Bladder Suspension Surgery for Stress Urinary Incontinence: A Surgeon's Overview

Introduction

Bladder suspension, also known as bladder neck suspension, is a surgical procedure designed to treat stress urinary incontinence (SUI) in women. SUI occurs when the bladder leaks urine during activities that increase abdominal pressure, such as coughing, sneezing, or exercising. This condition is most commonly caused by weakened pelvic floor muscles or a loss of support around the bladder neck and urethra, often resulting from childbirth, aging, or previous surgeries.

Bladder suspension procedures aim to restore the bladder's normal positioning and support, reducing or eliminating episodes of incontinence. These surgeries are often reserved for patients who have not responded to non-surgical treatments such as pelvic floor exercises, lifestyle modifications, or medications. With a variety of surgical techniques available, bladder suspension can offer durable and effective relief for patients struggling with SUI.

In this comprehensive article, we will explore all facets of bladder suspension surgery, including indications, preoperative evaluation, surgical techniques, postoperative care, complications, prognosis, alternative options, and recent advances in the field.

Indications for Bladder Suspension

Bladder suspension is primarily indicated for women who suffer from stress urinary incontinence due to hypermobility of the urethra or intrinsic sphincter deficiency (ISD). The following are the main indications for bladder suspension surgery:

1. Stress Urinary Incontinence (SUI): The main indication is moderate to severe stress urinary incontinence caused by hypermobility of the bladder neck and urethra.
2. Failure of Non-Surgical Treatments: Candidates for bladder suspension are usually patients who have not responded adequately to conservative management, including pelvic floor muscle training (e.g., Kegel exercises), biofeedback, electrical stimulation, or pharmacological interventions.
3. Symptomatic Impact on Quality of Life: Patients who report a significant reduction in their quality of life due to the physical and emotional burden of incontinence are suitable candidates for surgery.
4. Coexisting Pelvic Organ Prolapse: In cases where stress incontinence is accompanied by prolapse of the pelvic organs, a combined approach addressing both issues may be warranted.
5. Stable Medical Conditions: Ideal candidates are those who are medically stable and able to tolerate anesthesia and surgery.

Preoperative Evaluation

Proper patient selection and thorough preoperative evaluation are essential to the success of bladder suspension surgery. The following components should be part of the preoperative workup:

1. Detailed Medical History and Physical Examination:
   • Assessment of urinary symptoms, including severity, frequency, and triggers of incontinence.
   • Pelvic examination to evaluate the degree of urethral hypermobility and any coexisting pelvic organ prolapse.
   • History of previous surgeries, particularly in the pelvic region, and history of childbirth.
2. Urodynamic Testing:
   • Urodynamic studies help confirm the diagnosis of SUI and rule out other types of incontinence, such as urge incontinence or overflow incontinence.
   • Evaluation of bladder capacity, detrusor muscle function, and urethral closure pressure.
3. Imaging Studies:
   • Pelvic ultrasound or MRI may be used to evaluate the anatomy of the bladder, urethra, and surrounding structures.
   • Cystoscopy can be employed to rule out any bladder pathology that might contribute to incontinence.
4. Assessment of Comorbid Conditions:
   • Cardiovascular health, diabetes, and other comorbidities must be assessed to ensure that the patient can safely undergo surgery.
5. Counseling and Informed Consent:
   • Patients should be educated about the risks and benefits of the procedure, alternative treatment options, and the potential need for postoperative rehabilitation.

Contraindications

While bladder suspension can be an effective solution for many patients, there are certain contraindications to consider:

1. Untreated Urinary Tract Infections: Active infections should be treated prior to surgery.
2. Severe Comorbidities: Patients with severe uncontrolled medical conditions (e.g., cardiovascular disease, uncontrolled diabetes) may not be suitable candidates for surgery.
3. Neurological Conditions Affecting Bladder Function: Conditions such as multiple sclerosis or spinal cord injuries that impact bladder control may not respond well to bladder suspension.
4. Previous Failed Incontinence Surgeries: Patients who have undergone previous incontinence surgeries that have failed may require alternative approaches.

Surgical Techniques and Steps

Several surgical techniques are available for bladder suspension, with each method tailored to the patient’s anatomy and the surgeon’s expertise. The two primary categories of bladder suspension procedures are open retropubic suspension (e.g., Burch colposuspension) and laparoscopic or minimally invasive procedures.

1. Burch Colposuspension (Open Retropubic Suspension):

The Burch colposuspension is one of the most well-established techniques for treating SUI. The procedure involves suspending the bladder neck and urethra to the pelvic sidewalls, providing support and restoring normal anatomy.

