After Gusta Purvis had her hysterectomy she began to lose bladder control. Her doctor told her that another surgery–bladder neck suspension–would halt the problem.

But after the invasive surgery and rather lengthy recuperation of Surgery Number Two, the incontinence was worse.

For the next 15 years, Purvis had to wear pads, briefs or adult diapers to absorb the leakage. Even then, it often wasn't enough.

"I figured that this was just how it was going to be for the rest of my life," Purvis lamented. "It was very inconvenient, expensive and even with the pads and the briefs, I would end up wet and embarrassed."

When Purvis learned that a new surgical technique might help her, she made an appointment with urologist John Hairston, MD, at The University of Texas Medical School at Houston.

The outpatient procedure took 20 minutes and "it worked immediately."

20 Minutes to Freedom

Stress urinary incontinence (SUI), the bane of a woman's dignity and comfort is being banished successfully with this new minimally-invasive surgery.

The Trans-Obturator approach is so named for the anatomical landmark that sets it apart from the list of other SUI procedures. Together with a synthetic, mesh "hammock" or tape and a pair of twisted needles, surgeons can give a more natural support to the urethra, while still operating in the "zone of safety."

"What makes this procedure so elegant is its simplicity," Hairston says. "This is a completely different anatomical approach that obviates the need to enter the delicate structures behind the pubis or in the abdomen."

Additionally, this minimally invasive surgery is usually performed on an outpatient basis and patients generally can void on their own as soon as they wake up. Incision is minimal and recovery is rapid.

Best of all, rarely does an "over-correction" occur, unlike previous and current traditional methods.

Cradling the Urethra

Though a support sling–or in this case, a synthetic piece of tape or "hammock"–is still the centerpiece of the bio-mechanical fix, "we use an entirely different avenue into the body than that of the older, traditional approaches," Hairston says.

In the newer procedure, surgeons make two tiny incisions in the groin area. A third incision is made near the urethra in the vaginal area.

Using two curved needles on handles (one for each side) the surgeon threads a piece of mesh tape under the urethra and then anchors the ends of the tape at the groin incisions.

Most causes of SUI involve weakness in the collagen of the patient's pelvic floor. The mesh provides gentle but firm support under the urethra.

In other words, picture a garden hose cradled in a hammock.

Any adjustments to the tension of the mesh tape under the urethra can be made through the small incisions.

Typically, patients are able to void on their own in the recovery room and are sent home without a catheter.

Slings vs Hammocks

"The evolution of procedures over time has been phenomenal. We used to keep patients for days in the hospital with sometimes serious urinary retention and lengthy recoveries," Hairston said.

Traditional retro-pubic (behind the pubis) and/or bladder neck suspension surgeries always required more extensive pelvic and abdominal surgical involvement.

"The slings always came up around the urethra, often at too sharp an angle, because we had to come up through the pelvis," explains O. Lenaine Westney, MD, also assistant professor of surgery, Division of Urology at the Medical School, "which meant a lot of cutting in dangerous zones and possible complications."

Now, the sling is less of a sling shot–less of a "U" shape–and more of a wide hammock which more closely resembles the female natural pelvic floor support. This lessens the other common complication–over-correction, which can create an inability to urinate.

Who Qualifies?

There is a whole host of bladder problems that can cause female incontinence, from overactive bladder, interstitial cystitis, urge incontinence, "but this is not a treatment for that and the symptoms can be easily confused," she said.

Good surgical candidates are women who have had multiple vaginal births, hysterectomies, previous abdominal surgeries or whose pelvic floor collagen isn't genetically strong.

Very athletic women, such as distance runners may develop SUI from simple gravitational abuse. "Three times your body weight with each step you make can take its toll on the durability of the pelvic floor," Hairston concurred.

"Any woman who is constantly raising the abdominal pressure to a critical level from exercise or perhaps chronic cough is going to experience leakage," Westney explained.

The surgery itself takes about 20 minutes and patients generally go home that day unless they are having concurrent gynecological or other surgical procedures.

"I got up. I walked around and I felt freedom," Purvis recalls. She's now free to volunteer at her church, go to Astros Games she says, and free to travel without packing protection. "It really is amazing."

The Trans-Obturator approach has been used in Europe for over six years on more than 15,000 patients. Success rates are comparable to other current procedures averaging greater than 85 percent. Scant post-operative complications have been reported and, specifically, the incidence of post-operative voiding dysfunction appears to be less.

But, it is not for every woman, both surgeons say.

"If it's a fixed, wide-open urethra, sometimes referred to as a 'stovepipe' urethra, or if there have been multiple surgical repair attempts previously, we tend to use a more traditional approach," Hairston said. Neurogenic patients, such as those who have spinal cord injuries have a better end result with the older procedure.

For the healthy, active woman who can't lift her groceries or sneeze without leakage, the Trans-Obturator surgery has been a lifestyle-changing gift.

"It's a relatively simple and safe way to restore the natural pelvic floor support to the urethra without leaving the 'zone of safety,'" Hairston said. "And I have some very relieved and happy patients."

Last Updated: 5-20-2004

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