while in the remaining, only simple sutures were used. In all patients, the suprapubic tube was clamped on the second post-operative day and residual urine measured after each micturition. Once residual urine was less than 100 ml, the tube was removed and the patient discharged. The hospital stay of the study patients ranged between 4 and 10 days (mean, 5.9 days).


   Results Top


The grading of stress urinary incontinence in the study patients is given in [Table - 1]. The majority of cases (50%) were scaled as grade 1 stress incontinence. All patients were followed-up for a period of 4 to 43 months after surgery. We used Stameys definition of cure, that is absence of urinary incontinence for six months post-operatively. Our success rate was 93.1% (67 patients). In the remaining five cases, four were considered treatment failures (incontinence recurring within six months) while one patient had relapse (incontinence in the eleventh month post­operative) [Table - 2].

Post-operative complications were encountered in seven patients (9.8%) [Table - 3]. Urinary retention was seen in three patients in two of whom, the suprapubic catheter was kept in place for 3 and 4 weeks respectively before they were able to void with residual urine of less than 100 ml. In the third case, one of the sutures was removed and the patient was able to void freely without losing continence. One patient developed urinary tract infection which was treated with antibiotics for 14 days following which she recovered. One patient complained of voiding difficulty; urethral dilatation up to 20 F relieved her of the problem. One patient developed pulmonary embolism which was managed medically. Eight months post-op­erative; one patient complained of frequency and dysuria and investigations revealed a bladder stone which was formed around one of the Stamey stitches that was traversing the bladder submucosally and was not noticed during the procedure. The stitch was removed together with the stone. Her urinary continence was not affected by this complication.


   Discussion Top


Endoscopic suspension of the bladder neck has been widely accepted since it was first described by Stamey in 1973 [6] . The success rate reported in literature has ranged between 84% and 95.4% [7],[8],[9] . In our series of 72 cases, we achieved a success rate of 93.1%. The use of endoscopic coi ol prevents inadvertent bladder perforation and permits the direct evaluation of the closure of the bladder neck. The reduced post-operative pain and hospital stay is mainly attributed to the minimal dissection involved in this procedure. Many modifications have been added to the original procedure including the use of double prong needle, no dissection of the vaginal mucosa [10] , a silicon buttress with a metallic clip as well as flexible urethroscopy for urethropexy [11] . Such modifications, although simplifying the procedure and shortening the operative time, have not improved the success rate. Netto, et al reported that the use of double prong needle did not shorten the operative time significantly and the function was felt to be not as secure as with the single needle [9] . The so called "no incision technique" [10] which avoids vaginal incision is reported to have a significant failure rate mainly because of migration of the vaginal end of the suture [12] . We have used the classical Stamey method in all of our 72 cases with a success rate of 93.1% which matches well with reported figures. Thus, it seems that although a higher cure rate is obtained with the classical endoscopic technique than in modified one, the complication rate was lower in the latter method [9] .

The aim of Stamey procedure is to elevate the bladder neck to the intra-abdominal zone of pressure, ensure support to the bladder neck as well as increase the urethral outflow resistance without causing obstruction. The increase in the length of the urethra achieved following surgery is again one of the operative goals and a good indication of operative success. In our study, the urethral length pre­operatively ranged between 0.8 and 3 cm while post-operatively it ranged between 2.5 and 4.2 cm, thus causing a more than 75% increase. Analysis of the five cases of treatment failure in our study failed to offer any clear explanation to account for the failure.

In conclusion, our experience further confirms that classic Stamey endoscopic bladder neck suspension is an efficient procedure for the management of stress incontinence in females.

 
   References Top

1.Gaum L, Ricciotti NA, Fair WR. Endoscopic bladder neck suspension for stress urinary incontinence. J Urol 1984;132:1119-21.  Back to cited text no. 1  [PUBMED]  
2.Kelly HA, Dumm WM. Urinary incontinence in women without manifest injury to the bladder are port of cases. Surg., Obst 1914;18:444.  Back to cited text no. 2    
3.Marshall VF, Marchetti AA, Krantz KE. Thecorrection of stress incontinence by simple vesi-courethral suspension. Surg., Gynec &Obst1949;88:590.  Back to cited text no. 3    
4.Raz S. Modified bladder neck suspension for female stress incontinence. Urology 1981;17:82-5.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Mcguire EJ, Lytton B. Pubo vaginal sling procedure for stress incontinence. J Urol 1978;119:82-4.  Back to cited text no. 5  [PUBMED]  
6.Stamey TA. Endoscopic suspension of the vesical neck for urinary incontinence. Surg Gynecol Obstet 1973;136:547-54.  Back to cited text no. 6  [PUBMED]  
7.Stamey TA. Endoscopic suspension of the vesical neck for surgically curable urinary incontinence in the female. Urology 1981;2:56.  Back to cited text no. 7    
8.Mundy AR. A trial comparing the stamey bladder neck suspension procedure with colpo suspension for the treatment of stress incontinence. Br J Urol1983;55:687-90.  Back to cited text no. 8  [PUBMED]  
9.Rodrigues-Netto N Jr, Lemos GC, Palma PC, Fiuza JL. Comparison of the Stamey bladder neck suspension procedure with a modified endoscopic suspension for the treatment of stress urinary incontinence. Eur Urol 1988;15:62-5.  Back to cited text no. 9    
10.Gittes RF, Loughlin KR. No-incision pubo vaginal suspension for stress incontinence. J Urol1987;138:568-70.  Back to cited text no. 10  [PUBMED]  
11.Loughlin KR. The use of the flexible uretroscopein the Stamey urethropexy. J Urol 1989;142:1532.  Back to cited text no. 11  [PUBMED]  
12.Winter CC. Re: Review of an 8 year experience with modifications of endoscopic suspension of the bladder neck from female stress urinary incontinence (letters comment). J Urol1990;144:1481-2.  Back to cited text no. 12  [PUBMED]  

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Correspondence Address:
Hakem Al-Kadi
Department of Urology, King Hussein Medical Center, P.O. Box 73, Dahit Hamza, Marg Al Hammam, Amman
Jordan
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PMID: 18417768

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    Materials and Me...
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