Stamey and Gittes Bladder Neck Suspension

STAMEY BLADDER NECK SUSPENSION

Suspension of the bladder neck via a vaginal approach was initially described by Peyrera in 1959. Contemporary techniques of transvaginal bladder neck suspension have arisen as modifications of Peyrera’s description. The endoscopic needle suspension of Stamey, described in 1973, contributed several concepts to the surgical technique of bladder neck suspension. This procedure was the first to utilize the cystoscope to precisely place sutures at the bladder neck and visualize closure of the bladder neck with elevation of the suspension sutures. In addition, the procedure incorporates a knitted dacron graft as a bolster to buttress either side of the urethra and aid in the prevention of suture pull-out.

Indications for Surgery

The technique described by Stamey is indicated for correction of stress incontinence in the absence of a significant cystocele. We currently have abandoned simple bladder neck suspensions and perform vaginal wall slings for patients with stress incontinence and no significant cystocele. The choice between these techniques depends on the surgeon’s training and experience with the different procedures.

Alternative Therapy

Alternatives to needle suspensions of the bladder for stress urinary incontinence include transabdominal suspensions, vaginal wall slings, fascial slings, periurethral injections of collagen or Teflon, and conservative measures such as pessaries, pelvic floor stimulation, behavior modification, biofeedback, a-agonist therapy, and urinary collection devices including pads or diapers.

Surgical Technique

Positioning and Retraction

The patient is placed in the dorsal lithotomy position and prepped and draped in the standard fashion. A posterior weighted vaginal speculum and silk labial retraction sutures are placed to aid in exposure. A Foley catheter is placed, and the bladder is drained.

Exposure of Bladder Neck

A T-shaped incision is made in the anterior vaginal wall. The dissection is carried down to the glistening periurethral fascia and continues laterally until the surgeon is able to palpate the balloon of the catheter. This identifies the bladder neck and allows adequate exposure for later placements of the dacron pledgets.

Needle Passage

Two suprapubic stab wound incisions are made on each side of the lower abdomen, and the anterior rectus fascia is exposed. The single-pronged Stamey needle is then inserted into the medial edge of one of the suprapubic wounds and advanced, under fingertip control, into the vaginal incision. The needle passes through the rectus fascia, adjacent to the periosteum, alongside the bladder neck, and through the periurethral fascia as it traverses from the abdomen to the vagina. The Foley catheter is removed, and cystoscopy is performed to confirm correct positioning of the needle. An appropriately positioned needle, when moved medially, will indent the ipsilateral bladder neck. If the needle penetrates the bladder, it should be removed and repassed.

Suture Transfer and Dacron Graft

One end of a #2 nylon suture is threaded through the needle and transferred suprapubically. The Stamey needle is passed a second time, 1 cm lateral to the first pass, and its position is again cystoscopically confirmed. The vaginal end of the nylon suture is threaded through a 10- by 5-mm dacron arterial graft, and the free vaginal end of the nylon suture is then placed in the needle holder and transferred suprapubically. During the transfer of this nylon, an Allis clamp may be used to visually maneuver the dacron graft into appropriate position at the urethrovesical junction as the Stamey needle is pulled suprapubically. The periurethral tissues are now suspended on one side of the bladder neck, and the procedure is repeated on the contralateral side.

Cystoscopy and Closure

Cystoscopy is performed to evaluate the placement of the needle sutures and to confirm adequate functional closure of the bladder neck with minimal tension placed on the nylon sutures. The vaginal incision and graft material are irrigated with an antibiotic solution and closed with a running, locking 2-0 polyglycolic acid suture. An antibiotic-impregnated vaginal pack is placed, and the suprapubic nylon sutures are tied, without tension, such that the knots rest against the rectus fascia. A suprapubic catheter is placed, and the suprapubic wounds are closed with a 4-0 polyglycolic acid suture following antibiotic irrigation.

The vaginal packing may be removed 2 hours after surgery, and the patient may be discharged as early as 6 hours postoperatively. The suprapubic catheter is removed no earlier than 1 week after surgery once the postvoid residuals are less than 60 ml.

Several important technical points have been outlined by Stamey. The dacron graft should be positioned below the suture line to prevent graft erosion through the vaginal incision. Copious irrigation with an aminoglycoside solution should be performed before closing the vaginal incision to decrease the risk of dacron graft infection. The appropriate Stamey needle (0-, 15-, or 30-degree angle at the distal end containing the needle) should be used depending on the patient’s anatomy.

OUTCOMES

Complications

Complications particular to the Stamey needle suspension include erosion of suture and bolster material into the urinary tract, which can occur up to 7 years following the procedure. Stamey reports a 0.3% incidence of dacron buttress erosion into the bladder as well as a 0.3% incidence of failure of the vaginal incision to completely heal, resulting in an exposed piece of dacron. In both circumstances the exposed tube and suture were removed (endoscopically if the tube eroded into the bladder), and continence was maintained with the single remaining suture on the contralateral side. Sutures are removed in 1% to 2% of patients for pain or infection, and long-term retention may be resolved by loosening of the nylon loop under local anesthesia.

Results

Evaluation of the literature to determine the success rates of this operation is difficult. The majority of the studies with an adequate number of patients obtained their data in a retrospective manner without anonymous questionnaires to the patients (thus possibly introducing bias to their results), the follow-up in most studies was short (mean follow-up often 24 months or less), and the definition of success was different from author to author (completely dry versus improved). These provisos should be remembered as the literature is reviewed.

