Transcript Does TOT Enough to ISD Patients? - Yes

Point Counterpoint Discussion
Is TOT enough to ISD Patients?
좌장: 박원희(인하의대)
Yes
이동환(가톨릭의대)
No
주명수(울산의대)
Introduction
• In women with SUI, a spectrum of urethral
characteristics ranging from a highly
mobile urethra with good intrinsic function
to an immobile urethra with poor intrinsic
function; urethral hypermobility and ISD
• There is no standardized terminology or
definition for ISD.
• McGuire, 1982, referred to ISD as type III
incontinence, which he defined as low
urethral closure pressure in the proximal
urethra regardless of the degree of
urethral mobility.
• In failed cases with previous suspension
technique, presence of ISD suspected --Pubovaginal sling as the choice
• Integral theory by Petros and Ulmsten,
1990; TVT, 1996, by Ulmsten
• TOT, 2001, by Delorme
• Current sales of MUS devices in USA;
Transobturator slings make up just over
half of the total synthetic sling procedures
performed.
• Key words; ISD, TVT, TOT
ISD가 있는 SUI 환자의 수술적
치료로서;
1. TVT (or SPARC)를 사용한다.
2. TOT도 상관없이 사용한다.
3. Pubovaginal sling을 여전히 사용한
다.
ISD의 정의는?
• Maximum urethral closure pressure
(MUCP) of 20 cm H2O or less by Sand
et al., 1987
• Valsalva leak point pressure (VLPP) of
less than 60 cm H2O By McGuire et al.,
1993
• Other evaluation method ?
ISD의 definition
• VLPP<60 cmH2O or MUCP<20 cmH2O
• Medscape Women Health(1996): Selecting
the best surgical option for SUI. Traditional
urodynamic evaluation of SUI focusing on
MUCP has been found to be less useful than
VLPP in detecting ISD.
• VLPP<60 cmH2O : ISD
• VLPP>90 cmH2O : urethral hypermobility
Int Urogynecol J pelvic Floor Dysfunct(2001)
Ulmsten
• 49명의 ISD 환자에서 TVT 시행 후 4년간 follow
up.
• 74%-cured, 12%-improved(총 86%에서 성공)
• 실패한 7명 중 대부분이 70세 이상의 고령이고
MUCP 가 <10 cmH2O 이하
• Correlation of MUCP, LPP & incontinence
severity measure(Int Urogynecol J,2001):
MUCP 와 LPP가 낮을 수록 요실금의 정도도 심하
다. 따라서 이들 수치로 요실금의 정도를 예측할
수 있고, ISD를 평가하는 기준이 된다. 그러나 이
들 수치가 pad test 양, QOL과는 상관없다.
기타 ISD를 확인하는 방법
• Int. Urogynecol J Pelvic Floor Dysfunct(2002) :
video-UDS로 resting 시 및 복압증가시 bladder neck
의 모양으로 ISD를 다시 A,B,C 의 subtype으로 구분.
• 2008년 Smith & Appell등은 ISD환자는 요도의 저항이
낮으므로 UFM시 요속이 정상보다 더 빠를 것이라고 생
각(superflow), UFM로 ISD를 예측할 수 있지 않을까
라고 주장
• 2006년 Olivera등 – translabial ultrasonography로
urethra diameter를 측정, 6 mm이상이면 ISD라고 주장
• 가장 최근 Klarskov(J Urol. 2009), urethral pressure
reflectometry(very thin, highly flexible
polyurethrane-bag into urethra)로 요도 전체의 압력
을 측정하는 방법을 제시
Is it possible to diagnose ISD in women ?
Curr Opin Urol. 2009
• There’s some evidence women with ISD have a
poorer outcome if they are treated by TOT
compared with TVT.
• There have been some attempt at using
ultrasound to identify ISD, but without any
definite conclusion.
• Conclusion: ISD is an imprecise diagnosis.
Definition of ISD
• Low pressure urethra:
• Indicator of ISD
• Depends on age, measuring methods, circumstance
• 1976년 McGuire
• 수술 실패와 연관된 요인으로 저요도압을 보고
• AHCPR (Agency for Health Care Policy and Research)
• A cause of genuine stress incontinence: ‘. . . which may be due to congenital
sphincter weakness such as myelomeningocele or epispadias or may be acquired
after prostatectomy, trauma, radiation, or sacral cord lesion. In this condition,
the urethral sphincter is unable to coapt and generates enough resistance to
retain urine in the bladder, especially during stress maneuvers. In women, ISD is
commonly associated with multiple anti-incontinence procedures. Patients with
ISD often leak continuously or with minimal exertion.
