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Summary

Urethropexy is a surgical procedure performed to treat stress urinary incontinence, a condition in which a small amount of urine leaks out of the bladder during activities such as coughing, sneezing or exercising. Urine leakage may cause skin problems and affect the quality of life. The condition occurs due to weakening of the muscles and tissues that hold the bladder and urethra, causing these two organs to sag or drop abnormally lower than their original position. Urethropexy helps lift both the bladder and the urethra; thus, stopping the leakage of urine.

The operation lasts for about 90 minutes, and most women are discharged either on the same day of the surgery or after two to three days. It usually takes about six weeks to recover from the surgery completely.

  1. What is urethropexy?
  2. Why is urethropexy recommended?
  3. Who can and cannot get urethropexy?
  4. What preparations are needed before urethropexy?
  5. How is urethropexy done?
  6. How to care for yourself after urethropexy?
  7. What are the possible complications/risks of urethropexy?
  8. When to follow up with your doctor after a urethropexy?

Urethropexy is an abdominal surgery performed to treat stress urinary incontinence (SUI), a condition that occurs due to a sagging urethra and bladder neck. 

Urinary bladder is an organ present in the pelvic region that is responsible for storing urine. When you are ready to urinate, it contracts to push the urine into your urethra. Urethra is a tubular organ that carries urine to the outside of your body. The opening of the bladder into the urethra is guarded by sphincter muscles that open when the bladder contracts. Both the bladder and urethra are held in a fixed position by pelvic floor muscles and connective tissue called fascia. However, certain conditions such as being overweight, childbirth, and injury to the lower back can weaken pelvic floor muscles and the muscles of the sphincter between the urethra and bladder. This causes the bladder and urethra to hang abnormally lower than their normal position and urine to leak out of bladder during physical activity or activities that exert stress on the abdomen, such as sneezing or coughing. The condition is called stress urinary incontinence (SUI), and it occurs more commonly in women than in men.

The leakage of urine and resulting skincare issues (like soreness and irritation in the groin from the constant moisture), affect the overall quality of life of a person and may lead to exhaustion and depression. During urethropexy, this urine leakage is stopped urine by lifting the sagging lower part of the bladder and urethra.

This surgery is advised when other non-surgical methods like medications, Kegel exercises, and bladder retraining (a type of behavioural therapy that helps to hold urine) are not useful in the treatment of SUI. Women with SUI usually experience leakage of urine during common activities such as laughing, sneezing, coughing, lifting heavy objects, exercising, standing up, and having sex.

A surgeon may not perform urethropexy in the following conditions:

  • Type III stress urinary incontinence (occurs when a urethral sphincter that does not work, causes the urethra to stay open)
  • Central defect cystocele (the bladder presses into the anterior vaginal wall, causing a bulge)
  • Introital deficiency (problems with the opening of the vagina)
  • Rectocele (weakening of the posterior vaginal wall, causing the rectum to bulge into the vagina)
  • Before childbearing
  • If the person is in some way unfit for the surgery

A pre-operative assessment will be conducted a few days prior to the surgery wherein the surgeon will perform a physical examination. You will also have to undergo some tests, including:

  • Blood test
  • Urine test
  • Pad test: The test helps to study urine leakage caused by physical activity or exercise
  • Cystoscopy: Cystoscopy is performed by inserting a narrow tube fitted with a camera in the bladder (to view the inside of the bladder)
  • Urodynamic studies: This helps study the ability of the bladder, urethra, and sphincters to hold and pass urine.

The surgeon may also ask you to maintain a diary to record your fluid intake, frequency of urination, and activities that cause urine leakage. In addition:

  • The surgeon will ask whether you are pregnant or have any allergies.
  • You will be asked to share a list of all the medications that you take, including herbs, supplements, and over-the-counter medicines.
  • You will be asked to discontinue blood thinners like warfarin, aspirin, and ibuprofen a few days prior to the surgery.
  • If you smoke, you will be asked to stop smoking as it may otherwise delay healing after the surgery.
  • You should shower and remove body piercings, nail polish, and make-up before arriving at the hospital on the day of the surgery.
  • Your doctor may ask you to arrange for a family member, friend, or a responsible adult to drive you home after the procedure.
  • If you have flu, cold, or fever on the days leading to the surgery, your surgery may be postponed.
  • The surgeon will ask you to fast for six to 12 hours prior to the surgery as anaesthesia is associated with a risk of vomiting during the surgery.
  • You will need to sign an approval or consent form to grant your permission for the procedure.

