Urinary incontinence in women is a serious health problem and also a social problem. The most common form of urinary incontinence is more coughing and sneezing, while on the go. Multiple births, vaginal delivery, obesity are important risk factors for urinary incontinence. We have been successfully performing these surgeries for many years. We have research types and clinical studies on this subject published in international journals.

We have presented our studies on the subject in national and international congresses. In this article, I will provide general and up-to-date information on urinary incontinence surgeries in women, in the light of our own experiences and general literature.

What does urinary incontinence/urinary incontinence mean?

The International Continence Association defines incontinence as “involuntary urinary incontinence that disturbs the person socially and hygienically”. As it can be understood from here, urinary incontinence is a health problem that disturbs the person both hygienically and is a social problem. Especially in active and working women, this situation leads to serious social problems. It negatively affects people’s daily and business lives.

What are the types of urinary incontinence?

There are different types of urinary incontinence. The treatment for each of these is different. We can count the types of urinary incontinence as follows;

• Stress urinary incontinence: It is urinary incontinence by coughing, sneezing, while moving, sitting and getting up.
• Urge incontinence: It is the case of incontinence and incontinence of the patients when they feel a sudden urination. This group of patients is usually treated with medication.
• Overflow incontinence: It is the case of urine leakage as a result of the bladder being overfilled. It is often seen in nervous diseases of the bladder (neurogenous bladder) and in advanced stages of prostate enlargement in men.
• Mixed urinary incontinence: It is the simultaneous presence of more than one type of urinary incontinence. Often, stress and urge incontinence can coexist. Surgery is required for stress incontinence, and drug therapy is started for urge incontinence.

Stress type incontinence (what is urinary incontinence)?

Stress incontinence is a form of involuntary urinary incontinence, which is seen in situations such as coughing, sneezing, straining, standing up and moving, and is frequently encountered in women.

Stress incontinence is more common in women who have had a difficult vaginal delivery, those who have had multiple deliveries, and those who are obese (overweight). The incidence of urinary incontinence increases in postmenopausal women. The severity of the disease can vary from person to person. The social life of some patients is severely affected, so much so that women are afraid to leave the house or participate in an activity in public. However, most patients think of this as a natural consequence of giving birth and aging, or they are ashamed and hesitant to go to the doctor.

There are different causes of urinary incontinence. In this section, I will talk about “stress urinary incontinence”, which is common in women. Patients who apply to a doctor with urinary incontinence should be evaluated in detail and first the type of urinary incontinence should be determined, and then an appropriate treatment plan should be made. In some patients, more than one type can be found together, this situation is called mixed urinary incontinence. Stress urinary incontinence is often seen with urge incontinence. Urge incontinence (urgency urinary incontinence) is the condition of incontinence with the sudden feeling of urination, before the patients can reach the toilet. If more than one type is present in patients, treatments should be planned according to the type of urinary incontinence.

What are the risk factors for stress incontinence?

Stress urinary incontinence is more common in some women. Risk factors for this disease include:

• Multiple births
• Vaginal and difficult delivery
• Obesity (being overweight)
• Women in menopause

Surgical treatment of urinary incontinence (surgical methods)

For an effective treatment of urinary incontinence, its type must first be determined, because not all types of urinary incontinence can be treated surgically. The type of urinary incontinence that can be treated with surgery is the “stress type” urinary incontinence, which is especially common in women. There are 2 surgical methods with a very high success rate in this disease. These are TOT and TVT (transvaginal tape application and transobturator tape application) surgeries. Both surgeries are usually day surgeries that do not require a long hospital stay, and the duration of the operation is very short, such as 20-30 minutes. The basic principle in TOT and TVT surgeries is to lift the bladder neck, which is in a position that hangs down from the normal, with special suspension materials and hang it on the pelvis bone with the vaginal intervention.

Preparation before TOT and TVT surgeries

Patients fast for at least 5-6 hours before surgery. Blood tests required for the surgery, chest X-ray and, if necessary, ECG tests are requested. If these are normal, the patient is ready for surgery.

The list of drugs used by the patients is made, if they are using blood thinners such as aspirin, they should be discontinued 1 week in advance. Patients taking heart, blood pressure and diabetes medications should continue to take these medications as recommended by their doctors.

