Update on Retropubic Incontinence Surgery

A Comparison of Two Procedures

A 27-year study of 1300 women undergoing retropubic cystourethropexy using either the modified Marshall-Marchetti-Krantz procedure or the modified Pereyra procedure compares long-term results when the type of surgery is selected on the basis of patient criteria.

Stress urinary incontinence (SUI) is one of the most common yet complex problems confronting physicians who provide primary care for female patients. Nearly 40% (13 million) of all adult American women will experience various degrees of SUI during their lifetime.¹ Symptoms can range from occasional leakage of a few drops of urine to complete loss of urine under certain conditions of stress. Although nonsurgical methods such as dietary changes, bladder retraining, Kegel exercises, biofeedback, pessaries, electrostimulation, and drug therapies have been used successfully to treat these women, many patients eventually require surgical repair to relieve their symptoms.

Over the past century, many surgical procedures have been developed to correct SUI. Kelly and Dumm² first described the traditional Kelly plication and anterior vaginal repair in 1914. The procedure was performed for more than half a century for patients with SUI, and many surgeons still employ the Kelly technique with various modifications. However, studies indicate that the operation has a success rate of only 60% to 70%.³

Many types of retropubic procedures have been devised in an attempt to improve the cure rate of the standard Kelly repair. Abdominal procedures include the paravaginal repair, Burch procedure, and modified Marshall-Marchetti-Krantz (MMMK) procedure. Vaginal retropubic cystourethropexies include the Stamey, Raz, Gittes, Cobb-Ragde, and modified Pereyra (MP) procedures. Most of the studies involving these procedures have been restricted to short-term follow-up. Our first study⁴ followed some patients for up to 16 years, and this report is a continuation that includes follow-up of 27 years in some cases.

The type of surgery was dictated by patient criteria as opposed to random selection. Patients who presented with indications for abdominal surgery and associated SUI underwent the appropriate abdominal procedure followed by an MMMK procedure.⁵ Patients with indications for vaginal surgery and associated SUI underwent an MP procedure followed by an anterior and posterior vaginal repair.^6,7 The study sought to determine whether equally good long-term results could be achieved with the procedure performed via either route.

INCONTINENCE SURGERY STUDY

Materials and Methods

Over a period of 27 years, between January 1966 and December 1993, 727 patients underwent an MMMK procedure and 660 patients underwent an MP procedure combined with anterior colporrhaphy and associated vaginal surgery. Complete follow-up was not possible in 87 patients because either they left the area or no accurate records were available; these patients were not included in the current study. To date, 675 patients have been included in the MMMK group and 625 patients in the MP group, totaling 1300 patients with accurate records and follow-up.

All patients underwent a thorough history, with physical and pelvic examinations and basic office urinary stress testing. A history of involuntary loss of urine secondary to increased intra-abdominal pressure while coughing, sneezing, laughing, or straining was noted. The number of tampons, pads, or other protective devices was recorded as well. Patients with transient causes of urinary incontinence (eg, urinary tract infections, hypoestrogenism, cholinergic-stimulating medications, psychological disorders) were excluded from consideration. Likewise, patients whose incontinence was not bothersome did not undergo surgery. Only women whose symptoms disrupted their daily activities were considered as candidates for surgical correction. More than 300 patients were excluded owing to poor medical condition or various other reasons; whenever possible, a pessary was used in these cases.

The physical assessment focused on the abdomen and pelvis. Patients were examined with the bladder empty and then reexamined with a full bladder, usually in both the standing and supine positions. Degrees of uterine or vaginal prolapse were documented, including cystocele, enterocele, and rectocele. All patients underwent a lubricated cotton-swab test, bulbocavernosus reflex test, and Bonney-Marshall test.^8,9

The most important observation was actual visualization of loss of urine with coughing and/or straining. Especially in the early years of this study, it was felt that patients who easily demonstrated loss of urine did not require expensive urodynamic procedures that were not the standard of care at the time. However, any patient with no obvious SUI, a neurologic disorder, or a prior failed incontinence procedure was referred to a urologist for supplemental urodynamic evaluation to differentiate among urge, overflow, stress, or mixed incontinence. Only patients with genuine SUI were considered for surgical correction; women with other types of incontinence were treated by a urologist. Patients who demonstrated genuine SUI were subdivided into those who needed retropubic cystourethropexy combined with a vaginal surgical procedure or those who required retropubic cystourethropexy combined with an abdominal approach.