McGuire EJ, Lytton B, Pepe V, Kohorn EI. Stress urinary incontinence.
Obstet Gynecol 1976;47:255–264
Definition of ISD:
Assessment
Bent AE. Selection of treatment for patients with stress incontinence.
Int Urogynecol J 1999;10:213-4
ISD의 임상적 의미는?
• ISD 유무에 따라 수술 방법의 선택이 달
라지나요?
• 어떤 수술을 시행하더라도 tension조정이
나 다른 특별한 방법을 사용하나요?
Clinical significance of ISD
• Int Urogynecol J Pelvic Floor Dysfunct(2002):
VLPP and/or MUCP is abnormal, incontinence is
more severe and the incidence of poor
prognostic factors is increased.
• Neurourol Urodyn(2003): ,,,we divided the
patients into two categories: 50 patients
affected by pure ISD as they had severe SUI
and no urethral mobility, 42 patients suffering
from SUI without ISD as they had mild SUI and
marked urethral hypermobility.
• 즉, ISD는 AI 에 비해 요실금의 양도 많고, 빈도
도 잦다는 의미로 해석될 수 있다.
• Definition of mild, moderate, severe
incontinence on 24-hr pad test: BJOG(2004)
-24시간 pad test에서 측정된 실금의 양을 기준
으로 mild는 1.3~20g, moderate는 21~74 g,
severe는 75 g 이상으로 하자.
• 이 결과에 따라 보존적 치료를 할 것이냐, 아니
면 수술을 선택할 것이냐를 결정하고, 수술 후
cured, improved, 또는 failure를 판단하는데 도
움을 줄 것으로 기대.
ISD affects the choice of
surgical methods ??
• Surgical Treatment of SUI: Eur J Obstet Gynecol
Reprod Biol (1999) : International classification as:
Type 1 & Type 2(AI), and Type 3(ISD).
• Procedure of choice for Type 1 & Type 2 is BNS
that create a strong hammock. Type 3 has to be
treated by coaptation or compression of the
deficient sphincteric unit(sling or injection). Mean
cure rate after MMK is 77%, Burch is 81%, needle
suspension is 79%. Laparoscopy, bone anchor &
TVT represent a promising option to the traditional
techniques.
Curr Opin Urol(2004)
• There remains NO clear consensus as to whether
UDS enhances surgical outcome of SUI by
improving case selection or altering the surgical
approach based on study finding.
• It is NOT apparent either VLPP or MUCP can
accurately predict which patients will achieve the
best outcome of surgical treatment for SUI.
Clinical significance of ISD
• Grade of ISD
• ISD A : medical, with collagen injection being used for the failed cases
• ISD B : modified PVS (can correct IDS and hypermobility)
• ISD C : urethrolysis and take down of previous suspension was
required before using a sling, collagen injections in selected cases
Ghomiem GM et al. Int Urogynecol J 2002:13:99-105
Clinical significance of ISD
• MUCP and VLPP : different mechanism?
• MUCP ≤ 30cmH2O
• more severe incontinence
• Shorter urethral functional
length
• Previous urogynecological
operations
• Menopause
• Older age
• VLPP ≤ 60cmH2O
• more severe incontinence
• Shorter urethral functional
length
• Previous urogynecological
operations
• Poor urethral mobility
Pajoncini C et al. Int Urogynecol J 2002:13:30-5
Surgical options in ISD
•
•
•
•
Pubovaginal sling
TVT : initial and failed cases
TOT : 낮은 성공률을 감안하여 환자와 상의, tension
Injection therapy : initial and adjuvant (hypermobility)
Lee KS et al. J Urol 2007:178:1370-4
ISD환자의 수술적 치료에서
수술방법에 따른 성적의 차이가
있나요?
• 수술 방법의 차이에 대한 evidence 수준은?
