Abdominal, vaginal or laparoscopic approach for urinary incontinence?

Abstract

Urinary incontinence is extremely widespread. In general more women suffer from urinary incontinence than from diabetes, coronary disease or hypertension. Urinary incontinence is not a disease of recent decades. Throughout human existence, women have suffered from incontinence. There were different attempts to cure these patients conservatively or by surgery. In the oldest medical document in history, the Ebers papyrus, urinary incontinence is already mentioned with the therapeutic approach of vaginal pads. It is unclear whether they were used to raise the urethra or to apply certain medications.Nothing is known about the success of these early attempts.However, all we know is that even 3,500 years ago women suffered from urinary incontinence and were treated with a standardized therapy that was a conservative and not surgical one. Surgical approaches during this time are not yet described. Which approach did surgeons of more recent times choose to cure urinary incontinence? In 1907 Giordano mobilized part of the musculus gracilis and wrapped it around the urethra.At this time, no further development of this technique took place. However nowadays, we again find similar surgical approaches to cure urinary incontinence. In 1910 Goebell described the first surgical technique of retropubic suburethral slings.He separated the two parts of the musculus pyramidalis, led them retropubically through the spatium retzii. Then he connected both tips underneath the urethra, in the area of the vesicourethral angle,with the intent of tightening the suburethral tissue and stabilizing the urethra. This approach was later modified by Stoeckel in 1917. The pyramidalis muscle was no longer used because of its insufficient length and was replaced by parts of the aponeurosis, located ventral to the m. pyramidalis and m. rectus abdominis. The Goebell-Stoeckel surgical technique uses an abdominal approach combined with a small vaginal incision. There are no valid studies documenting the success rate of this surgery or long-term results.Nevertheless this technique was fully accepted for decades.However, there was an attempt to look for improvements. For example, one major disadvantage of this method was the dissolution of the tendinous membrane after a certain time and therefore the loss of functional stabilization of the urethra. The effort to improve this method by the concept of a retropubic suburethral sling was one of the early versions of the TVT used today.No long-term results can be found.