If there was a significant degree of uterine prolapse with associated cystocele and/or rectocele, a standard vaginal hysterectomy was usually performed. This was followed by an MP procedure as described by Pereyra and Lebherz¹⁰ with some minor modifications, along with anterior and posterior vaginal repair, when indicated.

Our modification of the original Pereyra procedure places #1 chromic sutures on a #885 needle vertically through the posterior pubourethral ligaments. The vertical sutures are placed in three or four consecutive, nonlocking bites, starting 1 cm down from and 1 cm lateral to the external urethral orifice and extending to the urethrovesical junction on each side. This technique differs from the horizontal helical sutures originally described by Pereyra and Lebherz.¹⁰ It is important to note that the Pereyra needle is continuously held against the index finger as it is advanced downward through the urogenital diaphragm to avoid possible puncture of the bladder or urethra. After the suture is carried through retro-pubically, the sutures are held above with hemostats on each side of the lateral edge of the incision until placement of the Kelly plication sutures. The sutures are then pulled upward to elevate the urethra and bladder neck and tied tautly across the suprapubic fascia, making sure to avoid strangulation of the tissue. The formation of a new posterior urethrovesical angle is readily apparent as it rises behind the pubic bone (Figure 1). The bladder is filled with 300 mL of sterile water so that a suprapubic catheter can be placed 1 inch above the suprapubic incision.

The MMMK procedure is performed as described originally in 1949,⁵ with some minor modifications. The appropriate abdominal surgery is performed, followed by closure of the anterior parietal peritoneum. A #1 chromic suture on a #885 needle is placed perpendicularly 1 cm lateral to the midurethra, and a second bite of the same suture is placed deeper into the same area to include a portion of the vaginal wall. This differs from the original Marshall-Marchetti-Krantz procedure in that the suture is placed into the midportion of the fibrocartilage of the median raphae of the symphysis pubis rather than into the periosteum, eliminating the potential for osteisis pubis. In another departure from the original technique, a second suture is positioned on each side 1 cm lateral to the urethrovesical junction. This suture is placed into the upper portion of the fibrocartilage of the median raphae of the symphysis pubis, or through the rectus fascia above the same area. The sutures are tied on each side while elevating the urethra toward the retropubic position (Figure 2).

Results

The combined study from 1966 to 1993 (27 years) includes 1387 retropubic procedures except for 87 patients who were lost to follow-up. The current combined study includes 675 MMMK procedures and 625 MP procedures, totaling 1300 retropubic cystourethropexies for which records and information were available.
The combined clinical cure rate for the two procedures was 86.1%, with improvement in 7.6% of cases and failure in 6.3%. There were 56 failures in the MMMK group and 29 in the MP group. After complete urologic evaluation, 55 of the 85 failed patients underwent repeat operations. For various reasons, 30 patients in the failed group did not undergo repeat surgery.

1

2

7

3

2

0

2

2

2

0

2

1

4

2

1

1

2

3

0

1

<10%

There were few direct or indirect serious complications in either group (Table 1). Seven patients in the MMMK group had a superficial wound collection/ infection, and four patients in the same group had a ureteral kinking obstruction without frank ligation; these patients underwent immediate repair performed by a urologist. Six patients in the MP procedure group sustained a rent in the bladder during dissection of the anterior vaginal mucosa from the urethra and bladder before entering into the retropubic space; these injuries were repaired at the time of surgery by the gynecologist. Also, 19 patients in the MP group developed vaginal synechiae most often secondary to the posterior vaginal repair, and some of which required vaginal dilatation and/or further surgical correction.

Fewer than 10% of patients in the MMMK group required prolonged use of a postoperative urethral catheter. The Foley catheter was usually removed on the day following surgery, and intermittent straight catheterization was rarely needed. A suprapubic catheter was routinely placed in the MP procedure group, however.

DISCUSSION

Traditionally, SUI has been viewed as a simple anatomic problem caused by loss of the posterior urethrovesical angle that could be corrected by merely "pushing up" the angle with a conventional Kelly plication. As more information about the anatomy, physiology, and urodynamics of the bladder and urethra became available, SUI emerged as a very complex problem that could be improved long-term by almost any procedure replacing the urethra to its normal anatomic position. Nonetheless, a review of the literature indicates much remaining uncertainty, misunderstanding, and differences of opinion regarding the methods of diagnosing and treating SUI. Few papers offer good long-term data for comparison; most studies include follow-up of less than 5 years. This report relates close follow-up of up to 27 years in some patients and includes a breakdown of overall results according to the number of years followed (Table 2).

