Dr David Molloy

Bladder neck suspension for incontinence    

Bladder Neck Suspension are used to support the bladder neck where the urethra joins the bladder to treat urinary stress incontinence i.e. loss of urine when you cough, sneeze or stain. The sutures can either be placed in position by using a larger cut above the hairline and pubic bone or using the laparoscope to minimise the incisions.

ADVANTAGES OF LAPAROSCOPIC BLADDER NECK SUSPENSION

  • Small incisions and less scarring
  • Better views of the bladder neck
  • Gentler handling of the body tissues and organs during the operation
  • Less blood loss during the operation
  • Less postoperative pain
  • Less postoperative narcotic use for pain relief
  • Shorter hospitalisation
  • Faster overall recovery with an earlier return to normal activity

TECHNIQUE OF LAPAROSCOPIC BLADDER NECK SUSPENSION

  1. Preoperative preparation involves a partial shave. Fasting for 6 hours preop is required.
  2. A general anaesthetic is administered.
  3. The laparoscope and other instruments are introduced as described.
  4. A catheter is placed in the bladder.
  5. The area of the bladder neck is dissected.
  6. Sutures are placed from the vagina under the bladder neck into the ligaments of the pubic bone to lift the bladder neck.
  7. A telescope (cystoscope) is placed into the bladder to check the sutures are in the right place.
  8. The wounds are closed.

SUCCESS RATES

This operation is viewed as the most successful operation for stress incontinence and is the standard by which other techniques are judged. It will be successful in 85-95% of cases initially. However, the failure rate at 5 years is 20-30% due to further laxity in the supporting tissues. Failure rates are higher in obese patients, smokers and patients with chronic respiratory illnesses.

RECOVERY

Immediate post operative recovery involves an average of 1 night in hospital. 4 in 5 patients can go home late the next day after surgery. Patients are welcome to rest in hospital for as long as they need to. Two in 5 patients will only need tablets and not injections for postoperative pain relief. If injections are required 1 is needed on average. Patients will be given as much pain relief as they request to make sure they are comfortable. You will come back to the ward with a catheter in your bladder. This will usually be removed the next day. You will be monitored carefully to make sure passing urine is comfortable and complete. Some patients have difficulty emptying their bladder and may need to be taught to self catheterise. This always sounds very daunting but is easy and patients manage it very well. The first few days at home should be taken very easily. The patient should have someone to help. Plenty of rest and fluids are advisable. Exercise your calf muscles to prevent clots. Oral pain relief e.g. Panadeine/Panadol may be needed, especially at night. Graded recovery occurs over a few weeks. Many patients can go back to light work within 1-2 weeks. Heavy lifting should be avoided. Driving is allowed. No intercourse should take place for 6 weeks. Everyone is different and each patient should assess their own recovery rate. Bladder neck suspension surgery is not very invasive and recovery is without excessive discomfort but other surgery e.g. hysterectomy is often performed at the same time. This will affect recovery times.

RISKS OF BLADDER NECK SUSPENSION

  1. Infection - Infection rates are low as preventative antibiotics are used at and after surgery. In hospital rates are 1-2%.
  2. Bleeding - At the time of the operation some blood will be lost. Very rarely this can be serious and require some emergency treatment such as transfusion. No such cases have yet occured in our unit but the possibility does exist. The bladder neck area is a large potential space and can form a bruise called a haematoma If large these cause added pain and there is an infection risk. They are uncommon.
  3. Damage to bladder and ureter - These structures are very close to the bladder neck and can be damaged. The risks are about 1 in 250-300 cases. Damage detected at the time of surgery is repaired immediately and will often not have serious consequences. A cystoscopy will be performed to check for this and minimise any risks. Sometimes the injury can be undetected or develop over several days after surgery e.g. where a burn is made to stop bleeding. A fistula can then develop. This is a connection of bladder or ureter to skin or vagina. Further surgery will be required to fix this. The risk of this is about 1 in 500 cases.
  4. Deep Venous Thrombosis or Pulmonary Embolus - A clot can form in the leg or pelvic veins and travel to the lungs. The risk it will happen is about 1 in 400-500. This is serious and can rarely be fatal. Tell your doctor if these have happened to you before or if you have a family history. During the surgery a number of precautions are taken to prevent these. Early mobilisation after laparoscopic surgery may also reduce the risk compared to larger incisions operations.
  5. Other risks of laparoscopy - As described in the Laparoscopic Surgery Information Sheet.
  6. Conversion to open bladder neck suspension - During the course of the operation the doctor may decide your case is not suitably safe for laparoscopic approach. A conventional suspension as could be done elsewhere will then be performed. The risk of this is 3 in 100 cases.

POSTOPERATIVE BLADDER INSTABILITY

There are two sorts of involuntary urine loss. Stress incontinence and urge incontinence. Urge incontinence is due to electrical bladder instability with the muscles of the bladder spasming and threatening to empty. Some patients have both sorts of incontinence. Surgical interference with the bladder commonly causes temporary bladder irritability. This usually settles after 2-6 weeks although occasionally may not. Some patients have their underlying urge incontinence exposed after surgery and then will need tablets to stabilise their bladder and settle the electrical activity.

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