SAND: What do you think about the new radiofrequency technologies being used to create support in periurethral tissues to correct hypermobility? Is there a role for this evolving technology?
LUBER: The concept of developing scar tissue adjacent to the urethra to provide better support underlies much of what we already do surgically. So there is some logic in the use of radiofrequency technologies to accomplish the same thing.
Still, there is the theoretical risk of further denervating the urethra, which is probably already denervated. Having looked at outcome studies for radiofrequency therapy, I think it’s a modality that can be embraced, but that should be done under the auspices of clinical research. Again, I’m old fashioned and am not comfortable integrating untested approaches into routine clinical care until we have adequate evidence of their effectiveness. In caring for incontinence, it is important that this effectiveness be looked at over a reasonable period of time, for example, 48 months.
It is hard to treat detrusor overactivity when the urethral sphincter is weak.—Dr. Myers
DAVILA: I have had some experience with radiofrequency therapy, and the tissue changes it stimulates are fairly impressive. I share your concern about the issue of denervation. In fact, my colleagues and I are hoping to initiate a trial in which we plan to look at pudendal latencies to the urethral sphincter in these patients. As of now, with limited experience, it appears that there is no worsening of urethral sphincter function with the therapy.
Tension-free vaginal tape
SAND: What about other new treatments on the horizon?
DAVILA: Like bulking agents, new minimally invasive surgical techniques are also increasing in number. The advent of the tension-free vaginal tape (TVT), a technique that moved from Sweden to the United States a couple of years ago, truly has revolutionized what we do in anti-incontinence surgery. I think we all can agree that it has changed our practice patterns quite significantly, and the modifications or theoretical improvements by different companies are likely to have a further impact.
Polypropylene mesh appears to be very well received by the body. It doesn’t get rejected or infected at a significant rate, so most physicians are comfortable with it. But I think it has become the surgeon’s preference as to which product works better.
For the Ob/Gyn, the primary issue remains the small yet well-recognized risks of retropubic needle placement, beginning with bladder perforation and including vascular or bowel injury. As a result, many Ob/Gyns have probably been hesitant to perform these procedures.
What the future holds is very exciting: the transobturator approach to surgery for stress incontinence. Instead of bringing the needle superiorly behind the pubic bone, the surgeon maneuvers it laterally beneath the pubic ramus and through the obturator membrane. This is an anti-incontinence procedure a gynecologist can embrace. It may not be necessary to perform cystoscopy afterward because the surgery is nowhere near the bladder.
The French have taken the lead in developing this technique and recently presented approximately 2 years of data.6,7 A US trial also is being initiated.
LUBER: TVT is billed as a midurethral procedure. However, when you consider where those tapes actually end up after a few months, it probably functions much like a traditional sling. Recent studies are in conflict: Some demonstrate the sling remains at the midurethra while others show that it readily migrates to the bladder neck. So the quest for a less obstructive procedure has not been fulfilled with the TVT.
In fact, in our recent TVT series that Drs. Lukacz and Nager are meticulously following, the voiding time increases and the maximum flow decreases postoperatively in roughly 30% of patients. So it definitely has some obstructive characteristics.
Quest for the Holy Grail continues
LUBER: I think we need to continue to explore these newer, less invasive procedures that offer wonderful potential. At this point, I might employ them in patients who are not able to tolerate the more invasive procedures or who flatly state that they want a less invasive operation. But I am not ready to embrace them as first-line therapy for all of my patients with stress incontinence.
Over the years, we have all seen various waves of surgical innovation, from the noincision urethropexies of the mid-1990s to the laparoscopic techniques prominent later in the decade. Now, more minimally invasive techniques are coming to the fore. At some point, we may even find the Holy Grail. But for the most part, we continue to evolve, examining new approaches until we are forced to reconcile with their limitations.