ISD 유무에 따른 수술 후의 성적
• 2004년 Rodriguez(J Urol): 174명의 환자에 sling 수술
• VLPP-not detected(60명), >80(27명), 30-80(71명),
<30(16명) 으로 구분
• VLPP치와 무관하게 대부분에서 성공률이 높았다
• 2007년 Porena등(Eur Urol): VLPP>,<60, MUCP>,<30
으로 나누어 TVT, TOT를 시행, 각 군간에 그리고 수술방
법간에 차이가 없다.
MUS to ISD Patients
• TVT in ISD patients (3-4year FU)
• SUI / recurrent / ISD
84.7% - 90% / 82% / 74%
• TVT 5year FU (retrospective)
Rezapour M et al. Int Urogynecol J 2001;(Suppl 2):S12–14
Doo CK et al. Eur Urol 2006:50:333-8
TOT to ISD Patients
• Risk factors for MUS
• Preop DO and MUCP ≤ 40cmH2O (TOT Monarc)
• Age ≥ 60years, previous anti-incontinence surgery (TVT-O)
• MUCP ≤ 30cmH2O, previous anti-incontinence surgery (TVT-O, ARIS)
• TOT comparison to TVT
• Cure rate worse in TOT; possible explanation is ISD (RTC)
• Monarc: 6 times more likely to fail than TVT in pts c MUCP ≤ 40cmH2O
Hsiao SM et al. Urology 2009:73:981-6
Chen HY et al. Int Urogynecol J 2007:18:443-7
Abdel-fattah et al. Int J Gynecol Obstet 2010 in press
Schierlitz et al. Obstet Gynecol 2008:112:1253-61
Miller JJ et al. Am J Obstet Gynecol 2006:195:1799-804
TOT to ISD Patients
• PVS, TVT, TOT (2years, retrospective)
Jeon MJ et al. . Am J Obstet Gynecol 2008:199:76.e1-76.e4
ISD only 환자와
ISD + hypermobility가 있는
환자의 수술 방법을 다르게
시행하나요?
The role of urethral hypermobility and ISD on
the outcome of TOT procedure: prospective
study - Int Urogy J Pelvic Fl Dysf, 2010
• group I, ISD with hypermobile urethra (n =
18) group II, ISD with fixed urethra (n = 16)
group III, hypermobile urethra without ISD (n
= 31)
• RESULTS: The cure and improvement rates of
groups I and III were similar(87.5% vs 96.4%).
Group II had the lowest cure and
improvement rates (66.7%).
• CONCLUSION: A lack of urethral hypermobility
may be a risk factor for TOT failure.
TOT to ISD with UHM Patients
• 2 year FU
• ISD VLPP ≤ 60cmH2O
• Hypermobile urethra Q tip >30 degree
• ISD with hypermobile urethra
• ISD with fixed urethra
• Hypermobile urethra without ISD
87.5%
66.7%
96.4%
• Lack of hypermobility may be a risk factor for TOT
failure
Haliloglu B et al. Int Urogynecol J 2010:21:173-8
소견 정리
• 이동환교수;
ISD 환자에게 TOT를 해도 정말 괜찮나요?
• 주명수교수;
ISD 환자에게 TOT는 성적이 좋지 않아서 정말
TVT(or SPARC)를 시행해야 하나요?
소견 정리
• 이동환교수;
ISD 환자에게 TOT를 해도 정말 괜찮나요?
• 주명수교수;
ISD 환자에게 TOT는 성적이 좋지 않아
서 정말 TVT(or SPARC)를 시행해야만
하나요?
My principle
•
•
•
•
•
•
•
•
•
Check VLPP and MUCP
Urethral hypermobility, fixed urethra
Previous pelvic surgery such as radical hysterectomy
Failed cases or initial case
Age and activity
Patient expectation, compromise cure rate?
Voiding function: MFR, curve pattern, Pdet
Injection therapy as a initial or adjuvant therapy
More tension ?
증례 토의
증례 1; ISD + OAB sx이 있는 환자의 수술 방법의 선
택은?
