Surgical Treatment of Stress Urinary Incontinence in Women in the Mainland of China: Current Status and Outlook.

Surgery for female stress urinary incontinence (SUI) has been making remarkable progress in recent decades. Hammock theory[1] has been a milestone in explaining the etiology of SUI, as introduced by Ulmsten, illustrating that dysfunction of pubourethral ligament and pubococcygeus is the major pathological mechanism of SUI. Anti-incontinence sling is divided into retropubic route[2] and obturator route:[3] retropubic route embraces “down-up” and “up-down” approach to complete puncture of sling placement and obturator route consists of “inside-out” and “outside-in” approaches to complete the puncture sling placement. Moreover, in recent years, a more minimally invasive operation has been developed based on these two kinds of routes: the single mini-incision sling, with minimal invasiveness, less sling implanted, and no skin incision of the skin. Tension-free vaginal tape (TVT) with the application of synthetic sling to strengthen the vagina pubourethral ligament has become the first choice of SUI treatment performed by urinary gynecologists, urologists, and gynecologists worldwide for its minimal invasion and durable effect.

Since Dr. Xiao-Wen Tong, who came from Department of Obstetrics and Gynecology, Tongji Hospital Affiliated to Shanghai Tongji University, successfully performed the first TVT surgery in the mainland of China in 1998, sling procedure has been widely used for SUI treatment.[4567] As there are no professional urogynecologic doctors in the mainland of China, procedures for SUI are performed by both urologists and gynecologists. There have been literatures published on antiurinary incontinence procedures since 2002 in China, by urologists and gynecologists, respectively. As shown in Figure 1, urologists published more articles than gynecologists before 2006, while the situation reversed after 2006. This trend in quantity of papers points out that gynecologists are getting more involved in this field. There are 55 papers reporting procedure through obturator internus by gynecologists and 39 by urologists, indicating that most gynecologists adopt transobturator way in TVT surgeries in the mainland of China. Apart from traditional Burch, we have Marshall-Marchetti-Krantz suspension procedures. For saving medical cost, novel autologous fascia suspensions or sling procedures were introduced in the mainland of China.

Figure 1

Publications on antiurinary incontinence procedures in the mainland of China.

So far, problems in the treatment of SUI in the mainland of China are as follows:

It is well known that SUI is diagnosed by clinical symptoms, with a misdiagnosis rate of at least 20% even supplied with the most comprehensive history. In another word, involuntary urinary incontinence can present in other clinical situations. Thus, further tests are required including routine tests, gynecologic examination, evidence for SUI, measurement of residual urine, urine routine, midstream urine culture, and urodynamics study if necessary.

Although surgical treatments for SUI have produced a satisfying long-term outcome, it is worthy to mention the famous comment by Dr. Roger Dmochowski: there are always misunderstandings in SUI patients that surgeries can cure the SUI symptoms. However, actually, it can only relieve symptoms to some extent in reality. Therefore, patients should be fully informed of the advantages and disadvantages of surgical treatment preoperatively, as well as the choices of surgical approaches. Plenty communication with patients and their families is of importance. Surgical approach should be decided by both doctors and patients with full regard to the advantages and disadvantages.

The application of the synthetic sling antiurinary incontinence surgery in SUI has become the first-line surgical treatment in the mainland of China. The therapeutic effect of pelvic floor rehabilitation on SUI should not be neglected yet. The Guidelines for Diagnosis and Treatment of Stress Urinary Incontinence delivered by Female Urogynecological Group of the Chinese Medical Association have been recommended.

The concepts and modes of treatment of SUI have changed greatly. Many doctors believe that they can accurately evaluate the quality of life of patients in clinical diagnosis. No urine leakage has believed a standard of full recovery. However, Class A evidence suggests that it is difficult and inaccurate for doctors to evaluate the quality of life of patients with pelvic floor disease. Because the anti-incontinence treatment is to improve the quality of life of patients, the treatment is very difficult to determine the definition of “success.” The result of questionnaires should include the major part of the evaluation of surgical outcome. It is also important to complete the long-term follow-up and get full understanding of the long-term clinical outcome.

Surgical treatment of SUI has entered a new period. Implantation of synthetic sling has become the first-line surgical treatment, but long-term outcome and complications caused by synthetic sling are still significant clinical problems, which need clinical doctors to make more efforts and long-term follow-up.