WALTERS: I find it somewhat amusing that I am increasingly considered “old-style” when I continue to recommend the Burch procedure.
All I can say is that I’m glad my partners, fellows, and I have the ability to perform this operation when necessary.
KARRAM: Unfortunately, since retropubic urethropexy is performed much less frequently in the past, residents no longer learn retropubic anatomy.
This has become a problem because a many synthetic midurethral slings require blind passage of a needle through the retropubic space.
“I don’t think TVT complications will increase because of lack of experience with the Burch procedure.”
KARRAM: Are we going to see more complications with these procedures because of a lack of clear understanding of the anatomy? If so, how do you think this can be resolved?
WALTERS: Although TVT works very well for SUI, I think our specialty abandoned Burch colposuspension prematurely, ignoring all the evidence supporting its efficacy. I wish residents were still being taught Burch procedures on open cases. I can see that general Ob/Gyns are slowly forgetting how to do the operation, making it more difficult for them to manage complications such as hematomas and infections.
That said, I don’t think TVT complications will occur more often because of this lack of experience with the Burch procedure. On the contrary, I expect them to remain rare. Use of transobturator slings avoids retropubic anatomy completely, but we need more outcome data before making a wholesale switch from TVT.
KARRAM: More injuries to blood vessels and other structures are inevitable when novice surgeons unfamiliar with anatomy attempt to blindly pass large needles.
BLAIVAS: I agree, but the developers of the new techniques are trying to make them idiot-proof—and maybe they will! It’s a sad day, though, when surgeons don’t know anatomy. Too many don’t!
KARRAM: The only solution is to aggressively teach anatomy in residency and demand preceptorships that teach anatomy before allowing inexperienced surgeons to adopt the procedure.
BLAIVAS: If enough mistakes are made, we’ll be forced to teach anatomy again. The best solution, in my judgment, is sub-specialization to the point where all surgeons doing these procedures have sufficient experience.
“No definitive data suggest doing procedures differently based on ISD tests”
KARRAM: Intrinsic sphincter deficiency has become a common term for severe forms of stress incontinence, although there is no widely accepted definition.
How do you define ISD? Is it important to detect it preoperatively? If so, how does ISD alter surgical management?
BLAIVAS: ISD was initially used to describe weakened sphincter mechanism, as distinct from incontinence because of urethral hypermobility.
For practical purposes, all patients with sphincteric incontinence have some degree of “intrinsic sphincter deficiency,” but I no longer use the term. Instead, I characterize the sphincter by vesical leak point pressure and the degree of urethral mobility as measured by a simple Q-tip test. The lower the leak point pressure, the weaker the sphincter, the more likely it will be designated ISD.
WALTERS: I still follow the rough guidelines I was taught: ISD exists at leak point pressures below 60 cm H2O on cystometrogram., although this is probably not that accurate. There is no cutoff defining ISD, but a gradually increasing weakness of the urethral sphincter that correlates roughly with severity of symptoms.
I doubt the concept of ISD would hold up to rigorous scientific scrutiny as a condition or prognostic factor. However, I still use it.
KARRAM: Although intrinsic sphincter deficiency is a vague concept, I believe there are cases that exhibit it—eg, patients who have had multiple operations, been radiated, or have neurologic disease, who essentially have a urethra that is open at rest, doesn’t move, and leaks urine with minimal increases in intraabdominal pressure. In situations such as these, I select procedures that bulk up or obstruct the urethra to correct or improve the incontinence.
Most cases identified as having ISD are based on a urethral function test that measures either leak point pressure or static urethral closure pressure. Unfortunately, little data prove that these tests truly measure urethral function.
There are no definitive data suggesting that a procedure needs to be done any differently based on these tests. So I think the term is presently used in a very cavalier fashion and requires a more objective mechanism to define the condition. Only then can its potential impact on clinical management be evaluated.
Dr. Karram has received research support from American Medical Systems, Yamounouchi, and Gynecare, and serves on the speakers bureau for Gynecare, Ortho-McNeil, Watson, and Indevus. Dr. Blaivas reports no relevant financial relationships. Dr. Walters is a consultant for American Medical Systems and a lecturer for Boston Scientific.