Urethro-raphy: A New Technique for Surgical Management of Stress Urinary Incontinence

In 1996 we suggested an explanation of the mechanism of micturition and urinary continence. Urinary continence depends on an intact and strong internal sphincter and an acquired behavior of keeping a high alpha sympathetic tone at the internal sphincter. Weakness of the internal sphincter causes SUI. Weakness is mostly due to rupture of its wall. 

Objectives: A new surgical technique for repairing the rupture in the wall of the internal sphincter was tried aiming at restoring its integrity, hence its strength and ability to maintain urinary continence.

Study design: 60 patients suffering from SUI grade II and III were evaluated clinically, by urodynamics, X-ray, and ultrasonic studies. Urethro-raphy was done with repair of the sphincter wall by longitudinal 5-8 stitches approximating the torn edges together. Lateral ruptures were sutured by separate stitches.

Results: Patients were re-evaluated for two years after surgery. 90% success was obtained immediately and during the follow up period. 3.3% improved whereas in 6.7% of the patients, the operation failed to cure the SUI.

Conclusion: Urethro-raphy is a simple and effective operation that restores the normal anatomical construction of the internal sphincter, so that it can perform its physiological function.

Introduction: Stress urinary incontinence is a medical and a social problem for many women. In spite of the work and effort done to clarify the pathogenesis of SUI, the problem has become more puzzling. In 1922 Sir Eardely Holland gave the name "Stress Urinary Incontinence" to involuntary leakage of urine on sudden increase of intra-abdominal, intravesical pressure as on coughing or sneezing. The condition was later subdivided into genuine stress urinary incontinence and detrusor instability. In women, however, a mixed type of stress urinary incontinence and urgency incontinence is the most common and constitutes approximately 55.5% ⁽¹⁾.

Stamey also mentioned that at least one third to two thirds of patients with surgically curable stress urinary incontinence also have urgency incontinence and they can be cured of both problems by surgical elevation of the vesical neck⁽²⁾. Furthermore, genuine SUI is classified into two types: urethral hypermobility and intrinsic sphincter deficiency⁽³⁾. However, urethral hypermobility is often present in continent women. Thus the mere presence of urethral hypermobility is not sufficient to make a diagnosis of a sphincter abnormality unless incontinence is also demonstrated ⁽⁴⁾. 

An attempt to explain the pathogenesis of SUI was made in 1996 ^(5,6,7). According to this concept, SUI is mainly due to a defect in the wall of the internal urethral sphincter. The defect is mostly due to rupture and/or splitting of the collagenous tissue layer, which leads to weakness of the internal urethral sphincter wall.

Objectives: This work suggests an operation which aims at reconstruction of a strong internal urethral sphincter, with high wall tension and subsequently high urethral closure pressure at rest and on stress. This is achieved by properly identifying the rupture in the wall of the internal urethral sphincter, causing the problem, and repairing it. Assessment of the operation was done through clinical evaluation, by ultrasound and urodynamic studies for two years after the operation.

Patients and Methods: All patients in this study gave an informed consent and the study was approved by the local ethics committee. Sixty patients suffering SUI were included in the study. Clinical evaluation of each patient started with a comprehensive history and physical examination to define and quantify the symptoms.
Each patient was asked to keep a voiding diary to assess the severity of the leakage, and to monitor the results in the post operative period. For each patient a pre-operative subjective and objective SEAPI score was determined ^(8,9). The mean score of the subjective SEAPI was 10, a range from 9 to 12. The mean score of the objective SEAPI was 7, a range from 3 to 12. These scores were later compared with post operative SEAPI scores to assess treatment outcome. 

Urinalysis was done to rule out infection. Urodynamic assessment was done by performing cystometry, urethral pressure profile with stress provocation and uroflowmetry. During cystometry Valsalva leak point pressure ranged from 40-80cm water, average 50cm water. In performing urethral pressure profile, urethral
closure pressure ranged from 30-95cm. water, average 55cm water. Detrusor instabitity was also found in 25 patients. Cystogram was done for each patient to evaluate the relation between the bladder neck and the symphysis pubis.

