Guideline on Surgical Management of Stress Urinary Incontinence
“This Guideline advises physicians to counsel their patients and set expectations prior to undergoing treatment,” AUA Guideline Panel Chair Roger Dmochowski, MD, said in a news release. “This is very important because often the patient thinks that surgery will completely cure their incontinence, when in reality, it may only make modest improvements.”
The new recommendations update the previous 1997 AUA guideline discussing surgery to treat SUI, based on articles retrieved for the previous guideline and those resulting from 4 MEDLINE searches beginning in December 2002 and ending in June 2005. There were 436 articles included in the meta-analysis and 155 articles considered to be suitable only for their complications data because follow-up duration was insufficient for efficacy outcomes analysis.
When considering surgery to treat female SUI, clinicians should perform a complete evaluation, including measurement of postvoid residual volume.
The updated guidelines also recommend counseling patients regarding the benefits and risks of both surgical and nonsurgical options for SUI. Potential treatment choices may include injectable agents, laparoscopic and retropubic suspension procedures, and midurethral and pubovaginal slings. The surgeon and patient should collaborate on formulating the treatment plan, considering the patient’s preferences as well as the surgeon’s judgment and expertise. The updated guideline also highlights issues involved in surgical correction of pelvic prolapse at the same time as SUI surgery.
Determining postvoid residual urine volume is a key feature of complete assessment of the patient with SUI. Surgical techniques should be tailored to specific patient needs based on detrusor contractility, urinary retention, or other comorbitities.
Other important features of the diagnostic workup of SUI are focused history, physical examination, looking for evidence of leakage with increasing abdominal pressure, urinalysis, and cultures. In some patients, urinary tract imaging, voiding diaries, cystoscopy, and urodynamics may also be indicated. Further testing to confirm the diagnosis of SUI may also be helpful in patients with known or suspected neurogenic bladder, concurrent symptoms of overactive bladder, excessive residual volume, dysfunctional voiding, or history of previous lower urinary tract surgery.
An important caveat is that patients who have urge incontinence in the absence of SUI should not be offered a surgical procedure for SUI. However, surgery may be helpful in patients who have mixed incontinence, involving urge incontinence and a significant stress component.
For long-term success measured in cure/dry rates, retropubic suspensions are still thought to be one of the most effective options, even though they have been largely supplanted by sling procedures. Patients should be counseled preoperatively regarding the slightly higher complication rates associated with retropubic suspensions, such as postoperative voiding dysfunction and longer postoperative recovery. These recommendations have not changed since the 1997 guideline.
For patients declining invasive surgery, collagen and other nondegradable synthetic injectable agents may be considered. However, efficacy and duration of treatment response seen with injectable agents are inferior to those achieved with surgery.
The updated guidelines recommend that artificial urinary sphincters be used only in patients with nonfunctioning urethras; for example, those with spina bifida, men with postprostatectomy incontinence, and patients with pelvic nerve trauma. Patients with severe intrinsic sphincteric deficiency who have failed other surgical procedures may benefit from the use of artificial urinary sphincters.
Synthetic slings should not be used in patients with SUI who have a concurrent urethrovaginal fistula, urethral erosion, intraoperative urethral injury, and/or urethral diverticulum, because use of synthetic material in these patients may increase risk for adverse effects. The guidelines panel suggests that use of autologous fascial and alternative biologic slings may be considered in these patients, but notes that data are severely limited regarding the use of cadaveric slings.
Specific guidelines recommendations for sling surgery are as follows:
- Patients should be instructed about the benefits and risks of both biological and synthetic sling materials. In particular, the US Food and Drug Administration recently issued an alert regarding surgical mesh.
- Before the conclusion of sling surgery, the bladder and urethra must be inspected with either a rigid or flexible cystoscope to identify potential intraoperative complications.
- When prolapse repair is performed at the same time as SUI surgery, the prolapse surgery should be fully completed before the sling is tensioned.
“The profession at large and the individual physician should insure the safety and efficacy of any new device or sling,” the guidelines authors conclude. “If safety and efficacy has not been shown with reasonable certainty, the new treatment should only be performed as part of clinical research studies and/or with informed consent recognizing that safety and/or efficacy has not been demonstrated.”
In collaboration with the American College of Obstetricians and Gynecologists, the AUA is developing physician performance measures reflecting all changes made in the 2009 SUI Guideline update. These measures, which will eventually be submitted to the National Quality Forum for endorsement, are being developed under the independent measure development process of the American Medical Association’s Physician Consortium for Performance Improvement.
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quite interesting…love it