A complete evaluation, including an assessment of post-void residual volume, is key when evaluating a female patient for surgery to treat stress urinary incontinence (SUI), according to a new clinical practice guideline released today by the American Urological Association (AUA). Also, patients should be counseled about the benefits and risks of both surgical and nonsurgical options for SUI (which include injectable agents, suspension procedures [laparoscopic and retropubic] and slings [midurethral and pubovaginal]).
Treatment should be a collaborative effort between the surgeon and patient, taking into consideration both patient preferences and the surgeon's judgment and expertise. The document updates the Association's previous guideline, published in 1997. Additionally, the guideline addresses the surgical correction of pelvic prolapse concurrent with SUI treatment.
Assessment of post-void residual urine volume should be undertaken as a part of fully evaluating the incontinent patient and assessing comorbitities - such as detrusor contractility and urinary retention - so that surgical techniques can be tailored accordingly.
The AUA Guideline Panel continues to recommend a focused history, physical examination and demonstration of leakage with increasing abdominal pressure, along with urinalysis, cultures and other diagnostic measures (such as imaging, voiding diaries, cystoscopy and urodynamics) if needed. Patients with known or suspected neurogenic bladder, concomitant overactive bladder symptoms, excessive residual volume, dysfunctional voiding or prior lower urinary tract surgery may need further evaluation to confirm an SUI diagnosis. It is important to note that patients with urge incontinence without stress incontinence should not be offered a surgical procedure for stress incontinence. Patients with mixed incontinence (both urge and stress) with a significant stress component may benefit from surgical treatment.
Appropriate Treatment Modalities
The Panel analyzed four categories of treatment options: retropubic suspensions, slings, injectable agents and artificial urinary sphincters.
Retropubic suspensions: Though largely supplanted by sling procedures, retropubic suspensions are still considered one of the most efficacious procedures for long-term success (based on cure/dry rates). Patients should understand that there are slightly higher complication rates associated with the procedure, including postoperative voiding dysfunction and longer convalescence. These recommendations remain unchanged from the 1997 guideline.
Injectable agents: Collagen and other nondegradable synthetic agents are an option for patients who do not wish to undergo invasive surgery and understand that both efficacy and duration are inferior to surgery.
Artificial urinary sphincters: Use of artificial urinary sphincters is generally restricted to those with nonfunctioning urethras (e.g., spina bifida patients, male adults with post-prostatectomy incontinence and victims of trauma to the pelvic nerve). It may be an option for patients with severe intrinsic sphincteric deficiency who have failed other surgical procedures.
Slings: The Panel does not recommend the use of synthetic slings for stress incontinence patients with a concurrent urethrovaginal fistula, urethral erosion, intraoperative urethral injury and/or urethral diverticulum. Using synthetic material in these circumstances may place the patient at higher risk for adverse effects. In such patients, the Panel believes that autologous fascial and alternative biologic slings are an option. Data on the use of cadaveric slings was severely limited.
The Panel asserts the following recommendations in regard to sling surgery:
- Patients should be made aware of the benefits and risks of both biological and synthetic sling materials (including surgical mesh, for which the U.S. Food and Drug Administration recently issued an alert).
- The guideline mandates that, in all patients undergoing sling surgery, the bladder and urethra must be inspected either with a rigid or flexible cystoscope prior to the conclusion of the procedure, in order to detect potential intraoperative complications.
- When concomitantly performing prolapse repair and SUI surgery, prolapse surgery should be fully completed before the sling is tensioned.
"This Guideline advises physicians to counsel their patients and set expectations prior to undergoing treatment," said AUA Guideline Panel Chair Roger Dmochowski, MD. "This is very important because often the patient thinks that surgery will completely cure their incontinence, when in reality, it may only make modest improvements."
The AUA is collaborating with the American College of Obstetricians and Gynecologists to develop physician performance measures based on this new guideline. These measures are being developed under the independent measure development process of the American Medical Association's Physician Consortium for Performance Improvement (AMA-PCPI) and will, ultimately, be submitted for National Quality Forum endorsement. The new measures will reflect all changes made in the 2009 Guideline update.
The complete text of the AUA's "Guideline for the Surgical Management of Female Stress Urinary Incontinence" is available online at www.AUAnet.org and will be published in The Journal of Urology® in 2010. For more information on the guideline or to schedule an interview with Dr. Dmochowski, please contact Lacey Dean at [email protected] or 410-689-4054.
American Urological Association