Review of the English literature in the past 5 years reports cure rates that range from 53% to 80%. Walker and Texler evaluated patients with a mail-in questionnaire and found 82% of 192 respondents improved and 65% of patients willing to undergo the procedure again.10 Early success rates with the Stamey bladder neck suspension may not be durable. O’Sullivan et al. reported a dry rate of 70% immediately after surgery in 67 patients, which decreased to 31% dry at 1 year (58 patients) and further decreased to 18% dry at 5 years (22 patients).8 Mills et al. found the cure rate in 30 patients decreased from an initial 67% to 33% over a 10-year period of time. Factors that may place patients at increased risk for postoperative failure include obesity, respiratory disease, number of pads used per day, prior Marshall–Marchetti–Krantz procedure and concomitant abdominal hysterectomy.

GITTES NO-INCISION URETHROPEXY

The technique of Gittes and Loughlin was described in 1987. Their simplified modification of the Peyrera needle suspension obviates the need for vaginal incisions. This technique is based on the concept that as a monofilament suture pulls through the vaginal wall, it heals as an autologous pledget, creating an internal bolster that tethers the anterior vaginal wall and prevents rotational descent with Valsalva.

Indications for Surgery

The technique described by Gittes is indicated for correction of stress incontinence in the absence of a significant cystocele. We currently have abandoned simple bladder neck suspension and perform vaginal wall slings for patients with stress incontinence and no significant cystocele. The choice between these techniques depends on the surgeon’s training and experience with the different procedures.

Alternative Therapy

Alternatives to needle suspensions of the bladder for stress urinary incontinence include transabdominal suspensions, vaginal wall slings, periurethral injections of collagen or Teflon, artificial urethral sphincters, and conservative measures such as pessaries, pelvic floor stimulaion, and urinary collection devices including pads.

Surgical Technique

Positioning and Retraction

The patient is placed in the dorsal lithotomy position and prepped and draped in the standard fashion. A posterior weighted vaginal speculum and silk labial retraction sutures are placed to aid in exposure. A Foley catheter is placed, and the bladder is drained.

Needle Passage

Two suprapubic stab wound incisions, approximately 5 cm lateral to the midline, are made on each side of the lower abdomen at the upper border of the symphysis pubis, and the anterior rectus fascia is exposed. The single-pronged Stamey needle is then inserted into the medial edge of one of the suprapubic wounds such that the tip of the needle scrapes the posterior aspect of the pubic bone. The anterior vaginal wall is identified just lateral to the Foley catheter balloon and simultaneously elevated with the surgeon’s second hand. The needle is then directed, from above, toward the intravaginal fingertip. Once the needle tip is palpable by the intravaginal fingertip, the needle is advanced through the anterior vaginal wall and out through the introitus. The Foley catheter is removed, and cystoscopy is performed to confirm correct positioning of the needle. An appropriately positioned needle, when moved medially, will indent the ipsilateral bladder neck. If the needle penetrates the bladder, it should be removed and repassed.

Suture Transfer

One end of a #2 Proline suture is threaded through the needle, transferred suprapubically, and secured with a hemostat. The Stamey needle is passed a second time, 1 to 2 cm lateral to the first pass, to provide a base of strong fascial support for the suspension. The second pass of the needle should perforate the vaginal tissue approximately 1 cm lateral to the initial pass to avoid tenting up a large amount of vaginal tissue at the completion of the procedure. The position of the Stamey needle is again confirmed with cystoscopy. The free end of the Proline is threaded through a Mayo needle, and two or three helical bites of vaginal tissue are taken between the first and second vaginal perforation. The Mayo needle is then unthreaded, and the free end of the Proline suture is then advanced through the eye of the previously positioned Stamey needle. The needle is withdrawn, and the two ends of the suspension suture are secured with a hemostat for later tying. The periurethral tissue is now suspended on one side of the bladder neck. Needle passage and suture transfer are then repeated on the contralateral side.

Cystoscopy and Closure

Cystoscopy is performed to evaluate the placement of the needle and sutures and to confirm adequate functional closure of the bladder neck with minimal tension placed on the Proline sutures. An antibiotic-impregnated vaginal pack is placed, and the suprapubic Proline sutures are tied, without tension, such that the knots rest against the rectus fascia. A suprapubic catheter is placed, and the suprapubic wounds are closed with a 4-0 polyglycolic acid suture following antibiotic irrigation.

The vaginal packing may be removed 2 hours after surgery, and the patient may be discharged as early as 6 hours postoperatively. The suprapubic catheter is removed no earlier than 1 week after surgery once the postvoid residuals are less than 60 ml.

Outcomes

Complications

An overall complication rate of 9.8% for the Gittes no-incision urethropexy has been reported. Potential complications include prolonged urinary retention (2% to 7%), suprapubic pain or cellulitis, genitofemoral or ilioinguinal nerve entrapment, vaginitis, and suture infection with abscess formation, which could require the removal of a suspension suture (and possibly lead to recurrent stress urinary incontinence).

Results

Reported success rates in the English literature for cure of stress incontinence with the Gittes no-incision urethropexy vary between 81% and 94% depending on the length of follow-up and definition of cure. There are no adequately done studies that have evaluated the long-term efficacy of the Gittes no-incision urethropexy. Kursh evaluated factors influencing the outcome of this procedure and found a significantly decreased cure rate in postmenopausal women and in patients with a greater degree of incontinence preoperatively. As expected, women with type 1 stress incontinence had better outcomes than patients with type 3 stress incontinence (97% versus 45% cure rate, respectively).

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