F/53
C.C; Urinary incontinence, aggravated, 1 year ago
P.I;
Voiding Sx.:Frequency(+,q1hr), Nocturia(+,#1/N), RUS(+),
Urgency(+), UI(-), Hesitancy(-), dysuria(-),
abd.strain(-)
Incontinence Sx. : Coughing (+),Laughing (+), Running (-)
Weight bearing (-) Walking (+),Resting (-)
P.Hx
DM(+), HTN(+), Pul Tbc(-), hepatitis(-)
PEx
Cystocele(-), Rectocele(-)
<UDS>
MCC: 300ml, Uninhibited contraction(-)
UFR : Qmax:27.9ml/sec Voided vol:189ml RU :21ml
Leak point pressure
-100cc bladder filling
cough pves 38cmH2O -> mild leakage
valsalva pves 53cmH2O -> mild leakage
-150cc bladder filling
cough pves 66cmH2O -> mild leakage
valsalva pves 30cmH2O -> scanty leakage
# Pad test : 12.2gm
Sling operation(MONARC) was done
OPD f/u, 3 months later
: leakage(-), urgency(-)
증례2; ISD환자인데 타 병원에서 TOT를 한 환자가
재발했다. 그 다음 수술 방법의 선택은?
F/55
C.C
Urinary incontinence, 1 year ago
P.I
내원 4년 전 개인 산부인과 병원에서 Sling op(TOT) 시행 받은
분으로 1년전부터 Urinary incontinence 재발했음.
P.Hx
DM(-), HTN(-), Pul Tbc(-), hepatitis(-)
OP Hx: Sling op(TOT) d/t SUI (‘2006)
R.O.S
Voiding Sx. : Frequency(-) Nocturia(-) Urgency(-) UI(-) RUS(-)
WUS(-) Hesitancy(-) dysuria(-) abd.strain(-)
Incontinence Sx. : Coughing (+), Laughing (+), Running (+)
Weight bearing (-), Walking (-), Resting (-)
P.Ex
Cystocele(-) Rectocele(-)
<UDS>
MCC: 310ml , Uninhibited contraction(-)
UFR : Qmax:20.6ml/sec Voided vol:147ml RU :36ml
Leak point pressure
-110cc bladder filling
cough pves 97cmH2O -> mild leakage
valsalva pves 44cmH2O -> mild leakage
# pad test : 1.3gm
증례3; VLPP가 64인 환자를 본원에서 TOT를 했는
데 약간 좋아졌지만 여전히 샌다.
어떻게 해야 하나요?
F/63
C.C; Urinary incontinence,
P.Hx
8
year ago
DM(-)/ HTN(+)/ Pulm Tb(-)/ hepatitis(-)
S/P ESWL#3 d/t Ureter stone, upper, Rt ('98,'03)
S/P spine op d/t herniated lumbar disc
Voiding Sx. :Frequency(+,q1hr) Nocturia(+,#2/N) RUS(+)
WUS(+) Urgency(+) UI(+) Hesitancy(-) dysuria(-)
abd.strain(-)
Incontinence Sx. : Coughing (+),Laughing (+), Running (-),
Weight bearing (-) Walking (-),Resting (-)
P.Ex
Cystocele(-) Rectocele(-)
<UDS> (2009.04.15)
MCC: 310ml, Uninhibited contraction(-)
UFR : Qmax:13.1ml/sec Voided vol:161ml RU :13ml
Leak point pressure
-100cc bladder filling
cough pves 49cmH2O -> mild leakage
valsalva pves 76cmH2O -> mild leakage
-150cc bladder filling
cough pves 89cmH2O -> mild leakage
valsalva pves 64cmH2O -> mild leakage
# Pad test : 6gm
Sling operation(MONARC)
Postop 3 mo ; still leakage
was done (2009.04.16)
Re-admission(2009-8-20)
Voiding Sx. : Frequency(+,q1hr30min), Nocturia(+,#3/N), RUS(-)
WUS(-), Urgency(+), UI(+), Hesitancy(-), dysuria(-)
abd.strain(-)
Incontinence Sx. : Coughing (+), Laughing (+), Running (-),
Weight bearing (-) Walking (-),Resting (-)
P.Ex
Cystocele(-) Rectocele(-)
Sling operation(TVT)
was done
--- postop. 1 mo.; leakage (-), frequency(-), urgency (-)
ISD가 있는 SUI 환자의 수술적
치료로서
향후
1. TVT (or SPARC)를 사용하겠다.
2. TOT도 상관없이 사용하겠다.
3. Pubovaginal sling을 여전히 사용하
겠다.