Üriner İnkontinans Tedavisinde Minimal İnvaziv Cerrahiler
Özet
Üriner inkontinans (Üİ), sosyal ve hijyenik sorunlara yol açan objektif idrar kaçırma durumu olarak tanımlanmakta ve kadınlarda yaşla birlikte artış göstermektedir. Klinik olarak stres (SÜİ), urge (UÜİ) ve mikst (MÜİ) olmak üzere üç ana tipe ayrılan bu rahatsızlıkta, en sık görülen tür karın içi basınç artışıyla tetiklenen SÜİ'dir. Tedavide UÜİ için medikal yöntemler ön plandayken, SÜİ için konservatif yaklaşımlar ve cerrahi seçenekler mevcuttur. Konservatif tedaviden fayda görmeyen komplike olmayan olgularda antiinkontinans cerrahileri uygulanmaktadır. Bu kapsamda Anterior Kolporafi, Kelly Plikasyonu ve Retropubik Üretropeksi (MMK ve Burch) gibi geleneksel yöntemlerin yanı sıra, günümüzde daha yüksek etkinlik ve kısa operasyon süresi sunan minimal invaziv midüretral sling (TVT, TOT) ve tek insizyonlu mini sling cerrahileri tercih edilmektedir. Retropubik yaklaşım (TVT) yüksek kontinans oranına sahip olmakla birlikte mesane perforasyonu riski taşırken, transobturator yaklaşım (TOT) daha düşük komplikasyon riski ve kasık ağrısı ile ilişkilidir. Mini slingler ise daha az postoperatif ağrı avantajı sağlamaktadır. Cerrahi prosedür seçiminde hastanın beklentileri ve risk faktörleri göz önünde bulundurularak kişiselleştirilmiş bir yaklaşım benimsenmelidir.
Urinary incontinence (UI) is defined as an objectively demonstrable involuntary loss of urine causing social and hygienic problems, and its incidence increases with age in women. Clinically divided into three main types as stress (SUI), urge (UUI), and mixed (MUI), the most common type is SUI, which is triggered by increased intra-abdominal pressure. While medical treatment is prominent in UUI, conservative and surgical options are available for SUI. Anti-incontinence surgeries are performed in uncomplicated cases that do not benefit from conservative treatments. In this context, in addition to traditional methods such as Anterior Colporrhaphy, Kelly Plication, and Retropubic Urethropexy (MMK and Burch), minimally invasive midurethral sling (TVT, TOT) and single-incision mini-sling surgeries, which offer higher efficacy and shorter operation times, are preferred today. Although the retropubic approach (TVT) has a high continence rate, it carries a risk of bladder perforation, whereas the transobturator approach (TOT) is associated with a lower risk of complications and groin pain. Mini-slings provide the advantage of less postoperative pain. In the selection of the surgical procedure, a personalized approach should be adopted by considering the patient's expectations and risk factors.
Referanslar
Abrams P, Blaivas J, Stanton S, Andersen J, Fowler C, Gerstenberg T, et al. Sixth report on the standardisation of terminology of lower urinary tract function. Procedures related to neurophysiological investigations: electromyography, nerve conduction studies, reflex latencies, evoked potentials and sensory testing. The International Continence Society Committee on Standardisation of Terminology, New York, May 1985. Scandinavian journal of urology and nephrology. 1986;20(3):161.
Abrams P, Cardozo L, Fall M, Griffiths D, Rosier P, Ulmsten U, et al. The standardisation of terminology of lower urinary tract function: report from the Standardisation Sub-committee of the International Continence Society. Neurourology and Urodynamics: Official Journal of the International Continence Society. 2002;21(2):167-78.
DeLancey JO. Structural support of the urethra as it relates to stress urinary incontinence: the hammock hypothesis. American journal of obstetrics and gynecology. 1994;170(5):1713-23.
Petros PEP, Ulmsten UI. An integral theory of female urinary incontinence: experimental and clinical considerations. Acta obstetricia et gynecologica Scandinavica. 1990;69(S153):7-31.
Hannestad YS, Rortveit G, Sandvik H, Hunskaar S. A community-based epidemiological survey of female urinary incontinence:: The Norwegian EPINCONT Study. Journal of clinical epidemiology. 2000;53(11):1150-7.
