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Retropubic suspension refers to the surgical procedures used to correct incontinence by supporting and stabilizing the bladder and urethra. The Burch procedure, also known as retropubic urethropexy procedure or Burch colosuspension, and Marshall-Marchetti-Krantz procedure (MMK) are the two primary surgeries for treating stress incontinence. The major difference between these procedures is the method for supporting the bladder. The Burch procedure uses sutures to attach the urethra and bladder to muscle tissue in the pelvic area. MMK uses sutures to attach these organs to the pelvic cartilage. Laparoscopic retropubic surgery can be performed with a video laparoscope through small incisions in the belly button and above the pubic hairline.
The urinary system expels a quart and a half of urine per day. The amount of urine produced depends upon diet and medications taken, as well as exercise and loss of water due to sweating. The ureters, two tubes connecting the kidneys and the bladder, pass urine almost continually and when the bladder is full the brain sends a signal to the bladder to relax and let urine pass from the bladder to the urethra. People who are continent control the release of urine from the urethra via the sphincter muscles. These two sets of muscles act like rubber bands to keep the bladder closed until a conscious decision is made to urinate.
The intrinsic sphincter or urethral sphincter muscles keep the bladder closed and the extrinsic sphincter muscles surround the urethra and prevent leakage. Incontinence is common when either the urethra lacks tautness and stability (genuine stress urine incontinence, SUI) and/or the sphincter muscles are unable to keep the bladder closed (intrinsic sphincter deficiency, ISD). Incontinence occurs in many forms with four primary types related to anatomic, neurological, dietary, or disease, or injury.
Stress incontinence
The most frequent form of incontinence is stress incontinence. This relates to leakage of the urethra with activity that puts stress on the abdominal muscles. The primary sign of stress incontinence is this leakage at sneezing, coughing, exercise, or other straining activities, which indicates a lack of support for the urethra due to weakened muscles, fascia, or ligaments. Pressure from the abdomen with movement, like exercising, uncompensated by tautness or stability in the urethra, causes the urethra to be displaced or mobile leading to leakage. Essentially, this hypermobility of the urethra is an indication that it is moving down or herniating through weakened pelvic structures.
To diagnose incontinence and determine treatment, three grades of severity for stress incontinence are used.
• Type I: Moderate movement of the urethra, with no hernia or cystocele.
• Type II: Severe or hypermobility in the urethra of more than 0.8 in (2 cm), with or without decent of the urethra into pelvic structures.
• Type III: Hypermobility of the urethra where the primary source of incontinence is the inability of the sphincter muscles to keep the bladder closed. This is due to weakness or deficiency in the intrinsic sphincter muscles.
Urge incontinence
Urge incontinence relates to the frequent need to urinate and may involve going to the bathroom every two hours. Accidents are common when not reaching a bathroom in time. Urge incontinence is not due to general changes in the urethra or supporting muscles. It is often linked to other disorders that produce muscle spasms in the bladder, such as infections. Urge incontinence can also be due to underlying illnesses like stroke, spinal cord injury, multiple sclerosis and Alzheimer’s disease, which cause detrusor hyperflexia—the contracting of the bladder muscle responsible for sending urine from the bladder to the urethra. Urge incontinence is very common in the elderly, especially those in long term care facilities.
Mixed incontinence
Mixed incontinence is a combination of stress incontinence and urge incontinence, especially in older women. Since each form of incontinence pertains to different functions or anatomy, it is very important to distinguish which part of the incontinence is to be treated by surgery.
Overflow incontinence
Overflow incontinence results in leakage from a bladder that never completely empties due to weakened bladder muscles. Overflow incontinence is involuntary and not accompanied by the urge to urinate. Many causes exist for overflow incontinence, including weak bladder muscles due to diabetes, nerve damage, or a blocked urethra. Men are more frequently affected than women.
Demographics
Over 15 million Americans have urinary incontinence and women comprise 85% of all cases. It affects 25% of women of reproductive age and 50% of women past menopause. Due to the female anatomy, women have twice the risk for stress incontinence compared to men. In addition, childbirth places pressure and burden on the pelvic muscles that often weaken with age, thereby weakening urethra stability. Women are more prone to surgeries for urological changes than men and severe urinary incontinence is often associated with these surgeries as well as hysterectomies. The majority of women with incontinence have stress incontinence or mixed incontinence. Male incontinence occurs primarily in response to blockage in the prostate or after prostate surgery. It is usually treated with implants and/or an artificial sphincter insert.
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