The consent form, which contains detailed information about the surgery, is read to the patients and they are asked to sign it.

How long is the operation time, type of anesthesia and hospital stay?

The surgery is performed under general anesthesia or spinal anesthesia. The operation time is about 20-30 minutes. Patients stay in the hospital for 1 day or are discharged on the same day. We usually take our patients out the same day. Sometimes we keep her in the hospital for a day.

What are TOT and TVT surgeries and how are they performed?

Stress incontinence in women is a disease that can be treated with surgery. There are 2 types of surgeries commonly performed for this purpose, these are TOT and TVT surgeries. Both of these surgeries are mid-urethral sling surgery methods. In both surgeries, a strip-shaped suspension material (mesh, mesh) made of a special material, which is not harmful to the body and does not cause a serious reaction, is passed just under the urinary canal (urethra), and the sagging bladder neck is suspended and thus brought to its normal anatomical position.

Both surgeries are very similar to each other surgically. During the surgery, small incisions are made in the lower abdomen and in the vagina. This strip-shaped band lifts the bladder neck and urethra. During the sling, the tension of this band is adjusted approximately and the band stays with the patient, becoming a part of the body over time. The surgical site and the sling material are invisible from the outside, and since the incisions are closed with absorbable sutures, they melt and fall off on their own over time.

There is no significant difference in the success rate, operation time and sling materials used between TOT and TVT surgeries. Since patients do not have knowledge about choosing these techniques, the doctor decides according to his own experience.

A Foley catheter is inserted into the bladder during the surgery, and after the patient regains consciousness at the end of this surgery, it is removed or remains attached for a day. Some patients may have a temporary inability to urinate after the catheter is withdrawn after the surgery, therefore, patients should be observed to urinate after the catheter is removed. In addition, a gas tampon with a batikon is placed in the vagina against bleeding during the surgery, this tampon is removed before the patient is discharged.

Patients start to take it orally 5-6 hours after the operation. There may be mild pain at the surgery site after the surgery, for this, painkillers and antibiotics are started against infection.

What is the course like after the surgery?

The surgery is performed under general anesthesia or spinal anesthesia and takes about 20-30 minutes. The success of the surgery is over 95%. After the surgery, the patient is kept in a special room until he/she is fully recovered and then taken to the bed. The catheter (Foley catheter) inserted into the urethra during the operation is removed when the patient regains consciousness and is able to urinate on his own. The tampon placed in the vaginal area during the surgery is also removed before the patient is discharged from the hospital after the patient regains consciousness. Patients who do not have any problems are usually discharged on the same day by prescribing painkillers and antibiotics and giving a control appointment. Sometimes patients may not be able to urinate after these surgeries, in such cases, the doctor should be contacted and a temporary catheter should be inserted if necessary.

What should be considered after the operation?

It goes very smoothly after the surgery. We tell our patients in detail what they should pay attention to after the surgery. It is important to note the following:

• Patients start their normal lives after one week.
• Regular use of given antibiotics and painkillers
• They should not have sexual intercourse for 4-6 weeks
• In the first 4-6 weeks after the surgery, heavy lifting and heavy sports should not be done.
• It is very important that patients do not gain weight. After the operation, this situation needs special attention.

What are the complications of TOT and TVT surgeries?

The success rates of these surgeries are high, the complications are extremely low and insignificant. Rare complications after surgery include:

• Inability to urinate after removing the catheter: Sometimes patients may not be able to urinate temporarily after the catheter is removed. This situation is temporary.
• Pain: There may be mild pain. It is possible to relax with painkillers.
• Discharge from the wound: There may be a slight discharge from the small wound around the urethra.

What are the success rates of TOT and TVT surgeries?

TOT and TVT surgeries are surgeries with a high success rate. Appropriate patient selection is crucial for success. Approximately 90-95% of these surgeries yield very successful results. We have achieved high success in all of our patients in our surgeries. It is very important that patients do not gain weight in later periods.

In summary: TVT and TOT surgeries have a high success rate in cases of stress incontinence type urinary incontinence in women. In our 10-15 years of follow-up, the patients are quite happy. Complications of the surgery are negligible.

Wishing you healthy days….

Prof. Dr. Emin ÖZBEK

Urology Specialist

Istanbul- TURKEY