Download presentation
Presentation is loading. Please wait.
Published byDalton Cooke Modified over 9 years ago
1
Sling Failures Jerry G. Blaivas, MD Clinical Professor of Urology
Weil-Cornell Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center
2
Why Do Operations Fail? Too tight Too loose Wrong position
Detrusor overactivity De-novo Persistent Erosion Wrong indication
3
Too Tight Urethral obstruction Detrusor overactivity Erosion
Devascularization > recurrent SUI
4
Urethral Obstruction Clinical: Urodynamics: De-novo symptoms
Weak stream OAB negative Q-tip angle Urodynamics: High detrusor pressure / low flow: pdetmax > 20 cm H20 Qmax < 12 ml/S Blaivas Groutz nomogram
5
- 45O
6
High pressure (pdetmax = 75)
Low flow (0) High pressure (pdetmax = 75) MSCO
7
Blaivas - Groutz Nomogram
Figure 1.Blaivas-Groutz Nomogram divides woman into 4 groups. Blaivas & Groutz, Neurourol & Urodynam 19: , 2000
8
Rx of Post op Urinary Retention
Depends on type of sling Initial Rx intermittent catheterization Synthetic sling early intervention days – weeks Autologous slings Delayed intervention – months
9
Rx of Post op Urinary Retention
? Need for further workup Q-tip cystoscopy urodynamics
10
Surgical Rx of Sling Obstruction
Sling incision midline lateral Urethrolysis antero-lateral circumferential +/- Martius flap interposition Technique determined intraop
11
Transvaginal Incision of Sling
Slightly curved/horizontal incision over sling Dissect superficial to sling Identify normal urethra Mobilize small vaginal wall flap & identify sling
13
Transvaginal Incision of Sling
Grasp sling with Allis clamps & pull outward Dissect between sling & urethra Incise sling in midline Sling should spring apart
16
Sling Incision Results
Type Success % SUI % Nitti, et al 19 Midline Incision 84% 17% Amundsen, et al 32 Various 94% 9% Goldman, et al 14 93% 21% Nitti et al. Early results of pubovaginal sling lysis by midline sling incision. Urology 2002. Amundsen et al. Variations in strategy for the treatment of urethral obstruction after a pubovaginal sling procedure. J Urol Goldman et al. Simple sling incision for the treatment of iatrogenic urethral obstruction. Urology 2003
17
Urethrolysis Vaginal Supra-meatal Retropubic
18
Urethrolysis Vaginal Supra-meatal Retropubic
19
Transvaginal Urethrolysis
Inverted “U” incision over point of obstruction Dissect superficial to obstructing tissue Incise sling laterally on either side
20
Transvaginal Urethrolysis
Perforate endopelvic fascia at lateral margin of dissection Mobilize vesical neck & urethra +/- Circumferential mobilization of urethra +/- Omental or Martius interposition
26
Circumferential Urethrolysis
27
Urethrolysis Vaginal Supra-meatal Retropubic
28
Supra-meatal Urethrolysis
Transverse incision just above urethral meatus Dissect in midline above urethra Press down on urethra with index finger
30
Supra-meatal Urethrolysis
Incise sling/sutures under direct vision +/- circumferential urethral mobilization +/- Martius or omental interposition
35
Urethrolysis Vaginal Supra-meatal Retropubic
36
Retropubic Urethrolysis
Transverse incision just above the pubis Enter retropubic space Downward pressure on bladder neck & urethra
37
Retropubic Urethrolysis
Incise sling/sutures under direct vision Open bladder if necessary +/- circumferential urethral mobilization +/- Martius or omental interposition
38
Urethrolysis Results N Type Success % SUI (%) Foster & McGuire 48
Transvaginal 65% 0% Nitti & Raz 42 71% Cross, et al 39 72% 3% Goldman, et al 32 84% 19% Petrou, et al Suprameatal 67% Petrou & Young 12 Retropubic 83% 18% Carr & Webster 54 Mixed 78% 14%
39
Too Tight Urethral obstruction Detrusor overactivity Erosion
Devascularization > recurrent SUI
40
Too Tight Urethral obstruction Detrusor overactivity Erosion
Devascularization > recurrent SUI
41
Bladder neck Bladder neck Eroded mesh
42
VLPP Barbara Jankowski UDS December 2005
Barbara Jankowski is a 65-year-old married woman who underwent urethral diverticulectomy in 10/04 by Judy Siegel. The diverticulum was very large and extended from the meatus to bladder neck. “The repair was buttressed with a Pelivichol patch.” .12/5/05 – incision of urethral stricture; 8/05 “stricture lasered.” on 11/10 she underwent collagen injection at the bladder neck and, at that time, a “distal urethovaginal fistula was diagnosed. She was referred to Basil Kocur and was diagnosed with multiple vesicovaginal fistulas and needed abdominal surgery. Her chief complaint is daily incontinence, but she doesn’t know for sure exactly when it happens other that to say, its worst when she is physically active and does not occur at night when she is in bed. She denies classic stress or urge incontinence. She ordinarily feels the urge to void about once an hour, but does not actually void each time. On average, the longest time she goes without urinating during the day is about three hours. The main reason she urinates as often as she does is because of normal feelings to urinate. She ordinarily initiates micturition without difficulty. The force of her stream is usually strong. She feels that she has not emptied her bladder after urinating rarely. She wears absorbent pads daily, and she changes them 6 times per day. The pads are usually clearly wet. Her AUA symptom score is 9. CYSTOMETROGRAM: The Cystometrogram was performed using radiographic contrast and a #7 double lumen catheter via constant infusion at a 'medium' filling rate with rectal pressure monitoring and the patient sitting. Residual bladder volume was 0ml, 0 hours after voiding. Empty bladder pressure was 0cm H20. First filling sensation occurred at 240.6ml, with a detrusor pressure of 0.5cm H20. The first urge occurred at 399.7ml with a detrusor pressure of 1cm H20 and a severe urge occurred at 1,006ml, with a detrusor pressure of 2cm H20. During bladder filling there were no spontaneous involuntary detrusor contractions. Bladder capacity was 1,006 ml. Maximum filling pressure was 3cm H20. Bladder compliance was high.
