Robotic-Assisted Surgery: Incontinence Surgery

For those that do not respond to conservative treatment such as Kegel exercises and suffer urinary incontinence, surgical procedures offer a permanent solution. There are surgical options for both stress (involuntary secretion) and urge (overactive bladder) incontinence, but no surgery treats both simultaneously. It should be noted that urinary incontinence surgery is best to be had after pregnancy.

These procedures will be done laparoscopically with a single incision, which is minimally invasive and an optimal means of operating inside the patient with minimum scarring. Although especially uncommon with laparoscopy, there are possible side-effects of urinary incontinence surgery, which may include: temporary urination difficulty (urinary retention), urinary tract infection, and painful intercourse. Consultation with a healthcare provider will allow for more detailed risks and benefits of the surgery.

  • Conventional mini sling: Support in the form of a sling is created under the urethra or bladder neck (the section of muscle that connects the bladder to the urethra) with the patient’s tissue or in some cases synthetic mesh tape or donor tissue. Tension is applied to the sling and fixed to the abdominal wall or pelvic tissue using sutures. This reduces strain on the urethra and assists it in staying closed when necessary to avoid leaking urine. The recovery process may require a possible stay overnight in hospital and the subsequent time of recovery may extend beyond three to five weeks. A temporary catheter may be required post-surgery during healing time. Sexual activity may resume after approximately seven weeks.
  • Tension-free mini sling: Exactly the same as the conventional sling procedure above, however no suturing is required and only synthetic mesh tape is used. The mesh is held in place with body tissue and eventually the body will form scar tissue around the area to completely secure the tension-free sling. Recovery time ranges from two to four weeks before the patient can return to work and intense activities such as heavy lifting and exercise. Sexual activity may be resumed after six weeks. Although synthetic mesh tape can be effective and safe, there is a small chance for the material to erode and become infected due to its artificial nature.
  • Laparoscopic bladder neck suspension: This procedure reinforces the urethra and prevents it from sagging, creating support to compress against, which prevents leakage. A keyhole incision is made in the patient’s navel and adjacent bladder neck tissue is sutured to either the ligament near the pubic bone or the pubic bone cartilage; the two suturing sites are classified as the Burch procedure and Marshall-Marchetti-Krantz procedure respectively. The bladder neck suspension procedure is recommended if the patient is undergoing abdominal surgery simultaneously such as pelvic organ prolapse repair.
  • Nerve stimulation: Sacral and tibial nerve stimulation can be performed. Sacral stimulation involves implanting an electrode-tipped wire beneath the skin near the buttock and externally wearing a pacemaker-esque device that stimulates the sacral nerve, which counteracts the signals sent by an overactive bladder to the brain. If this procedure is successful, the patient can opt in to have the pacemaker implanted with the wire. Percutaneous tibial nerve stimulation does not involve surgery and instead involves inserting a needle in the ankle area to reach the tibial nerve and stimulate it electrically, sending messages to the nerves that control the bladder. This procedure is repeated weekly for up to 12 weeks.
  • Urge incontinence can be treated without the need for surgery:
    • Pelvic floor exercises and magnetic chair: strengthens the pelvic floor muscles and simultaneously the bladder
    • Reduce acidic sustenance e.g. orange juice and tomato juice
    • Increase magnesium intake
    • Send a urine test to a lab to exclude urinary infection
    • Bladder drilling: practice holding the bladder and not going to the toilet
    • Use oestrogen cream if directed by doctor
    • Botox in the bladder wall, no surgery required

Laparoscopic/Vaginal Pelvic Floor Repair

The pelvic floor, also known as the pelvic diagram, is a muscular partition that supports the pelvic organs, such as the uterus, bladder, and intestines. It is necessary in maintaining optimal pressure within the abdomen and ensuring a safe birth-passage during conception.

Damage to the pelvic floor can occur during pregnancy or delivery, and possibly as a consequence of a hysterectomy. Other causes of damage to the pelvic floor are also pelvic surgery between the coccyx and anus (the perineal approach), and the removal of the coccyx (coccygectomy). Amongst female high-level athletes, perineal trauma is rare and only certain sports such as bicycle racing, water-skiing, and equestrian sports are associated with it.