Labrie J, Lagro-Janssen AL, Fischer K, et al. Predicting who will undergo surgery after physiotherapy for female stress urinary incontinence. Int Urogynecol J 2015; 26:329.)SUİ tedavisinde cerrahi yaklaşımlar konservatif yöntemlerden daha yüksek etkinliğe sahiptir.( Bø K, Talseth T, Holme I. Single blind, randomised controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones, and no treatment in management of genuine stress incontinence in women. BMJ 1999; 318:487.
Ford AA, Rogerson L, Cody JD, et al. Mid-urethral sling operations for stress urinary incontinence in women. Cochrane Database Syst Rev 2017; 7:CD006375.
Kelly HA. Urinary incontinence in women, without manifest injury to the bladder. Surg Gynecol Obstet. 1914;18:444-50.
Stanton S, editor Randomised study of the anterior repair and colposus-pension operation in the control of genuine stress incontinence. Proceedings of the 15th International Continence Society meeting London; 1985.
Burch JC. Cooper's ligament urethrovesical suspension for stress incontinence: nine years' experience—results, complications, technique. American journal of obstetrics and gynecology. 1968;100(6):764-74.
Vancaillie TG, Schuessler W. Laparoscopic bladder neck suspension. J Laparoendosc Surg. 1991;1:169-73.
Dean N, Ellis G, Wilson D, et al. Laparoscopic colposuspension for urinary incontinence in women. Cochrane Database Syst Rev 2006 Jul 19;(3):CD002239
Ulmsten U, Petros P. Intravaginal slingplasty (IVS): an ambulatory surgical procedure for treatment of female urinary incontinence. Scandinavian journal of urology and nephrology. 1995;29(1):75-82.
Ulmsten U, Henriksson L, Johnson P, Varhos G. An ambulatory surgical procedure under local anesthesia for treatment of female urinary incontinence. International urogynecology journal. 1996;7(2):81-6.
Ulmsten U, Johnson P, Rezapour M. A three-year follow up of tension free vaginal tape for surgical treatment of female stress urinary incontinence. BJOG: An International Journal of Obstetrics & Gynaecology. 1999;106(4):345-50.
Nilsson CG, Kuuva N, Falconer C, Rezapour M, Ulmsten U. Long-term results of the tension-free vaginal tape (TVT) procedure for surgical treatment of female stress urinary incontinence. International urogynecology journal. 2001;12(2):S5-S8.
Serati M, Ghezzi F, Cattoni E, Braga A, Siesto G, Torella M, Cromi A, Vitobello D, Salvatore S. Tension-free vaginal tape for the treatment of urodynamics tress incontinence: efficacy and adverse effects at 10-year follow-up. EurUrol. 2012 ;61:939-46
Gold RS, Groutz A, Pauzner D, Lessing J, Gordon D. Bladder perforation during tension-free vaginal tape surgery: does it matter? The Journal of reproductive medicine. 2007;52(7):616-8.
Delorme E. Transobturator urethral suspension: mini-invasive procedure in the treatment of stress urinary incontinence in women. Progres en urologie: journal de l'Association francaise d'urologie et de la Societe francaise d'urologie. 2001;11(6):1306- 13.
Ogah J, Cody D, Rogerson L. Minimally invasive synthetic suburethral sling operations for stress urinary incontinence in women: a short version Cochrane review. Neurourology and urodynamics. 2011;30(3):284-91.
Daneshgari F, Kong W, Swartz M. Complications of mid urethral slings: important outcomes for future clinical trials. The Journal of urology. 2008;180(5):1890- 7.
Petros PE, Richardson PA. Midurethral Tissue Fixation System sling–a ‘micromethod’for cure of stress incontinence–preliminary report. Australian and New Zealand journal of obstetrics and gynaecology. 2005;45(5):372-5.
Abdel-Fattah M, Ford JA, Lim CP, Madhuvrata P. Single-incision mini-slings versus standard midurethral slings in surgical management of female stress urinary incontinence: a meta-analysis of effectiveness and complications. Eur Urol 2011;60:468–80.
Mostafa A, Lim CP, Hopper L, Madhuvrata P, Abdel-Fattah M. Singleincision mini-slings versus standard mid-urethral slings in surgical management of female stress urinary incontinence: an updated systematic review and metaanalysis of effectiveness and complications. Eur Urol. In press
