Surgical%20Treatment%20of%20Stress%20Urinary%20Incontinence - PowerPoint PPT Presentation

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Surgical%20Treatment%20of%20Stress%20Urinary%20Incontinence

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Surgical Treatment of Stress Urinary Incontinence Dr Cecilia Cheon Consultant, Department of Obs. & Gyn. Queen Elizabeth Hospital, Hong Kong, China – PowerPoint PPT presentation

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Title: Surgical%20Treatment%20of%20Stress%20Urinary%20Incontinence


1
Surgical Treatment of Stress Urinary Incontinence
Dr Cecilia Cheon Consultant, Department of Obs.
Gyn. Queen Elizabeth Hospital, Hong Kong, China
President, HK Urgynaecology Association
2
Definition of Urinary Incontinence
  • Urinary incontinence is the complaint of any
  • involuntary leakage of urine.
  • Abram P et al. Neuro Urodyn 02

3
Terminology - Symptoms
  • Stress urinary incontinence (SUI)
  • - Involuntary leakage on effort or exertion, or
    on sneezing or coughing

4
Urodynamic Terminology
  • Urodynamic stress incontinence (USI)
  • - Involuntary leakage of urine during increased
    abdominal pressure, in the absence of a detrusor
    contraction
  • - Old term Genuine stress incontinence (GSI)

5
Impact on Quality of Life
  • Embarrassment
  • Reduced Self esteem
  • Impaired emotional psychological well-being
  • Poorer sexual relationships
  • Impaired social activities and relationships

6
Economic Issues
  • USA estimated to be 8.1 billion (Hu, 1984)
  • Active evaluation and treatment of nursing home
    residents resulted in considerable cost savings
  • Indirect benefit improve QOL of sufferers,
    difficult to quantify

7
Stress incontinence Weakness of the pelvic
floor muscles
8
Treatment Strategy in women with USI / SUI
  • Conservative treatment is the first line of
    treatment for women with SI
  • International Consultation on Incontinence 01,
    Paris

9
Treatment for SUI
  • 1. General measures
  • 2. Pelvic floor exercises, PFEs
  • 3. Biofeedback
  • - perineometer, vaginal cones
  • 4. Electrical stimulation treatment
  • 5. Mechanical devices
  • 6. Pharmacological treatment
  • 7. Surgery

10
Surgical Treatment
  • Paravaginal repair
  • Bladder neck suspensions
  • Bladder Neck Slings / Midurethral slings
  • Periurethral injections
  • Artificial sphincter

11
Surgical Treatment
benefit
risk
minimal complication
Best long term result
12
Bladder Neck Suspensions
  • To use the anterior vagina as a hammock to
    elevate the bladder neck
  • Needle suspensions
  • Retropubic suspensions
  • - abdominal
  • - laparoscopic

13
Retropubic Suspensions
  • Burchs
  • MMK

14
Burchs Colposuspension
  • Suspension of anterior vagina to the
    iliopectineal ligament(Coopers ligament)
  • Abdominal
  • ? Laparoscopic

15
Burch Colposuspension
16
Burch Colposuspension
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Subjective Cure Rate for Burchs Operation
19
Objective Cure Rate for Burchs Operation
20
Burchs
  • Success rate
  • 39 trials, 3,301 women
  • 1st year 85 90
  • 5 year 70
  • No significant difference between open and
    laparoscopic approach
  • Lapitan et al, Cochrane Database Systematic
    Reviews 2008

21
Burchs Colposuspension
  • Complications
  • Detrusor overactivity 5 10
  • Voiding difficulty 10 15
  • Apical / posterior 5 17
  • compartment prolapse

22
Slings
  • Sling under the bladder neck or mid-urethra
  • Correct hypermobility
  • Increase sphincter closure pressure

23
Midurethral-slings
  • To date, three major slings available
  • - Tension-free vaginal tape (retropubic
    approach) TVT
  • - Tension-free vaginal tape (transobturator
    approach) TOT / TVT-O
  • - Minisling

24
The Integral Theory of Continence
  • Pelvic organ prolapse mainly caused by connective
    tissue laxity in the vagina or its supporting
    ligaments
  • Stress urinary incontinence is essentially due to
    pelvic floor muscle weakness

