Transcript Intrinsic Sphincter Deficiency & Slings

Intrinsic Sphincter Deficiency
&
Slings
Nader Gad
MBChB, MChGO, FRCOG, FRANZCOG
Consultant & Senior Lecturer in O&G
Royal Darwin Hospital, Darwin, Australia
Definition of ISD
• SLPP less than 60 cmH2O
• MUCP less than 20 cmH2O
• Type III Stress Incontinence (Proximal urethra
open at rest)
Classification of SUI
Clinically &
During UDA
Type 0
Type I
Type IIA
Type IIB
Type III
No SUI is seen
Probably due to
momentary voluntary
contraction of
External Urethral
sphincter
Bladder neck & proximal
urethra
During Rest
closed at rest
At or above inferior
Margin of SP
Bladder Neck & Proximal
urethra
During Stress
Descend & open
Cystocele
Closed at rest
Above inferior Margin of
SP
Closed at rest
Above inferior Margin of
SP
Open
Descend less than 2 cm
None or Small Cystocele
Open
Rotational descent
characteristic of cystouretherocele
Open
May be further descent
Present
Closed
At or below inferior
Margin of SP
Open at rest
Proximal urethra no
longer function as
sphincter
None
Causes Of ISD
•
-
Previous Pelvic Surgery
Anti-incontinence surgery
Urethral diverticulectomy
Radical Hysterectomy
Urethrotomy
Resection or incision of vesical neck
• Aging & Hypo-oestrogenic States
• Pelvic Irradiation
•
-
Neurologic Conditions
Myelodysplasia
Anterior spinal artery syndtome
Lumbosacral neurologic conditions
Shy-Drager syndrome
Treatment of ISD
• McGuire et al(1978 )were the first to note that
ISD present in :
- 75% of women of patients who failed in
multiple surgeries for SUI
- 13% with no previous anticontinence surgery
Difficult to determine is it cause or effect?
Treatment 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 H2O
• Failure rate of Burch at 3 months FU:
- Low MUCP: 54%
- Normal MUCP: 18%
Treatment of ISD
• Most data show simple elevation of the
bladder neck is ineffective
• Recommend more obstructive procedure
Treatment of ISD
1. Proximal Suburethral slings (Traditional)
2. Mid-Urethral Tension-free Slings:
a. TVT
b. TOT
3. Artificial sphincter
4. Urethral Bulking Procedures
Proximal Suburethral Slings
• First introduced by Giordano in 1907 using
Gracilis muscle flap
• Aldridge in 1942, developed the Fascial sling
• The 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
Types of Proximal Slings
Biologic
Synthetic
Fascia lata
Rectus fascia
Gracilis muscle flap
Pyramidalis muscle flap
Round ligament
Ox dura mater
Porcine small intestine
submucosa
Cadaver fascia
Mersilene
Nylon
Marlex
Gore-tex
Silastic
Polypropylene mesh
Patient most un-suitable
• History of irradiation
• Previous sling erosion
• Having surgery on the urethra at the same
time (e.g., urethral diverticulectomy)
• Having POP surgery at the same time
Proximal Urethral slings
• Overall success for SUI + ISD at 5 years = 80 –
90%
• Summitt et al (1990)
Sling procedure success rates were:
- 93% in ISD + HMBN
- 20% in ISD + no HMBN
Common Complications of
Proximal Suburethral Slings
- Longer recovery
- Has the highest rate of retention: 2-37%
TVT & ISD
•
•
-
Rezapour (2001) First report on 49 women:
F-U for 3-5 years:
74% completely cured
12% improved
14% no improvement:
Majority more than 70 years old & MUCP less
than 10 cmH2O
TVT & 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
TVT Complications
•
•
•
•
•
•
•
•
•
Voiding difficulties
Recurrent UTI
Bladder perforation (5-10%)
Erosion (3 – 5 %)
Vascular injury
Bowel injury
Haematoma
Nerve injury
Death (6 reported deaths by September of 2002)
TOT & Slings
• It leaves the sling in a more horizontal or
hammock-like rather than U-orientation
• Less operative time
• Avoid risk of injury to bladder (only few
reported cases) bowel & major vessels
TVT 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 less
were exclusion criteria of TOT but not TVT
Failure Rate TVT vs TOT
Miller et al 2006
All (145)
Objective
Subjective
MUCP 42 or less (81) Objective
Subjective
Objective
Subjective
MUCP more than 42 (64)
TVT (60)
Monarc (85)
3%
14%
3%
13%
4%
16%
9%
16%
16%
23%
2%
6%
TVT 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: 87
- TVT: 94
- TOT: 72
TOT (polypropylene; Iris, Dowmedics Co, Korea, Outside – in )
- Regional of General Anaesthesia
TVT 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%
TVT vs TOT vs Sling
Jeon et al (2008)
Complications
PVS (n=87)
TVT (n=94)
TOT (n=72)
P value
Bladder injury
1 (1.2%)
0
0
0.6
De novo
urgency
14 (16%)
14 (15%)
13 (18%)
0.9
Voiding
dysfunction
18 (19%)
17 (18%)
8 (11%)
0.75
V.D. Requiring
surgery
0
3 (3.1%)
1 (1.4%)
0.26
Recurrent UTI
2 (2.3%)
6 (6.4%)
0
0.06
Mesh Erosion
-
1 (1.1%)
1 (1.4%)
1
(one month or longer)
Darwin Experience
•
Retrospective study of my First 25 cases of
the TVT-O procedures (J&J)
• Procedure were completed in all women
under sedation and local anaesthesia
• Outcome of the procedure:
a. Complication: intra- & post-operative
b. Success rate: Subjective & Cough test
c. Any difference in outcome when ISD
present?