Once you reach the hospital, the medical staff will provide you with a hospital gown. They will start an intravenous line in your arm or hand to supply essential fluids and medicines during the procedure. Thereafter, the surgeon will insert a catheter (thin, flexible tube) into your bladder to drain out urine. Although urethropexy can be performed by many methods, Burch colposuspension (a surgery to support the neck of the bladder) is the most commonly used method.

Burch colposuspension is done under general anaesthesia so that you are in a deep sleep during the procedure and do not feel any pain. The procedure is performed by two ways:

  • Open technique: The surgeon will make a large incision (cut) in the lower part of your abdomen to access your vagina, bladder, and urethra.
  • Laparoscopic technique: In case of a laparoscopic surgery, the surgeon will make multiple small cuts in your lower abdomen through which he/she will insert a tube fitted with a camera and other small instruments required for the surgery.

After the incision:

  • The surgeon will stitch a part of your vaginal wall, neck of your bladder and urethra to the ligament next to your pubic bone (Cooper’s ligament). This will create a hammock-like support for the neck of your bladder and help lift it up.
  • Once that is done the surgeon will close the cuts either with staples, sutures, or surgical tape.

The surgery lasts for about 90 minutes. Those who undergo laparoscopic surgery experience less postoperative pain, require shorter hospital stays and are able to resume normal routine activities quicker than those who undergo open surgery.

When you wake up after the surgery, you will feel groggy, tired, or restless and have a dry mouth or sore throat. These are side effects of anaesthesia and will fade away within a few hours. You will be discharged either on the same day or after two to three days under observation.

You may be discharged with the catheter inserted in your urethra to drain urine. If the catheter is removed at discharge and you cannot urinate normally, you may need intermittent catheterisation, wherein you will be required to use the catheter when you urinate.

It may take around six weeks for you to completely recover from the surgery. Before you are discharged from the hospital, the surgeon will provide you with some instructions to take care of yourself during the recovery period. These include:

  • You will experience some pain around the operated area after the surgery. The surgeon will prescribe some medications for it that should be taken as directed.
  • Avoid indulging in strenuous activities and lifting objects that weigh more than 5 kilograms.
  • Drink one to two litres of fluids, mostly water, each day.
  • You may experience constipation during the recovery period. The following tips will help you avoid it:
  • Your doctor will tell you when to resume showering after the surgery.
  • Avoid sex and insertion of objects such as tampons into your vagina during the recovery period.

When to see the doctor?

You should contact the surgeon if you experience any of the following symptoms:

The potential risks and complications associated with urethropexy include:

You will be given a schedule for follow-up appointments before you leave the hospital after surgery. If you were discharged with a catheter in your urethra, you will need to visit the surgeon after 10 days to get the catheter removed.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.

References

  1. UW Health: American Family Children's Hospital [Internet]. Madison (WI): University of Wisconsin Hospitals and Clinics Authority; Retropubic Suspension for Urinary Incontinence in Women
  2. Urology Care Foundation [Internet]. American Urological Association. Maryland. US; Stress Urinary Incontinence (SUI)
  3. Johns Hopkins Medicine [Internet]. The Johns Hopkins University, The Johns Hopkins Hospital, and Johns Hopkins Health System; Muscle Pain: It May Actually Be Your Fascia
  4. Mount Sinai [Internet]. Icahn School of Medicine. New York. US; Urinary incontinence - retropubic suspension
  5. National Association for Incontinence [Internet]. South Carolina. US; Stress Urinary Incontinence in Women
  6. Bergman A, Koonings PP, Ballard CA. Negative Q-tip test as a risk factor for failed incontinence surgery in women. J Reprod Med. 1989 Mar;34(3):193-7. PMID: 2724231.
  7. Groenen R, Vos MC, Willekes C, Vervest HA. Pregnancy and delivery after mid-urethral sling procedures for stress urinary incontinence: case reports and a review of literature. Int Urogynecol J Pelvic Floor Dysfunct. 2008 Mar. 19(3):441-8. PMID: 18071619.
  8. National Health Service [Internet]. UK; Before surgery
  9. Hernandez A, Sherwood ER. Anesthesiology principles, pain management, and conscious sedation. In: Townsend CM Jr, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 20th ed. Philadelphia, PA: Elsevier; 2017:chap 14
  10. Cohen NH. Perioperative management. In: Miller RD, ed. Miller’s Anesthesia. 8th ed. Philadelphia, PA: Elsevier Saunders; 2015:chap 3
  11. Beth Israel Lahey Health: Winchester Hospital [Internet]. Winchester. Maryland. US; Urethral Suspension—Retropubic Suspensions
  12. Sohlberg EM, Elliott CS. Burch Colposuspension. Urol Clin North Am. 2019 Feb;46(1):53-59. PMID: 30466702.
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