Each patient was assessed by ultrasonic examination. Three-dimensoinal U.S. examination of the bladder, bladder neck and the urethra, using a vaginal probe multifrequent 5-7.5 MHz Kretz 530 machine, was done. Also transrectal three-dimensions U.S. examination was done. The mean age of the patients was 48 years, range from 35 to 69 years. The mean parity was 4, range from 2 to 9 and the mean body weight was 70 kgs, range from 55 to 110 kgs. All patients needed pads, mean 5 pads per day, range from 4 to 10 pads per day. Twenty two patients of these had previous anterior colpo-raphy and Kelly plication operation 1 to 3 years ago. Eighteen patients had no genital prolapse, 38 patients had cystorectocele with no uterine descent. Four patients had first degree uterine descent and cystocele.

The surgical procedure: The operation had been explained to the patient and every patient gave a written consent before surgery. General or regional (spinal or epidural) anaesthesia was used, the patient was put in the Lithotomy position. The patient was cleaned up and draped with sterile drapes. The patient was catheterized and urine sample was sent for urinalysis. A posterior wall vaginal speculum was introduced, the cervix uteri was visualized and the anterior lip was caught with two tenaculums. Subvaginal infiltration was done with adrenaline/saline solution 1/200,000 infiltrating 10ml. to 20ml., to help in separating the anterior vaginal wall from the urethra and the bladder; and for its haemostatic effect. A transverse incision was made in the vaginal wall below the bladder sulcus, about 3-4 cm long. Two Kocher forceps were then used to catch the upper edge of the vaginal flap, a pair of dissecting scissors was passed beneath the vaginal wall and then opened to dissect the vaginal wall anteriorly from the bladder and the urethra. This step was repeated several times till the submeatal sulcus was reached; and then the vaginal wall was cut in the midline from the transverse incision up to the submeatal sulcus. Six pairs of Kocher forceps were then used to catch the edges of the two vaginal flaps, three on each side. Careful dissection of the urethral wall was made separating it from the vaginal wall using sharp dissection at first, followed by blunt dissection. This was carried on along the whole length of the urethra on both sides, taking good care to separate the collagenous tissue layer from the vaginal wall. Dissection of the urethra from the vagina should not extend very far laterally to avoid injury to the neurovascular supply of the urethra. The "rupture" in the urethral wall was usually seen in the midline but sometimes lateral ruptures were seen (Fig. 1, 2, 3, 4). (Also Fig 4A, 4B, 4C, 4D)

Freeing the entire length of the urethra was very important. The defect in the urethral wall was identified and urethro-raphy was done using "slowly" absorbable suture material e.g., number "0" vicryl on a rounded needle . Two or three stitches were made at first at the bladder neck as a stay stitch and as a landmark of the upper most end of the repair. Five to eight stitches were made approximating the torn edges of the urethral wall together. It was found better to re-start at the submeatal sulcus and go up, till the bladder neck was reached. Good "bite" of the torn edges of the collagenous tissue layer was taken and sutures were tied with enough strength to bring the torn edges together.

It was important to dissect the urethral wall clearly free from the vaginal wall. When clearly dissected the urethral wall would be obvious with the rupture nicely demonstrated either affecting the whole length of the sphincter or part of it. The muscle fibers with its brownish colour were seen through the rupture. Sometimes the rupture was like "a button hole" as seen in fig 1, but in can be any shape and extent.

