FEMALE UROLOGY

Long-Term Results of Ingelman-Sundberg Denervation Procedures for Urge Incontinence Refractory to Medical Therapy
Westney OL, Lee JT, McGuire EJ, Palmer JL, Cespedes RD, Amundsen CL
Division of Urology, University of Texas, Houston Health Sciences Center, Houston, Texas, USA
J Urol. 2002; 168:1044-7

• Purpose: Urge incontinence refractory to anticholinergic medication and behavioral techniques is a therapeutic challenge. We evaluated the durability of the modified Ingelman-Sundberg detrusor denervation procedure as minimally invasive surgical therapy for intractable urge incontinence.
• Materials and Methods: Patients presenting with severe urge incontinence unresponsive to medical and/or behavioral therapy were injected subtrigonally with 10mL 0.25% bupivacaine. The patients were contacted 24 hours later to determine whether they experienced a decrease in urgency and urge incontinent episodes. The 28 patients with temporary resolution of symptoms were offered operative management. All patients were evaluated with history, physical examination, and fluoroscopic urodynamics. The procedure consists of transvaginal dissection of the perivesical fascia from the area of the trigone, including sharp division of the terminal branches of the pelvic nerve.
• Results: A total of 28 patients 28 to 83 years old (mean age 54.6), underwent the Ingelman-Sundberg procedure from April 1993 to September 1997. All patients presented with a history of urge incontinence, 10 reported concomitant stress incontinence and 10 had documented unstable detrusor contractions on urodynamic evaluation. Needle suspension and the pubovaginal sling procedure were performed with the Ingelman-Sundberg procedure in 1 case each. Mean follow-up was 44.1 months (range 14 to 67). Of the patients 15 (54%) achieved the complete durable resolution of urge incontinence, 4 (14%) were improved and 9 (32%) were unchanged.
• Conclusions: Ingelman-Sundberg bladder denervation resulted in a 68% long-term cure or improved rate in a difficult patient population, namely those with intractable urge incontinence. This brief, minimally invasive procedure is an excellent alternative to more aggressive surgical options.
  
  
• Editorial Comment
  The authors describe the technique of the Ingleman-Sundberg transvaginal denervation, as well as their long-term data in the treatment of patients with this surgery.
  The value of this paper is heightened secondary to the increasing discussion of the treatment of this population of patients with peripheral or sacral nerve neuromodulation.
  The materials and methods section is very clear and to the point. With regard to the anesthetic block description, previous publications on this topic by the senior author have provided the reader with a little more concise direction on the actual injection (1). In addition, care must be taken when injecting the test block, secondary to the vascular nature of the area and the potential for calamity if the patient over absorbs the bupivicaine (2). The operative technique mirrors very closely the dissection used for a pubovaginal sling. In addition, the response rate for the cure of associated urge incontinence mirrors very closely the success rate of the I-S (69% vs. 54%), (3). One must ponder the degree of denervation that takes place during classic transvaginal dissection. For readers that have not previously performed the I-S denervation, having had the privilege of operating with the senior author, I can attest that the operation in experienced hands is as rapid as described. Other authors have discussed the need for bilateral versus unilateral transection, using parameters such as post void residual, but this paper does not broach this subject (4,5). In addition, a potential topic of interest would have been a cost analysis of this technique versus sacral nerve neuromodulation in a set of patients with similar diagnoses.
  This technique may differ from neuromodulation in that it is neuroablative, and does not really strive to modulate neural response to bladder physical changes. A potential danger in neural ablation may be the long term effects of the down stream denervated tissue; for example, will later neuroplastic changes leave the end organ in a more pathologic state than before the performance of the procedure?

References
1. Cespedes RD, Cross CA, McGuire EJ: Modified Ingelman-Sundberg bladder denervation procedure for intractable urge incontinence. J Urol. 1996; 156:1744-7.
2. Groban L, Dolinski SY: Differences in cardiac toxicity among ropivacaine, levobupivacaine, bupivacaine, and lidocaine. Tech Reg Anest Pain Manag. 2001; 5: 48-55.
3. Fulford SCV, Flynn R, Barrington J, Appanna T, Stephenson TP: An assessment of the surgical outcome and urodynamic effects of the pubovaginal sling for stress incontinence and the associated urge syndrome. J Urol. 1999; 162:135-7.
4. Warrell DW: Vaginal denervation of the bladder nerve supply. Urology 1977; 32:114-6.
5. Ingelman-Sundberg A: Partial denervation of the bladder: A new operation for the treatment of urge incontinence and similar conditions in women. Acta Obstet et Gynec Scand 1959; 38:487.

Dr. Steven P. Petrou
Associate Professor of Urology
Mayo Medical School
Jacksonville, Florida, USA