Female bladder control problems and female urinary incontinence (bladder leakage) is one of the most common problems affecting aging women. It is estimated that in the United States, close to 20 million women suffer from it with incontinence affecting half of all the women over the age of 60.
The most common cause of bladder control problems and urinary incontinence in women is relaxation and prolapse of the female pelvic genital organs. This pelvic prolapse, in turn, is caused by prior pregnancy, aging, menopause, and hereditary factors.
Stress Urinary Incontinence
The most common type of urinary incontinence in women is stress urinary incontinence (SUI). This condition affects women of all ages. It is caused by the gradual weakening and “falling down” of the pelvic floor leading to the weakening of the special anatomical angle between the bladder neck and the urethra that acts as a valve. The anatomical changes associated with bladder and pelvic prolapse are caused by aging, childbirth, hormonal changes and genetic factors. This results in urine leakage every time the patient makes a strenuous activity like coughing, sneezing, laughing or even walking because the “valve” controlling the urine is weak
The treatment of stress urinary incontiencne is surgical. While pelvic exercises (such as Kegel exercises) and certain medications can be of some help, only surgery can secure a long lasting favorable result. Many surgical approaches have been tried with various successes. In a consensus statement in 2001, the American Urological Association stated that only two types of “bladder suspension” procedures are proven to have effective long-term cure rates for the treatment of SUI. These procedures are the open abdominal anterior urethropexy (Burch or MMK) and the sling procedure that is done completely vaginally.
With patient demand for minimally invasive treatments, the vaginal sling procedure has pretty much replaced every other type of surgery for the treatment of SUI. The introduction of the tension-free vaginal tape procedures in the late 90’s (SPARC, TVT) to the United States radically changed the treatment of SUI.
State of the Art procedures
The latest advance in the tension-free vaginal slings is the MiniArc and the Monarc Transobturator Sling (also called Monarc Subfascial Hammock (TM) or ObTape(TM) trans-obturator tape or TOT). It is less invasive than the other tension free tapes because the transobturator approach eliminates potential complications that stem from blindly passing a large needle carrier through the retropubic space (as is done with SPARC and TVT). Serious complications with the upward or downward vaginal passage of trocars have been reported with injury to the bladder, bowel, pelvic arteries, veins and nerves.
The Monarc Subfascial approach (also known as Monarc procedure) greatly reduces the risk of these complications. A half-inch mesh is introduced under the urethra to support it during anoutpatient or short stay procedures. It takes about 15-20 minutes. By remaining subfascial, operating below the vital pelvic structures, the transobturator approach eliminates the risk of injury to bladder, bowel or major vessels. Cystoscopy is not routinely required unlike the other retropubic sling procedures.
Because of the safety and simplicity of the Monarc sling procedure, older women who were previously denied the more extensive retropubic sling procedures can now have an alternative procedure that will permanently rid them of stress incontinence.
More advanced prolapse can also be repaired with a small vaginal incision. The Elevate Anterior Prolapse Repair System is used for advance bladder prolapse with or without enterocele and theElevate Posterior Prolapse Repair System can be used for large rectocele with vaginal vault prolapse with or without enterocele.
The cure rates and complications of the Monarc sling procedure are comparable to other tension-free slings at one year. Recently, the Mayo Clinic urologists reported their clinical results. About 82% of women were completely dry, 9% were greatly improved and 9% were slightly improved.
True to their philosophy of providing minimally invasive, state-of-the-art urological care to their patients, Associated Urologists of Orange County have taken the lead in introducing the Monarc sling procedure to Orange County. Our physicians hold regular training sessions and offer one-on-one preceptorships to other surgeons who are eager to learn this new technique.
Since Monarc was first introduced in Orange County late in the fall of 2003, our group has performed over 1000 Monarc transobturator sling procedures, many including more complex prolapse repairs using the Elevate Anterior and Posterior Prolapse Repair systems.