Presentation on theme: "Intrinsic Sphincter Deficiency & Slings"— Presentation transcript:
1Intrinsic Sphincter Deficiency & Slings Nader GadMBChB, MChGO, FRCOG, FRANZCOGConsultant & Senior Lecturer in O&GRoyal Darwin Hospital, Darwin, Australia
2Definition of ISD SLPP less than 60 cmH2O MUCP less than 20 cmH2O Type III Stress Incontinence (Proximal urethra open at rest)
3Classification of SUI Clinically & During UDA Bladder neck & proximal urethraDuring RestBladder Neck & Proximal urethraDuring StressCystoceleType 0No SUI is seenProbably due to momentary voluntary contraction ofExternal Urethral sphincterclosed at restAt or above inferior Margin of SPDescend & openNoneType IClosed at restAbove inferior Margin of SPOpenDescend less than 2 cmNone or Small CystoceleType IIARotational descent characteristic of cysto-uretherocelePresentType IIBClosedAt or below inferior Margin of SPMay be further descentType IIIOpen at restProximal urethra no longer function as sphincter
4Causes Of ISD Previous Pelvic Surgery Anti-incontinence surgery Urethral diverticulectomyRadical HysterectomyUrethrotomyResection or incision of vesical neckAging & Hypo-oestrogenic StatesPelvic IrradiationNeurologic ConditionsMyelodysplasiaAnterior spinal artery syndtomeLumbosacral neurologic conditionsShy-Drager syndrome
5Treatment of ISDMcGuire et al(1978 )were the first to note that ISD present in :75% of women of patients who failed in multiple surgeries for SUI13% with no previous anticontinence surgeryDifficult to determine is it cause or effect?
6Treatment of ISD Sand et al (1987): High failure rate of Burch colposuspension in women with low MUCP compared to those with MUCP more than 20cm H2OFailure rate of Burch at 3 months FU:Low MUCP: 54%Normal MUCP: 18%
7Treatment of ISDMost data show simple elevation of the bladder neck is ineffectiveRecommend more obstructive procedure
9Proximal Suburethral Slings First introduced by Giordano in 1907 using Gracilis muscle flapAldridge in 1942, developed the Fascial slingThe principle:Create a hammock underneath bladder neck to prevent descent and provide a backboard at UVJ against which the urethra is compressed during increase of intra-abdominal pressure
10Types of Proximal Slings BiologicSyntheticFascia lataMersileneRectus fasciaNylonGracilis muscle flapMarlexPyramidalis muscle flapGore-texRound ligamentSilasticOx dura materPolypropylene meshPorcine small intestine submucosaCadaver fascia
11Patient most un-suitable History of irradiationPrevious sling erosionHaving surgery on the urethra at the same time (e.g., urethral diverticulectomy)Having POP surgery at the same time
12Proximal Urethral slings Overall success for SUI + ISD at 5 years = 80 – 90%Summitt et al (1990)Sling procedure success rates were:93% in ISD + HMBN20% in ISD + no HMBN
13Common Complications of Proximal Suburethral Slings Longer recoveryHas the highest rate of retention: 2-37%
14TVT & ISD Rezapour (2001) First report on 49 women: F-U for 3-5 years: 74% completely cured12% improved14% no improvement:Majority more than 70 years old & MUCP less than 10 cmH2O
15TVT & ISD Overall Success rate: 55 – 74% (less than the 80-90% with PSUS)Some experts advise when TVT in ISD:tape is placed in immediate proximity with urethra (still without tension) instead of aiming for a ¼ inch gap
16TVT Complications Voiding difficulties Recurrent UTI Bladder perforation (5-10%)Erosion (3 – 5 %)Vascular injuryBowel injuryHaematomaNerve injuryDeath (6 reported deaths by September of 2002)
17TOT & SlingsIt leaves the sling in a more horizontal or hammock-like rather than U-orientationLess operative timeAvoid risk of injury to bladder (only few reported cases) bowel & major vessels
18TVT vs TOT (Monarc) Miller et al (2006) Retrospective study of 145 women Comparing TOT (Monarc) vs TVT under GA or Spinal anaesthesia :Monarc was nearly 6 times more likely to fail at 3 months after surgery in women with borderline MUCP (42 cm H2O or less)In this study women with MUCP 20cmH2O or lesswere exclusion criteria of TOT but not TVT
19Failure Rate TVT vs TOT Miller et al 2006 Monarc (85)All (145) ObjectiveSubjective3%14%9%16%MUCP 42 or less (81) Objective13%23%MUCP more than 42 (64) Objective4%2%6%
20TVT vs TOT vs Sling Jeon et al (2008) Retrospective study of 253 women with ISD defined as: LPP less than 60 cmH2O or MUCP less than 20 cmH2O- PVS: 87TVT: 94TOT: 72TOT (polypropylene; Iris, Dowmedics Co, Korea, Outside – in )Regional of General Anaesthesia
21TVT vs TOT vs Sling Jeon et al (2008) Cure rates after 2 years:PVS: 87%TVT: 87%TOT: 35 %Cure rate after 7 years:PVS: 59%TVT: 55%
22TVT vs TOT vs Sling Jeon et al (2008) ComplicationsPVS (n=87)TVT (n=94)TOT (n=72)P valueBladder injury1 (1.2%)0.6De novo urgency14 (16%)14 (15%)13 (18%)0.9Voiding dysfunction(one month or longer)18 (19%)17 (18%)8 (11%)0.75V.D. Requiring surgery3 (3.1%)1 (1.4%)0.26Recurrent UTI2 (2.3%)6 (6.4%)0.06Mesh Erosion-1 (1.1%)1
23Darwin ExperienceRetrospective study of my First 25 cases of the TVT-O procedures (J&J)Procedure were completed in all women under sedation and local anaesthesiaOutcome of the procedure:Complication: intra- & post-operativeSuccess rate: Subjective & Cough testAny difference in outcome when ISD present?