It is worthwhile mentioning that Urethro-raphy is different from Kelly plication operation concerning the pathogenesis of the condition, the aim of the procedure and the technique of the operation. Kelly, and Kelly-Kennedy plication operations aim at supporting and elevating the bladder neck and urethra to a high retropubic position. Also they aim at narrowing the funneled bladder neck by plicatory stitches. This is done by deeply infolding, plicating and suturing together the adjacent pelvic, subpubic and periurethral fasciae by several mattress sutures^(10,11). On the other hand in Urethro-raphy we aim at restoring a strong and sound internal urethral sphincter with compact, thick walls with high wall tension. This is achieved by identifying the rupture in the wall of the internal sphincter and repairing it by approximating the torn edges together by simple sutures. The false impression of urethral hypermobility and funneling of the bladder neck is caused by the damaged torn weak wall. Reconstruction and repair of the torn wall will restore the normal shape and station of the bladder neck and urethra.

Any lateral rupture was repaired by separate sutures. The redundant vaginal mucosa was cut and the vaginal incision was sutured continuously with "0" vicryl suture material. Other necessary surgical procedures were done e.g. repair of a rectocele. Foley catheter size 16-18F was introduced and fixed in place and a tight vaginal pack was put in the vagina. The pack, and the catheter were removed after 24 hours. Post-operative follow up was made and the patient was assessed clinically, by ultrasound examination and urodynamic studies. Patients were assessed after one month and then every six months thereafter.

Results: Subjective cure is defined as no urine loss on provocation, in addition, the patient should not have any voiding problems, e.g. urine retention, urge nor residual urine, more than 100 ml. Improvement is defined as marked reduction in the number of leakage episodes, more than 50% the number before the operation, in addition no voiding problems. Failure is defined as post operative leakage episode more than 50% the number before the operation. Using these criteria, continence was gained by 54 patients (90%). The success rate was more clear with patients who had no previous surgery; 35 out of 38 were continent 92%. While of the 22 patients who had previous repair, 19 gained continence 86%. Two women, 1 who had no previous repair and 1 had previous repair, improved 3.3%. Whereas the operation failed in 4 women, 2 who had previous repair, and 2 who had not, 6.7%.

Each patient was assessed by subjective and objective SEAPI score. In the patients who were cured, mean subjective SEAPI score one month after the operation was 2, range from 0-4. The score remained satisfactory for the whole post operative period. Mean objective SEAPI score in the post operative two years follow up was 1, range from 0-3. The problem of postoperative urine retention which is frequently encountered after plicatory operations, never happens after urethro-raphy as we do not close the lumen by plicatory mattress sutures. Also post voiding residual urine volume was always less than 40ml.

In the urodynamics studies, patients with low maximal urethral closure pressure, less than 60cm water, showed higher values, more than 90cm water in the post operative period.

On stress, the urethral closure pressure did not drop. Ultrasonic studies demonstrate restoration of the internal sphincter wall structure in contrast to the torn wall seen before surgery. The wall regained its thickness, its linearity and its normal ultrasound picture with three different echo, mucous membrane, muscle and collagen and with no echo-lucent areas. During the follow up period the patients were continent and happy.

Discussion: A new concept was described in 1996 explaining micturition and urinary continence ⁽⁵⁾. Mechanism of micturition in human beings can be divided into two stages:

I- Stage one: In infancy, micturition occurs spontaneously as a spinal cord reflex. As the urinary bladder fills, afferent impulses reach the spinal cord, and when it is full, efferent impulses, through the pelvic parasympathetic (S 2,3,4) stimulate detrusor muscle contraction thus emptying the bladder irrespective of time and place.

II- Stage two: In humans (this is also applicable to some domestic animals), the mother starts to teach her infant (age 18-24 months) how to hold himself. This is achieved by gaining an acquired behaviour, learning how to keep a high alpha sympathetic tone (T10-L2), thus keeping the internal urethral sphincter closed all the time till the appropriate time and place are available. On desire to void and/or in need the person, first through the high centers, inhibits this acquired high alpha sympathetic tone, thus allowing the internal sphincter to relax and open allowing voiding to occur. Urinary continence depends on three main factors ^(5,6,7).

I- The presence of an intact, sound, and strong internal urethral sphincter.