44
Treatment of Erosions. remove as much of sling as possible
closure of the urethra +/ - urethral reconstruction +/ - biologic sling +/ - Martius flap
45
Too Tight Urethral obstruction Detrusor overactivity Erosion
Devascularization > recurrent SUI
46
Why Do Operations Fail? Too tight Too loose Wrong position
Detrusor overactivity De-novo Persistent Erosion Wrong indication
47
Too Loose Urethral hypermobility Intrinsic sphincter deficiency
Recurrent sphincteric incontinence
48
VLPP VLLP = 92 cm H20 Qtip = 0 > 60O AG AG AG
Figure 9. Stress incontinence with urethral hypermobility and type 1 OAB. This corresponds to Type 2 SUI according to the Blaivas/Green/McGuire classification. AG is a 51 year old white woman with a chief complaint of gradually worsening stress incontinence of 10 years duration. About once or twice a month she soaks her clothes when she has been walking or does high impact aerobics. She wears one mini-pad all day which, at the end of the day is damp; "sometimes they're wetter than others”. She also gets urgency & urge incontinence when she puts the key in her door lock, but has learned to control this by voiding beforehand. A.Urodynamic tracing. FSF = 10 ml; First urge = 251 ml; Severe urge = 492 ml. VLLP = 85 cm H2O. Bladder capacity = 585 cm H20. When asked to void, she strained a bit, but could not generate a detrusor contraction and was unable to void (light blue oval). VLPP = 50 cm H20 AG AG AG
49
Figure 9 B. X-ray exposed at VLPP shows rotational descent of the urethra and incontinence. Q-tip angle was 65O. Comment: AG has classic type 2 stress incontinence and would likely do well after anti-incontinence surgery, but when advised of the remote possibility of urinary retention, elected behavioral therapy. AG
50
JK VLPP = 42 cm H20 Q tip = 0
52
Treatment of Recurrent SUI
no compelling data for hypermobility, surgeon choice for poorly mobile or pipe - stem urethra, biologic bladder neck sling
53
Why Do Operations Fail? Too tight Too loose Wrong position
Detrusor overactivity De-novo Persistent Erosion Wrong indication
54
Wrong Position Too far proximal Too far distal
persistent sphincteric incontinence urethral obstruction ureteral injury Too far distal urethral hypermobility
55
Sling proximal to BN VLPP = 35 cm H20 MS
56
sling
57
No flow High pdet Figure . Urethral obstruction due to autologous fascial pubovaginal sling. A. Urodyanmic tracing. There is a sustained detrusor contraction to over 75 cm H20 and no flow.This corresponds to a grade 2 urethral obstruction on the Blaivas Groutz nomogram. MSCO
58
Fig B.X-ray exposed at pdetmax shows complete obstruction of the urethra at the bladder neck (black arrow), presumably from a prior sling operation. Note the left vesicoureteral reflux (white arrows) MSCO
59
MSCO C. The vesicoureteral reflux extends into the kidney and distends the collecting system.(grade 3).
60
Why Do Operations Fail? Too tight Too loose Wrong position
Detrusor overactivity De-novo Persistent Erosion Wrong indication
61
Wrong Indication Urinary fistula mistaken for sphincteric incontinence
Overactive bladder mistaken for sphincteric incontinence Sine-qua-non - Never operate on stress incontinence without actually diagnosing sphincteric incontinence with your own eyes
62
Conclusion Complications & failures after incontinence surgery are not uncommon Early evaluation to rule out remediable causes should be undertaken UTI Urethral obstruction sling erosion foreign body A successful outcome is likely in the majority of patients
Similar presentations
© 2024 SlidePlayer.com Inc.
All rights reserved.