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Some women try medications and exercises for relief of incontinence but still are plagued by bothersome symptoms. For these women, surgery may provide much needed relief.
One of the goals of surgery for the treatment of incontinence is the restoration, by a number of proven techniques, of the bladder and urethra to their normal position. But for some women, changes that occur as a result of the lengthening and stretching during childbirth cause significant incontinence that interfere with their daily lives. Incontinence does play havoc with a woman's ability to live and enjoy her life. For those women, surgery can restore a sense of basic good health and a return them to a life free of worry and wetness.
The tension-free vaginal tape procedure, or TVT, is a new procedure first developed in Sweden in 1995. This procedure is similar to the sling in principle it forms a hammock under the urethra that bolsters it when you laugh, cough, exercise, or strain in any other way. TOT (Tension free vaginal tape trans-obturator) is a similar procedure done in a slightly different location. (See below).
This procedure has been performed on over 250,000 women in Europe and 100,000 in the United States, and the initial results are excellent. The success rate so far is 85% after 3 years. Surgery takes about 30 minutes and may be performed with local or epidural anesthesia. Most women can leave the hospital within a few hours. Most women urinate without problems immediately after surgery.
A thin strip of supporting tape is used to form a hammock under the urethra. The tape is made of a synthetic nylon-like mesh that grips the surrounding tissues and holds itself in place without sutures until scar tissue grows into the mesh. The procedure is performed through a small incision in the vagina directly below the urethra. A loose hammock is made beneath the urethra, and the ends of the hammock are pulled up through two very small (1/4 inch) incisions made side by side in the skin just above the pubic bone (or just outside the edge of each labia in the case of TOT). Once the tape is placed properly below the urethra, the extra material is trimmed, and the incisions on the skin's surface are closed.
While the TVT and was initially developed for stress incontinence, it has also been used with some success for ISD combined with stress incontinence. It is likely that this procedure will be useful for many women with incontinence, and we have been impressed with the results in our own practice.
Recovery is very rapid following TVT or TOT. The small incisions, the one in the vagina and the two above the pubic bone or in the crease of the groin near the labia, only cause mild discomfort for a few days. Since the surgery can be performed under local or epidural anesthesia with mild sedation, there is none of the grogginess people sometimes feel after general anesthesia. Our patients are usually walking around within a few hours and go home from the hospital shortly thereafter. However, as is true with all incontinence surgery, it is important to limit strenuous activity for three months to allow all the healing to take place.
An anterior repair, or cystocele repair, was one of the first operations developed to support the bladder and urethra to prevent incontinence. The operation supports the bladder from underneath but does not correct the loss of support experienced with the extra pressure of a cough or exercise. The anterior repair is performed through a vaginal incision just under the bladder and uses stitches to pull together the strong vaginal tissue for support. This replaces the bladder and urethra closer to their original positions. Unfortunately, this operation does not work very well for incontinence, with only 37% of women having long-term cures (5 years). Many doctors still use this operation for incontinence even though it is no longer state-of-the-art. An anterior repair is a very good procedure for putting a dropped bladder back into place to relieve bulging of the bladder. It also is helpful for women who are unable to empty their bladder because of the urine that collects in the bulging portion. But, if leakage is a problem, we perform a bladder suspension operation, sling or TVT in order to successfully treat stress incontinence.
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