II- The internal sphincter is composed of a cylinder of a compact sheet of collagenous and elastic tissues extending down from the bladder neck for almost the entire the urethral length. The collagenous fibers run concentrically outwards surrounding the urethral mucosa. The muscle fibers lie on and intermingle with the collagen fibers in the middle part of this compact collagenous sheet with the collagen and elastic fibers extending beyond the muscle layer. The muscle fibers are connected with the detrusor muscle above.

The collagenous and elastic tissues give the high wall tension to the internal sphincter and hence the high urethral closure pressure. The muscle layer is responsible for closure and opening of the internal sphincter controlled by the alpha sympathetic activity (T10-L2).

III- An acquired behaviour gained by learning in early childhood is how to keep a high alpha sympathetic tone thus keeping the internal sphincter closed. Weakness of the internal sphincter would reduce the wall tension and subsequently the urethral closure pressure, so that sudden increase of the intra-abdominal, intravesical pressure would overcome it leading to leakage of urine. This initiates a quick reactive sympathetic response that increases the internal sphincter tone preventing further leakage. Weakness of the sphincter is due to a defect of the collagenous tissue layer. The most common cause is rupture and split of the collagenous fibers. Other causes include atrophy, and degeneration caused by several factors, e.g., trauma, infection and hormone deficiency. Stress urinary incontinence is a common problem more prevalent in women than men. This can be explained by the passage of the huge female genital tract close to the internal urethral sphincter causing in some women splitting of the collagenous bundles constituent of the internal sphincter⁽⁶⁾. The posterior wall of the urethra is intimately related to the anterior vaginal wall. The vagina is markedly distended during labor, the contact area in the posterior wall of the urethra would either stretch simultaneously or rupture and be torn.

Transrectal 3D U.S. (Fig. 12A, 12B) clearly illustrates such relation. It also shows the internal urethral sphincter with its anterior wall is intact while its posterior wall and the anterior vaginal wall are torn together. Repeated distension of the vagina would repeat the insult on the posterior wall of the urethra and the damage inflicted. Splitting and rupture of the internal sphincter wall causes its weakness. The internal sphincter extends from the bladder neck for almost the entire urethral length. Ultrasonic assessment of continent women demonstrate a thick wall with three different echo (mucous membrane, muscle and collagen) extending from the bladder neck for almost the entire urethral length (Fig. 5, 6). Patients with SUI, ultrasonic examination reveal rupture of the wall with irregular thickness with areas of echo-lucency denoting defective wall. The urethral lumen is open and irregularly dilated due to weakness of the wall. Funneling at the bladder neck is seen (Fig. 7, 8, 9, 10, 11, 12A, 12B).

The extent and site of the damage in the internal sphincter wall will determine the type and degree of the incontinence. If the bladder neck (the entrance) suffers more damage than the midpiece this will lead to detrusor instability alone or in addition to SUI. This can be explained by the passage of some urine on stress into the upper part of the urethra, which will stimulate detrusor contractions. The same trouble will occur after surgery for SUI if attention is made on the midpiece ignoring the upper part (Fig. 7, 12A, 12B). On the other hand, the damage can affect the lower part of the internal urethral sphincter more than its upper part. This will lead to "genuine stress urinary incontince". In such condition the upper part of the sphincter is more intact and narrow, while the torn lower part is wide and dilated, appearing on U.S. in a "flask" shape.

The same trouble and appearance will occur after surgery for SUI if attention is made on the upper part ignoring the lower part (Fig. 10, 11). If the whole length of the internal urethral sphincter is damaged this leads to mixed type of incontinence which is more prevalent (Fig. 7, 9, 12A, 12B). In some patients suffering from SUI, the urodynamic studies show high urethral closure pressure. This can result from just splitting of the compact collagenous sheet, without any observable defect in this compact layer, leaving the internal sphincter with high wall tension at rest. However, on stress the split weak wall yields leading to leakage of urine. This defect can be better assessed by ultrasonic studies.