Over the past three decades, the gynecologic and urologic literature has included many articles related to abdominal and vaginal retropubic cysto-urethropexy procedures. However, it has only been in the past 10 years that studies have begun to appear comparing vaginal needle suspension procedures with abdominal suprapubic procedures. Most studies compare only small numbers of patients, often handled by different surgeons at different institutions using different techniques. In this study, however, all patients underwent surgery in the presence of at least one of the authors at the same institutions using the same technique. In addition, the results are consistent with those of a study of 194 patients11 in which the cure rate for treating genuine SUI increased from 75% to 94% when vaginal retropubic urethropexy was used in conjunction with a Kelly procedure.

There has been much controversy as to which type of suture material is most effective for use in elevating the periurethral tissues (Table 3). Numerous studies have compared absorbable and nonabsorbable sutures in various retropubic cystourethropexy procedures. This report represents the largest number of cases and the longest follow-up using absorbable sutures to date. The results seem to contradict the theory that the nonabsorbable sutures in more recent use have a better cure rate.¹² Indeed, it appears that good results may depend more on proper suture placement and operative experience than on the type of suture material used.

There are various reports of success rates for the MP procedure. The lowest cure rate was 54%¹³ and the highest was 97%.¹⁴ However, these two studies included only a small number of patients that were followed for only 1 to 3.5 years. In this study, the MP procedure yielded a cure rate of 87.8% and an improvement rate of 7.6%, with only 29 failures.

The cure rates for the MMMK procedure range from 57% to 100%. A retrospective review of 56 articles¹⁵ showed an overall success rate of 86.1% in 2712 cases, with 92.1% success in primary and 84.5% in repeat operations. One of the largest studies15 followed 239 patients clinically, of whom 39 underwent urodynamic testing during a 3- to 6-year follow-up. Results included a 69% cure rate, a 25% improvement rate, and relief of prolapse symptoms in 83%. The urodynamic cure rate was only 66%, but it can be argued that the most important criterion of success is the subjective opinion of the patient about her quality of life rather than objective postoperative urodynamic testing under nonphysiologic conditions.

The complication rate in both the MMMK and MP groups was minimal given the large number of patients studied. In almost every MMMK procedure, a Penrose drain was placed in the space of Retzius to allow for drainage and prevent retropubic hematoma. Four cases of partial ureteral obstruction occurred in the MMMK group, but there were no cases of total urethral obstruction in either group. Six neocystostomies occurred in the MP group at the time of anterior repair, sometimes secondary to scarring from prior surgery. These were repaired in two layers at the time of surgery.

Because few anterior repairs were performed at the time of the MMMK procedures, a Foley catheter was placed and removed the following morning postsurgically. Repeat catheterization was required in fewer than 10% of patients. However, a suprapubic catheter was routinely placed in the MP group because anterior colporrhaphy and Kelly plication were usually performed at the same time. Bladder training was initiated on postoperative day 2. More than 90% of patients were sent home on day 2 or 3 with the suprapubic catheter in place. Most patients achieved normal voiding patterns with small residual values by days 7 to 10, at which time the catheter was removed. Fewer than 10% of patients had catheterization times exceeding 10 days. No patient required a catheter for longer than 3 weeks.

Our combined overall results using #1 chromic absorbable sutures indicate a slightly higher cure rate with the MP procedure versus the MMMK procedure (87.8% versus 84.8%). A similar number of patients--approximately 7% in each category--showed improvement.

In patients who initially obtained a clinical cure and then later fell into the improved category, the sequence occurred at a later time in the MMMK group than in the MP group (7.5 years versus 5.1 years). However, patients who went from an initial cure to failure showed an opposite trend, with the MMMK group failing earlier than the MP group (5.5 years versus 7.3 years).

In this study, retropubic suspension procedures for genuine SUI resulted in similar cure rates whether performed abdominally or vaginally. The type of procedure was selected according to the associated findings, with no one type of procedure being performed on all patients. If there were indications for abdominal surgery and the patient had SUI, the abdominal surgery was performed followed by abdominal retropubic MMMK suspension. If the patient had indications for vaginal surgery, an MP procedure was combined with standard anterior colporrhaphy to correct the cystourethrocele.

CONCLUSION

Replacing the urethra to its normal anatomic position via retropubic cystourethropexy is one of the most rewarding advances in surgical techniques for the treatment of SUI. These procedures have better overall long-term cure rates, and can be performed vaginally or abdominally with equal success.

