16 Sling Incision Results TypeSuccess %SUI %Nitti, et al19Midline Incision84%17%Amundsen, et al32Various94%9%Goldman,et al1493%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 UrolGoldman et al. Simple sling incision for the treatment of iatrogenic urethral obstruction. Urology 2003
36 Retropubic Urethrolysis Transverse incision just above the pubisEnter retropubic spaceDownward pressure on bladder neck & urethra
37 Retropubic Urethrolysis Incise sling/sutures under direct visionOpen bladder if necessary+/- circumferential urethral mobilization+/- Martius or omental interposition
38 Urethrolysis Results N Type Success % SUI (%) Foster & McGuire 48 Transvaginal65%0%Nitti & Raz4271%Cross, et al3972%3%Goldman, et al3284%19%Petrou, et alSuprameatal67%Petrou & Young12Retropubic83%18%Carr & Webster54Mixed78%14%
39 Too Tight Urethral obstruction Detrusor overactivity Erosion Devascularization > recurrent SUI
40 Too Tight Urethral obstruction Detrusor overactivity Erosion Devascularization > recurrent SUI
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.
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 H20AGAGAG
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
57 No flowHigh pdetFigure . 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 MSCOC. 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 overactivityDe-novoPersistentErosionWrong indication
61 Wrong Indication Urinary fistula mistaken for sphincteric incontinence Overactive bladder mistaken for sphincteric incontinenceSine-qua-non - Never operate on stress incontinence without actually diagnosing sphincteric incontinence with your own eyes
62 ConclusionComplications & failures after incontinence surgery are not uncommonEarly evaluation to rule out remediable causes should be undertakenUTIUrethral obstructionsling erosionforeign bodyA successful outcome is likely in the majority of patients