24Darwin ExperienceISD was defined as valsalva or cough LPP = less than 60 cmH2O and/or MUCP = 20 cm H2O or lessWomen with ISD were given the option to chose between TVT vs TVT-O:TVT have a higher cure rate than TVT-O in women with ISDTVT has the potential risk of bowel or major blood vessels injury
25Previous surgery for SUI Previous Hysterectomy Patients studiedPublic728%Private1872%GP referral2080%Specialist Ref520%Age39 – 66 yearsParity1 – 6Presence of SUIIn All women100%Urgency9/2536%Urge incontinence5/25Frequency6/2524%NocturiaPrevious surgery for SUI3/2512%Previous Hysterectomy10/2540%Previous POP repair
26UDA Findings Presence of POP 15/25 60% HMBN 21/25 84% ISD 10/25 40% 6/2524%ISD alone4/2516%DI2/258%
27ISD Of the ten women with diagnosis of ISD: a. 5 women (50%) had MUCP < 20cm H2O4 women had leakage on valsalvathe remaining patient had leakage on Cough LPP of less than 60 cm H2O, this patient was the only patient lost to follow up.
28Sedation Bolus of 1-2 mg midazolam Then propofol 1% infusion at a rate of 20-40mls/hour titrated to effectA small bolus of propofol (10-30mg) and/or alfentanil (100 – 200mcg) may be used when required in some patients during penetration of Obturator membranes.
29Local AnaesthesiaThe local anaesthetic agent used was a total of 80 – 100 ml of 0.25% prilocaine with adrenaline (1:200,000)
30Local Anaesthesia Administration of local anaesthesia to: the area of the suburethral vaginal incisionparaurethral lateral dissectionexpected tape passage through the Obturator foramen and muscles and the exit on the skin of the inner upper part of the thigh on both sides.
31Cough Test Once tape is inserted, cessation of all sedation Bladder is filled to a volume similar to that when SUI was demonstrated during UDACystoscopy performedWhen patient is awake enough, operative table is tilted head up about 30 degreespatient is instructed to cough strongly and the tape is very slowly adjusted to the point when urinary leakage just stops
32Operative & Short-term Complications Intra-operative complications0%Short term Urinary retentionShort Term DI1/254%One woman had 2 episode of nocturnal enuresis on the 2nd and 7th postoperative and day that resolved by the time she was reviewed 5 weeks laterShort term postoperative complications2/258%2 patients (8%) developed significant pain in the upper thigh that resolved by 6 weeks post surgery
33Hospital Stay AM list 7 28% 6/7 86% PM List 18 72% 2/18 11% 14/18 78% Discharge of AM list on same day6/786%PM List1872%Discharged on the same day2/1811%Discharged next morning14/1878%Discharged within 48 hours
34Follow-up Duration of FU Duration to Audit Mean = 4 – 52 weeks Average = 13.3 weeksDuration to AuditMean = 7 – 156 weeksAverage = 53 weeks
35Long Term Outcome Urinary retention 0% Urgency 2 8% 0%Urgency28%Two woman developed mild urgencyOther complications14%Pain in the vagina required excision of part of the tapeNo further SUI24/24100%
36August 2008 Anast et al from Missouri, USA TOS (Trans-Obturator Sling) placement a outside-in (ObTape –Coloplast Surgical, Humeleback, Denmark)124 patients had leakage on valsalva:29% had low VLPP (Less than 60 cmH2O)71% had higher VLPP
37August 2008 Anast et al, Missouri, USA At a mean of 12 monthLow VLPP (29%)High VLPP (71%)Subjective Cure rate93%79%Bladder perforation(6 patients)3%6%Complication rate11%29%
38ConclusionTVT-O under local anaesthesia and sedation with the Cough Test in Theatre is very effective and safe surgical treatment of SUI in women with or without ISD.Shortcomings of the Study:RetrospectiveSmall number of the patient in this studyRelatively short term follow up period