Many practicing gynecologic surgeons and residents are not performing retropubic surgery on a regular basis, probably owing to factors such as lack of training, fear of complications, and reluctance to change. However, physicians must learn these successful retropubic treatment techniques because more patients are reaching menopause and living longer in the postmenopausal state, raising the possibility of an SUI epidemic. The cooperation and/or participation in surgery of a urologist or urogynecologist may be indicated. More comprehensive resident training is needed as well.

Although the perception of SUI has changed markedly during the past 40 years, the renaissance in gynecourologic procedures will probably continue. With this renaissance comes a pressing need for additional investigation, organization, cooperation, and communication regarding the diagnosis and treatment of SUI.

References:

REFERENCES

1. Urinary Incontinence in Adults Guideline Update Panel. Urinary incontinence in adults: acute and chronic management. Clinical practice guideline II, 1996 update. Rockville, Maryland: US Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research; March 1996. AHCPR 96-0682.

2. Kelly HA, Dumm WM. Urinary incontinence in women without manifest injury to the bladder. Surg Gynecol Obstet. 1914;18:444.

3. Quigley GJ, King SK. Transvaginal retropubic urethropexyÑthe revised Pereyra procedure: report of 50 cases. Am J Obstet Gynecol. 1981;139:268-272.

4. Riggs JA. Retropubic cystourethropexy: a review of two operative procedures with long-term follow-up. Obstet Gynecol. 1986;68:98-105.

5. Marshall UF, Marchetti AA, Krantz KE. The correction of stress incontinence by simple vesicourethral suspension. Surg Gynecol Obstet. 1949;88:509.

6. Pereyra AJ. A simplified procedure for the correction of stress incontinence in women. West J Surg Obstet Gynecol. 1959;67:233.

7. Pereyra AJ, Lebherz TB. Combined urethrovesical suspension and vagino-urethroplasty for correction of urinary stress incontinence. Obstet Gynecol. 1967;30:537-546.

8. Slate WG. Disorders of the Female Urethra and Urinary Incontinence, 2nd ed. Baltimore: Williams and Wilkins; 1982.

9. Bonney VB. Diurnal incontinence of urine in women. J Obstet Gynecol Br Eng. 1923;30:358.

10. Pereyra AJ, Lebherz TB. The modified Pereyra procedure. In: Gynecologic and Obstetric Urology, 2nd ed. Philadelphia: W.B. Saunders; 1982:259-277.

11. Beck RP, McCormick S, Nordstrom L. A 25 year experience with 519 anterior colporrhaphy procedures. Obstet Gynecol. 1991;78:1011-1018.

12. Korn AP. Does use of permanent suture material affect outcome of the modified Pereyra procedure. Obstet Gynecol. 1994;83:104-107.

13. Christ T, Shingleton MH, Robertson WE. Urethrovesical needle suspension. Obstet Gynecol. 1969;34:489.

14. Roberts JA, Angel JR, Raju T, et al. Modified Pereyra procedure for stress incontinence. J Urol. 1981;125:787-789.

15. Mainprize TC, Drutz HP. The Marshall-Marchetti-Krantz procedure: a critical review. Obstet Gynecol Surv. 1988;43:724-729.

16. Pereyra AJ, Lebherz TB, Growdon WA, Power JA. Pubourethral supports in perspective: modified Pereyra procedure for urinary incontinence. Obstet Gynecol. 1982;59(5):643-648.

17. Bergman A, Koonings PP, Ballard CA. Primary stress urinary incontinence and pelvic relaxation: prospective randomized comparison of three different operations. Am J Obstet Gynecol. 1989;161(1):97-101.

18. Poryazov K. Modified Marshall-Marchetti-Krantz method by Joseph A. Riggs in urinary stress incontinence (our experienceÑa preliminary report. Folia Med (Plovdiv). 1990;32(3):26-29.

19. Wheelahan JB. Long-term results of colposuspension. Br J Urol. 1990;65(4):329-332.

20. Colombo M, Scalambrino S, Maggioni A, Milani R. Burch colposuspension versus modified Marshall-Marchetti-Krantz urethropexy for primary genuine stress urinary incontinence: a prospective, randomized clinical trial. Am J Obstet Gynecol. 1994;171(6):1573-1579.

Joseph A. Riggs, MD, is a Professor of Obstetrics and Gynecology and John C. Riggs, MD, is a Clinical Instructor in Obstetrics and Gynecology at Thomas Jefferson Medical University in Philadelphia, Pennsylvania; they are also attending gynecologists both at West Jersey Voorhees and Our Lady of Lourdes Medical Center, Camden, New Jersey.

Originally published in The Female Patient -- November, 1997

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