MONARC™ -
Minimally Invasive Surgery for Stress Urinary Incontinence

Article by Michael J. Altamura, M.D., F.A.C.S.

Stress urinary incontinence is the loss of urine that may occur with coughing, sneezing, laughing, pushing, pulling, lifting, jumping, bending or even just walking. This condition is due to weakness of the pelvic floor muscles, which together form the pelvic diaphragm. When an activity is performed that results in an increase in the pelvic pressure, the weak pelvic muscles cannot support the intrapelvic structures which leads to a sagging or drop not only of the pelvic diaphragm itself but also the structures that it is meant to support. It is this anatomical change that results in urinary incontinence. Some of the causes for the weakness in the pelvic floor diaphragm include pregnancy, childbirth, trauma, radiation, and prior surgery. There is also clearly a genetic predisposition to this condition.

The cure for stress urinary incontinence requires a means of supporting the urethra during an increase in intrapelvic pressure. Historically, this was accomplished in the past by entering the pelvis through an incision in the lower abdomen. The patient was hospitalized for 3 days and experienced a moderate degree of pain. Eventually, this operation was abandoned in favor of a newer procedure, the implantation of a urethral sling. This operation is less invasive and does not require entering the pelvis, however, it does require passing sutures through the pelvis with the attendant risk of possibly puncturing the bladder. The patient was hospitalized overnight with an indwelling catheter and generally sent home the next day.

More recently, however, a further modification obviates the need for passing sutures through the pelvis so that the risk of injuring the bladder is eliminated. This operation is referred to as the Monarc procedure and the urethral sling is called the Monarc Subfascial Hammock. The hammock cradles the urethra and gives it a solid point to rest on and press against during increases in intrapelvic pressure thus closing the urethra more tightly and preventing incontinence. The operation requires a vaginal incision and two tiny skin incisions made near the inner thigh. The sling is inserted through the small incision in the vagina and placed under the urethra, then secured in place under the skin. This operation is done in less than an hour and the patient is discharged on the same day of surgery generally without a catheter. In the event that the bladder does not empty properly, then a catheter must be used until normal voiding resumes. Although many women have little or no pain after surgery, a mild analgesic may be prescribed.

Heavy lifting, rigorous exercise and sexual intercourse should be avoided for the first four to six weeks. Most women will experience complete continence immediately after the operation. The success rate with this operation is at least as favorable as others done in the past and in the order of 90%. No operation exists, yet, that guarantees a 100% success rate for the correction of stress urinary incontinence.