Stress urinary incontinence has been claimed to be caused by descent of the bladder neck below the pelvic floor, and also due to funneling of the bladder neck with loss of the urethro-vesical angle. So, the aim of Kelly, Kelly-Kennedy plication operations is elevation of the bladder neck to a high retro-pubic position above the pelvic floor; and narrowing the funneled bladder-neck. On the other hand we claim that SUI is due to a damaged weak internal urethral sphincter. In urethro-raphy operation, we aim at reconstructing and restoring a strong intact internal urethral sphincter with compact sound thick walls, with high wall-tension and subsequently high urethral closure pressure. This is achieved by properly identifying the rupture in the wall, and carefully approximating the torn edges together and closing the defect. This is done by simple interrupted fine sutures. Since we do not put any plicatory stitches, there is no voiding troubles e.g., urine retention nor postvoiding residual urine. Completing urethro-raphy the internal urethral sphincter regains its strength subsequent to the repair of the damaged wall. The repaired strong wall, with high wall tension restored, corrects the apparent shortening caused by the collapse of the torn walls. Also the urethro-vesical angles become more acute .

The high wall tension keeps the lumen closed at rest and on stress. The reconstruction of the internal sphincter restores the normal urethro-vesical angles seen in continent women. Follow up, 3-D. ultrasonic assessment, shows linearity of the urethra, thickness of the wall and narrowing of the lumen. In addition cross section of the repaired internal sphincter shows compactness of the fibers with no defects nor sonolucent areas (Fig. 13). Patients with SUI who had no previous surgery are expected to have a torn wall with no degeneration nor fibrosis and will benefit more from urethro-raphy. While those who had more extensive wall damage and defects may do better with collagen injection. ^(11,12) Urethro-raphy is a simple effective operation that corrects and repairs a torn wall and allows the internal sphincter to perform its physiological function in keeping urinary continence.

Subjective SEAPI staging system

Fig. 1: Rupture in the wall of the internal urethral sphincter. The upper and lower edges are intact.The Rupture is a button- hole shape . A hemostat is holding the torn edge.

Fig. 2: An oblique rupture of the internal urethral sphincter with prominent torn edges.

Fig. 3: Ruptured internal urethral sphincter wall with the bladder seen.

Fig. 4: Sutures are made in the torn edges of the internal urethral sphincter wall closing the rupture. (Also Fig 4A, 4B, 4C, 4D)

Fig. 5a  & 5b: 3D ultrasonogram showing normal urethra. The internal sphincter has a thick wall with 3 sono ecchogenic characters. It extends from the bladder neck downwards for almost the entire urethral length.

Fig. 6: Cross section of the normal internal sphincter showing mucous membrane, collagenous tissue and muscle layer overlying the middle part of collagenous
tissue. Notice the compactness of the fibers with no rupture or defects in the wall.

Fig. 7: 3D ultrasonic picture in of patient with SUI grade III. The urethra is dilated with irregular outline. The sphincter wall is thin and torn.

Fig. 8: Cross section of torn sphincter with large defects and loose fibers.

Fig. 9: 3D ultrasonic picture of the internal sphincter of a patient with SUI grade III. The damage affects the whole length of the internal urethral sphincter.

Fig. 10: 3D ultrasonogram of the internal sphincter of a patient with SUI who had a previous Kelley operation. Notice that the upper part is repaired leaving a
weak lower part .

Fig. 11: 3D ultrasonogram of the internal sphincter of a patient with SUI. The rupture affects the lower part more than the upper part giving a "flask"

Fig. 12A and 12B: Trans-rectal 3D ultrasonogram of the internal sphincter of a patient with SUI. It illustrates the relation of the internal urethral sphincter with the
vagina. The anterior wall of the sphincter is intact. The post wall of the sphincter and the anterior wall of the vagina are torn and irregular.

Fig. 13: 3D ultrasonogram of the internal sphincter 18 months after urethroraphy showing linearity of the urethra, thickness of the wall and compactness of the
tissues.

References:

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