25
The pictorial diagnostic algorithm summarizes the
relationships between structural damage in the
three zones and urinary and fecal symptoms.
Arrows represent directional muscle
forces. Anterior zone external urethral meatus
to bladder neck middle zone bladder neck to
cervix posterior zone vaginal apex, posterior
vaginal wall, and perineal body. PRM
m.puborectalis PCM pubococcygeus PUL
pubourethral ligament ATFP arcus tendineus
fascia pelvis N bladder base stretch receptors
26
Tension-free Vaginal Tape (TVT)
  • Ulmsten et al in 1996
  • Treats stress incontinence by positioning a
    polypropylene mesh tape underneath the urethra
  • Monofilament, macroporous, gt75 microns
  • Free passage of marophages
  • In growth of fibroblast
  • Minimize erosion / infection

27
Tension-free vaginal Tape
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Transobturator Tape (TOT)
  • Delorme1 in 2001 described the transobturator
    (outside-in TOT) procedure
  • Insert mesh tape under the urethra through small
    incisions in the groin area
  • eliminates retropubic needle passage

37
Transobturator Tape (outside in)
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Transobturator Tape (TOT-O)
  • A variation of the technique has been described
    in 2003 by de Leval termed the TOT vaginal tape
    inside-out technique (TVT-O)

50
Transobturator Tape (inside out)
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Imaging
53
TVT / TOT / TVT-O Complications
  • 3
  • Voiding difficulty, hemorrhage, hematoma, bladder
    perforation, infection
  • No report of rejection, erosion or fistula

54
Comparison of Mid-urethral sling (TVT) to
various procedure
Tension-Free Midurethral Slings in the Treatment
of Female Stress Urinary Incontinence A
Systematic Review and Meta-analysis of Randomized
Controlled Trials of Effectiveness

Giacomo Novara et al. (Italy) 2007
55
Comparison of Mid-urethral Sling vs
Colposuspension (QEH)
Colposuspension Mid-urethral Sling
No. of patients 222 402
Age 50.74 60.36 (plt0.001)
Bladder injury () 0.9 4 (p0.03)
Days of bladder training (mean) 3.96 3.41
1 year subjective success () 82.7 89 (p0.03)
1 year objective success () 89.1 83.4
1 year DO () 27.7 30.2
3 years subjective success () 76.3 (169) 87.7 (173) (p0.007)
3 years objective success () 77.1 85.6 (p0.04)
5 years subjective success () 75.8 (95) 89.2 (74) (p0.03)
5 years objective success () 77.9 91.9 (p0.01)
56
  • Today, mid-urethral slings not only have replaced
    the Burch colposuspension as the gold standard in
    the treatment of SUI but also are even more often
    performed than colposuspension
  • Easy to perform, superior in terms of operation
    time, postoperative pain, and hospital stays
  • but similar cure rates

57
Peri-urethral Injection
  • Use of injectable bulk forming agents to increase
    the urethral closure pressure

58
Peri-urethral Injection
  • Material
  • Fat
  • Collagen
  • Silicone

59
Peri-urethral Injection
  • Advantages
  • Safe
  • Disadvantages
  • Low success rate 25 60
  • Expensive
  • Need to be repeated every 1-2 year

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Artificial Sphincter
  • Last resort
  • Use when all the other operation have failed

64
Artificial Sphincter
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Conclusions
  • 1 in 2 women in HK has urinary symptoms
  • 1 in 3 women has SUI
  • Much advances made in the care of female urinary
    incontinence
  • Effective treatment available which can
    significantly improve womens QoL

66
Conclusion
  • The concept of the midurethral sling has
    revolutionized surgical treatment of SUI. Its
    minimally invasive approach and success rates
    have led to an increasing acceptance of the
    technique
  • TVT and TOT are both comparable in cure rate
  • The TOT approach is a potentially safer method
    owing to the avoidance of the retropubic space
    bladder, vessels, bowel injury
  • Pregnancy is not contraindicated and cesarean is
    not abolute

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  • Long-term studies and RCTs are needed to identify
    the proper indications for the various types of
    slings and to assess efficacy and complication
    rates over time.

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