Needle Bladder Neck Suspension

Definition
Purpose
Demographics
Description
Diagnosis/Preparation
Morbidity and mortality rates
Normal results

Definition

Needle bladder neck suspension, also known as needle suspension, or paravaginal surgery, is performed to support the hypermobile, or moveable urethra using sutures to attach it to tissues covering the pelvic floor. Of the three popular surgical procedures for urethral instability and its results in urinary stress incontinence, needle bladder neck suspension is the quickest and easiest to perform. It has many variants, such as the Raz, Stamey, modified Pereyra, or Gattes procedures, but its long-term results are less impressive than other, more extensive, anti-incontinent surgeries.

Purpose

Fifty years of work to treat incontinence, especially in women, has resulted in three types of surgery tied to essentially three causes of a particular type of incontinence related to muscle weakening of the urethra and the “gate-keeping” sphincter muscles. Stress urinary incontinence, the uncontrollable leakage of urine when pressure is put on the bladder during sneezing, coughing, laughing, or exercising, is very common in women. It is estimated to affect 50% of elderly women in long-term care facilities. The inability to hold urine has two causes. One has to do with support for the urethra and bladder, known as genuine stress incontinence (GSI), and the other is related to the inability of sphincter muscles, or intrinsic sphincter deficiency (ISD), to keep the opening of the bladder closed.

In GSI, weak muscles supporting the urethra allow it to be displaced and/or descend into the pelvic-floor fascia (connective tissues) and create cystoceles, or pockets. The goal of surgery for GSI is to stabilize the suburethral fascia to prevent the urethra from being overly mobile during increased abdominal pressure.

The other major source of stress incontinence is due to weakening of the internal muscles of the sphincter, as they affect closure of the bladder. These muscles, called the intrinsic sphincter muscles, regulate the opening and

KEY TERMS

Genuine stress incontinence (GSI)— A specific term for a type of incontinence that has to do with the instability of the urethra due to weakened support muscles.

Hypermobile urethra— A term that denotes the movement of the urethra that allows for leakage or spillage of urine.

Intrinsic sphincter deficiency— A type of incontinence caused by the inability of the sphincter muscles to keep the bladder closed.

Urinary stress incontinence— The involuntary release of urine due to pressure on the abdominal muscles during exercise or laughing or coughing.

closing of the bladder when a decision is made to urinate. Deficiency of the intrinsic sphincter muscles causes the opening to remain open and thus leads to chronic incontinence. ISD is a source of severe stress incontinence and may be combined with urethral hypermobility.

The challenge of surgery for stress incontinence is to adequately evaluate the actual source of incontinence, whether GSI or ISD, and also to determine the likelihood of cystoceles that may need repair. Under good diagnostic conditions, surgery for stress incontinence will utilize a suprapubic (above the pubic area) procedure, or Burch procedure, to secure the hyper-mobile urethra and stabilize it in a neutral position. Surgery for ISD uses what is known as a sling procedure, or “hammock” effect, that uses auxiliary tissue to undergird the urethra and provide contractive pressure to the sphincter. Most stress incontinence surgeries fall into one of these two procedures and their variants.

Needle neck bladder suspension, the third most utilized procedure for stress incontinence, simply attempts to attach the urethra neck to the posterior pelvic wall through the vagina or abdomen in order to stabilize the urethra. It is, however, considered a poor choice in comparison to the other two procedures because of its lack of long-term efficacy and its high incidence of urinary retention as an operative complication.

Demographics

More than 13 million people in the United States, both males and females, have urinary incontinence. Women experience it twice as often as men due to pregnancy, childbirth, menopause, and the structure of the female urinary and gynecological systems. Anyone can become incontinent due to neurological injury, birth

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Surgery is performed by a urological surgeon who has a medical degree with advanced training in urology and in surgery. Surgery is performed in a general hospital.

defects, cardiac conditions, multiple sclerosis, and chronic conditions in later life. Incontinence does not naturally accompany old age but is associated with many chronic conditions that occur as age increases. Incontinence is highly associated with obesity and lack of exercise. As many as 15-30% of adults over 60 have some form of urinary incontinence. Stress incontinence is, by far, the most frequent form of incontinence and is the most common type of bladder control problem in younger and middle-age women.

