Stress urinary incontinence

Urinary incontinence is one of the most common chronic diseases of women. The multifactorial aetiopathogenesis results in multiple forms of this disease. The most common is stress ur inary incontinence (SUI), which is characterised by urine leakage during an increase in intra-abdominal pressure. Accurate diagnosis of the type of incontinence is fundamental to the choice of treatment and its outcome.

Treatment

SUI therapy is based on the assumption that the cause of this condition is an acquired anatomical defect in the tissues that provide stability and proper spatial relations of the pelvic organs. Therefore, a prerequisite for successful SUI corrective treatment is the restoration of the anatomy of the lower urinary tract.

The first operation used to treat SUI was the Kelly operation (1945). The success rate of this surgery was approximately 50%.

Needle procedures (Pereira, Raza, Stamey, Gittes) have a higher success rate but are fraught with a high number of complications and a complicated performance technique.

Urethral injection and implantation of an artificial urethral sphincter are used in a minority of patients after other surgical techniques have failed.

The operations that best restore the damaged urethral ligament apparatus are procedures with a kink access (e.g. Burch's method) and loop operations (e.g. TVT, IVS, TOT).

Everard Williams (1947) was the first to publish details of bladder suspension surgery from extravesical access. A similar operation was described by Marshall, Marchetti and Krantz (1949). In this method, the bladder neck should be freed from the załon access, two or three sutures should be placed on the vaginal wall at the side of the urethra and, from the bottom upwards, anchored in the periosteum on both sides in such a way that, when tied, they elevate the urethra and bladder neck towards the posterior aspect of the pubic bone. Marchetti used additional sutures for the bladder neck and ran them through the lower rectus abdominis muscle as additional support.

The most commonly used cystourethropectomies today include the Burch and Hisch technique. In the Burch operation, the cartilage and periosteum of the pubic symphysis are spared, as the attachment of the vaginal and urethral fascia occurs to the Cooper's ligaments (iliac crest ligaments) a few centimetres lateral to the pubic cusp. The opening of the pre-bladder space and the visualisation of the transvaginal tissues at the lateral vaginal vaults correspond to the management of the Marshall, Marchetti and Krantz operation.

In the Hirsch operation, the fibres of the vaginal fascia should be attached to the obturator fascia over a wide area. The attachment proceeds without the unfavourable high tension (found in the Burch method).