Darwin Experience
• ISD was defined as valsalva or cough LPP = less
than 60 cmH2O and/or MUCP = 20 cm H2O or
less
• Women 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 ISD
- TVT has the potential risk of bowel or major
blood vessels injury
Patients studied
Public
7
28%
Private
18
72%
GP referral
20
80%
Specialist Ref
5
20%
Age
39 – 66 years
Parity
1–6
Presence of SUI
In All women
100%
Urgency
9/25
36%
Urge incontinence
5/25
20%
Frequency
6/25
24%
Nocturia
5/25
20%
Previous surgery for SUI
3/25
12%
Previous Hysterectomy
10/25
40%
Previous POP repair
6/25
24%
UDA Findings
Presence of POP
15/25
60%
HMBN
21/25
84%
ISD
10/25
40%
HMBN + ISD
6/25
24%
ISD alone
4/25
16%
DI
2/25
8%
Sedation
• Bolus of 1-2 mg midazolam
• Then propofol 1% infusion at a rate of 2040mls/hour titrated to effect
• A small bolus of propofol (10-30mg) and/or
alfentanil (100 – 200mcg) may be used when
required in some patients during penetration
of Obturator membranes.
Local Anaesthesia
• The local anaesthetic agent used was a total of
80 – 100 ml of 0.25% prilocaine with
adrenaline (1:200,000)
Local Anaesthesia
• Administration of local anaesthesia to:
a. the area of the suburethral vaginal incision
b. paraurethral lateral dissection
c. expected 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.
Cough Test
• Once tape is inserted, cessation of all sedation
• Bladder is filled to a volume similar to that when SUI
was demonstrated during UDA
• Cystoscopy performed
• When patient is awake enough, operative table is
tilted head up about 30 degrees
• patient is instructed to cough strongly and the tape is
very slowly adjusted to the point when urinary
leakage just stops
Operative & Short-term Complications
Intra-operative
complications
0
0%
Short term
Urinary retention
0
0%
Short Term DI
1/25
4%
Short term
postoperative
complications
2/25
8%
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 later
2 patients (8%)
developed
significant pain in
the upper thigh that
resolved by 6 weeks
post surgery
Hospital Stay
AM list
7
28%
Discharge of AM list on
same day
6/7
86%
PM List
18
72%
Discharged on the same day
2/18
11%
Discharged next morning
14/18
78%
Discharged within 48 hours
2/18
11%
Follow-up
Duration of FU
Mean = 4 – 52 weeks
Average = 13.3 weeks
Duration to Audit
Mean = 7 – 156 weeks
Average = 53 weeks
Long Term Outcome
Urinary
retention
0
0%
Urgency
2
8%
Other
complications
1
4%
No further SUI
24/24
100%
Two woman
developed
mild urgency
Pain in the
vagina required
excision of part
of the tape
August 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:
(A)29% had low VLPP (Less than 60 cmH2O)
(B)71% had higher VLPP
August 2008
Anast et al, Missouri, USA
At a mean of
12 month
Subjective
Cure rate
Bladder
perforation
(6 patients)
Complication
rate
Low VLPP
(29%)
93%
High VLPP
(71%)
79%
3%
6%
11%
29%
Conclusion
• TVT-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:
Retrospective
Small number of the patient in this study
Relatively short term follow up period