Description

Needle bladder neck suspension surgery can be performed as open abdominal or vaginal surgery, or laproscopically, which allows for small incisions, video magnification of the operative field, and precise placement of sutures. Under a general anesthetic, the patient is placed in a position on her back with legs in stirrups allowing access to the suprapubic area. A Foley catheter is inserted into the bladder. The open procedure involves the passage of a needle from the suprapubic area to the vagina with multiple sutures through looping. Cytoscopic monitoring (using an endoscope passed into the urethra) prevents passage of the needle through the bladder or the urethra. The laparoscopic method allows visualization of the needle pass made from the suprapubic area to the vagina and the looping technique. The vagina and the surrounding areas are thoroughly irrigated with an anti-biotic solution throughout the procedure. The patient is discharged the same evening or the next morning with the catheter in place. She is kept on antibiotics and examined on the fourth day after surgery with the removal of the catheter. The follow-up examination includes wound inspection and a evaluation of residual urine. A pelvic examination is performed to check for bleeding or injury.

Diagnosis/Preparation

Stress urinary incontinence can have a number of causes. It is important that patients confer with their physicians to rule out medication-related, psychological, and/or behavioral sources of incontinence as well as physical and neurological causes. This involves complete medical history, as well as medication, clinical,

QUESTIONS TO ASK THE DOCTOR

• Is surgery my only alternative to living with urinary incontinence?
• Are there other surgical procedures that are more effective for my incontinence?
• Can you recommend any literature I can read that explains my surgical options for incontinence?
• Can you explain why this procedure is preferable to what is known as a “sling procedure?”

neurological, and radiographic evaluations. Once these are completed, urodynamic tests that evaluate the urethra, bladder, flow, urine retention, and leakage, are performed and allow the physician to determine the primary source of the stress incontinence. Patients who are obese and/or engage in high-impact exercise are not good candidates for this surgery. Patients with ISD may not be cured with this procedure, since it is primarily intended to treat the hypermobile urethra.

Morbidity and mortality rates

Urologic surgery has inherent morbidity and mortality risks related primarily to general surgery, with lung conditions, blood clots, infections, and cardiac events occurring in a small percentage of surgeries, independent of the type of procedure. In addition, the American Urological Association (AUA) has concluded that needle suspension surgery has a number of complications related directly to suturing in the suprapulic area. These complications include:

• a 5% incidence of bladder injury
• urethral injury, although rare, in a small percentage of cases
• bleeding, with an incidence of 3-5%, primarily from the area below the pubic area
• nerve entrapment (8-16% of cases) due to lateral placement of the sutures into the fascia at the back of the suprapubic area (This has improved with a change in the placement of sutures.)
• wound infections in about 7% of cases, with higher rates among those with diabetes or obesity

These operative complications, coupled with the procedure’s high rate (10%) of reported pain after surgery, and its relatively high rate (5%) of urinary retention lasting longer than four weeks, have resulted in needle neck suspension having a limited role in the management of stress urinary incontinence.

Normal results

Despite modifications in the needle suspension procedure, the long-term outcome of the procedure does not indicate its lasting efficacy. According to a recent report by the AUA, a study of the effects of needle suspension found only a 72-91% cure, or “dry rate,” after 48 months, with delayed failures of sutures in a very high percentage (33-80%) of cases.

Resources

BOOKS

Katz VL et al. Comprehensive Gynecology. 5th ed. St. Louis: Mosby, 2007.

Wein, AJ et al. Campbell-Walsh Urology. 9th ed. Philadelphia: Saunders, 2007.

PERIODICALS

Bodell, D. M. and G. E. Leach. “Needle Suspension Procedures for Female Incontinence.” Urologic Clinics 29 (August 2002).

Takahashi, S., et al. “Complications of Stamey Needle Suspension for Female Stress Urinary Incontinence.” Urology International 86 (January 2002): 148–151.

ORGANIZATIONS

American Foundation for Urologic Diseases. The Bladder Health Council. 300 West Pratt Street, Suite 401, Baltimore, MD 21201.

American Urological Association. 1120 North Charles Street, Baltimore, MD 21201.(410) 727-1100. Fax: 410-223-4370. http://www.urologyhealth.org.

The Simon Foundation for Continence. P.O. Box 835, Wilmette, IL 60091. (800) 237-simon or (800) 237-4666. Toll-free (847) 864-3913. (847) 864-9758.

OTHER

“Urinary Incontinence.” MD Consult Patient Handout. January 2, 2003 [cited July 7, 2003]. http://www.MDConsult.com.

Nancy McKenzie, PhD

Needle suspension seeNeedle bladder neck suspension

Needles seeSyringe and needle