A repercussion of pelvic floor damage is not only urinary incontinence, but pelvic organ prolapse, which is when the pelvic organs displace into or outside of the vagina. Physical factors that contribute to pelvic organ prolapse include asymmetries caused by physical damage to the pelvis and disproportionate, excessive, or insufficient muscle tone. Other factors such as age, hormonal status, pregnancy, and family history can all contribute to developing pelvic organ prolapse.

Kegel exercises may be performed to strengthen pelvic floor muscles and their function, however surgery may be necessary to repair significant damage to the pelvic floor.

Specific methods aside, the general technique used for laparoscopic surgery to treat pelvic organ prolapse is as follows:

Preparation for the surgery is undertaken, which involves shaving the area of operation, an enema, and a fasting of six hours. General anaesthetic is applied, the laparoscope and assistive instruments are inserted, and the appropriate areas (uterus, pelvic structures) are checked and visualised. The vagina and bowel are separated and a column support is created with a series of sutures in the ligaments and back wall of the vagina. If necessary, the lateral pelvic muscles are sutured by opening the side areas of the vagina. To amend severe tissue damage, native tissue (from the patient), animal tissue, or animal-augmented tissue may be used to strengthen the pelvic floor. Synthetic mesh is an option, too, but must be considered carefully due to possible side-effects such as mesh erosion and rejection. Often a bladder neck suspension is performed before the wounds are sealed appropriately.

There are several forms of pelvic organ prolapse and the techniques of laparoscopic surgery varies depending on the type of prolapse and location:

Vault prolapse:

Found at the top of the vagina and repaired using Laparoscopy.

  • Sacrospinous fixation surgery: the vagina is attached to the tailbone and possibly supported by synthetic mesh.

Alternatively vault suspensions may be performed.

Rectocoele:

Found in the rectum through the back wall of the vagina and repaired using Laparoscopy.

  • Connective tissue between the vagina and rectum are secured to reduce the bulge size, and excess tissue is removed.

Urethrocoele:

Found in the urethra at the lower front wall of the vagina and repaired using Laparoscopy with bladder neck suspension.

Cystocele:

Found in the bladder through the front all of the vagina and repaired using Laparoscopy.

  • The bladder is moved upwards and secured by connective tissue, which is fixed in place. Excess tissue is removed. If urinary incontinence is present, bladder neck suspension is recommended to support the urethra.

Laparoscopic Hysteropexy:

A resuspension of the prolapsed uterus, anteriorly and posteriorly, using a strip of synthetic mesh to lift the uterus and hold it in place. One end of the mesh is attached to the cervix and the other to a bone (sacrum or sacral bone) near the spine. The mesh is inserted laparoscopically to avoid any transvaginal complications. Most Gynaecologists offer hysterectomy when the uterus is prolapsed, but it is a difficult decision for many women who wish to preserve fertility and indeed women who have completed their families still wish to preserve their uterus. Laparoscopic resuspension and preservation of the uterus as an alternative to hysterectomy is not widely available. The theoretical advantages of this operation over hysterectomy, as well as preservation of fertility, are a stronger repair with less risk of recurrent prolapse. Cuts to the vagina itself are also avoided so it is likely there is less risk of subsequent sexual problems.

Laparoscopic Sacrocolpopexy:

Is a procedure to correct prolapse of the vaginal vault (top of the vagina) in women who have had a previous hysterectomy. The operation is designed to restore the vagina to its normal position and function. Sacrocolpopexy is performed as a keyhole procedure (using a laparoscope or with a surgical robot), under general anaesthesia. A graft made of permanent synthetic mesh is used to cover the front and the back surfaces of the vagina. The mesh is then attached to the sacrum. The mesh is then covered by a layer of tissue called the peritoneum that lines the abdominal cavity; this prevents the bowel from getting stuck to the mesh. Sacrocolpopexy can be performed at the same time as surgery for incontinence or vaginal repair for bladder or bowel prolapse. How successful is this surgery? This is the gold standard procedure performed over decades. Studies show that 80 to 90% of women having sacrocolpopexy are cured of their prolapse and prolapse symptoms by 5 years.

Recovery time is relatively short. Post-surgery recovery requires several days in hospital. A catheter will be required and general pain-killers such as paracetamol are optional. Patients are often in a light working condition within six weeks but can take up to 3 months. Heavy lifting should be avoided, as it can cause damage.