Medical vs surgical treatment of urgency urinary incontinence
IUGA Academy. Jager W. Jun 30, 2018; 212915; 470 Topic: Stress Incontinence
Wolfram Jager
Wolfram Jager

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470

Medical vs surgical treatment of urgency urinary incontinence

Jaeger, W1; Ludwig, S1

1: Urogyne university of Cologne

Introduction: Urgency Urinary Incontinence (UUI) in women is considered a neurophysiological disorder of the bladder detrusor muscle. Patients with UUI are treated with several forms of medication. However, UUI is only symptomatic in the upright body position. That, however, is a strong limitation of the “increased detrusor activity-hypothesis”. On the other side, it has long been proposed that the main cause of UUI is a flaccidity of the anterior vaginal wall. One of the reasons is considered to be the missing tension of the anatomical holding apparatus. Since decades several surgical procedures have been used for treating cystoceles. All procedures which tightened the endopelvic fascia can lead to continence. However, the procedures were never investigated on their special effects on UI. We therefore decided to evaluate the effects of the different levels of the vagina on UI by repairing. We started with Level 1 and developed a standardized bilateral suspension of the uterosacral ligaments (cervico-sacropexy and vagino-sacropexy). In this randomized clinical trial (RCT), we compared the clinical effects of the replacement of the USL by CESA or VASA with a standard medical treatment with solifenacin (URGE 1).

Material and Methods: The enrolled patients were diagnosed as having a so far untreated UUI or mixed UI (MUI). They were randomized to receive either 10 mg of solifenacin daily (control) or a surgical replacement of the USL as cervicosacropexy (CESA) or vaginosacropexy (VASA) (www.cesa-vasa.com). The USL repair procedure was identical in all patients. The CESA and VASA operations were developed under the aim of a high level of replicability so that they can be identically performed in every patient. The primary study aim was to determine the effects of CESA or VASA alone on UUI. The secondary aim was to examine the effects of CESA and VASA on MUI. Incontinence was determined by a doctor or study nurse by conducting preoperative interviews using standardized questionnaires.

Results: The RCT included 96 patients; 41 patients were in the control arm and 55 patients in the treatment arm of the study, respectively. 23 patients (42%) were free of any incontinence symptoms after CESA or VASA. In 15 patients (27%), the symptoms of MUI disappeared. These patients did not have a reduction of urine loss episodes but no loss of urine at all (“ I feel cured!”). In the control group, one patient (2%) became continent and 4 patients (10%) reported an improvement in their UUI symptoms. This difference was considered highly significant; therefore, the study was terminated by the ethical committee.

Discussion: This study confirms previous observations that UUI can be effectively treated by surgery. The USL exerted tension on the apical end of the pubocervical fascia (Level 1). In our approach, the bilateral replacement of the USL by identical tapes with identical lengths of the USL in all patients resulted in continence rates of 42% [confidence interval (CI): 29%–55%]. The effect on incontinence was so impressive that the patients called themselves as “cured”. In the solifenacin arm of study only 4 patients (CI: 1%–19%) reported an improvement of symptoms but no cure. All patients were suffering from the side effects of medical treatment. Our surgical approach was focused on the apical suspension of the anterior vagina. Preliminary studies already demonstrated that the repair of the other Levels will further increase the number of continent women. As a next step, we will evaluate the role of Level III repair.

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Work supported by industry: no.

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