Steps:

1. Incision: A lower abdominal incision is made to access the retropubic space.
2. Bladder Mobilization: The bladder is gently mobilized to expose the bladder neck and urethra.
3. Suture Placement: Sutures are placed on both sides of the bladder neck and secured to the Cooper’s ligaments or the fascia of the pelvic sidewalls.
4. Suture Tensioning: The sutures are carefully tensioned to elevate and support the bladder neck without causing obstruction.
5. Closure: The incision is closed in layers, and a catheter is placed for postoperative bladder drainage.

2. Laparoscopic Bladder Suspension:

Laparoscopic techniques offer a minimally invasive alternative to traditional open surgery, with shorter recovery times and less postoperative pain. The laparoscopic approach follows similar principles to the open procedure but is performed using small incisions and specialized instruments.

Steps:

1. Port Placement: Several small incisions are made in the abdomen, and trocars are inserted to allow for the introduction of laparoscopic instruments.
2. Bladder Mobilization: The bladder is mobilized, and the bladder neck is exposed using laparoscopic dissection.
3. Suture Placement: Sutures are placed on either side of the bladder neck, similar to the open procedure, and secured to the pelvic sidewalls or Cooper’s ligaments.
4. Suture Tensioning and Closure: The sutures are adjusted, and the abdominal incisions are closed.

3. Other Techniques:

• Marshall-Marchetti-Krantz (MMK) Procedure: This older technique involves attaching the bladder neck to the pubic bone, though it is less commonly used today due to a higher complication rate.
• Robotic-Assisted Laparoscopic Suspension: Robotic surgery offers enhanced precision and visualization, allowing for meticulous dissection and suture placement.

Postoperative Care

Proper postoperative care is critical for ensuring optimal outcomes after bladder suspension surgery. Postoperative management includes:

1. Catheterization: Patients typically require a Foley catheter for bladder drainage during the initial postoperative period. The catheter may remain in place for 1-2 days, depending on the procedure and patient recovery.
2. Pain Management: Analgesics and anti-inflammatory medications are prescribed to manage postoperative pain.
3. Activity Restrictions: Patients are advised to avoid heavy lifting, strenuous activities, and sexual intercourse for 4-6 weeks to allow for healing and prevent suture disruption.
4. Pelvic Floor Rehabilitation: Physical therapy and pelvic floor exercises may be recommended to enhance recovery and optimize long-term continence.
5. Follow-Up: Regular follow-up appointments are scheduled to monitor healing, assess bladder function, and address any complications.

Possible Complications

As with any surgical procedure, bladder suspension carries certain risks and potential complications. Surgeons must inform patients about these risks during preoperative counseling. Some of the complications include:

1. Urinary Retention: Difficulty in emptying the bladder postoperatively may occur due to excessive tension on the sutures or swelling.
2. Infection: Urinary tract infections or surgical site infections can develop postoperatively.
3. Bladder or Urethral Injury: Accidental injury to the bladder or urethra can occur during the dissection or suture placement.
4. Recurrence of Incontinence: While bladder suspension has a high success rate, some patients may experience recurrent incontinence over time.
5. Dyspareunia: Painful intercourse may develop if the sutures are too tight or if there is excessive scarring.
6. Hemorrhage: Intraoperative or postoperative bleeding may require additional interventions.

Prognosis and Outcomes

Bladder suspension surgery generally offers excellent long-term outcomes for patients with stress urinary incontinence. Success rates vary depending on the specific technique used and patient factors, but many studies report success rates ranging from 70% to 90%. The durability of the procedure also varies, with many patients experiencing lasting continence for over a decade.

Key factors influencing outcomes include the severity of incontinence, the presence of pelvic organ prolapse, the surgeon’s experience, and adherence to postoperative care instructions. Patients with mild to moderate incontinence and no significant comorbidities tend to have the best outcomes.

Alternative Treatment Options

While bladder suspension is an effective option for many women, alternative treatments are available for those who may not be suitable candidates for surgery or who prefer less invasive approaches. These alternatives include:

1. Pelvic Floor Muscle Training: Also known as Kegel exercises, these exercises strengthen the pelvic floor muscles and improve bladder control. Biofeedback and electrical stimulation may enhance the effectiveness of these exercises.
2. Pessary: A vaginal pessary is a device inserted into the vagina to support the bladder neck and urethra, reducing incontinence. Pessaries are particularly useful for women with coexisting