incontinence and it's management

8/7/2019 Incontinence and It's Management

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INCONTINENCE

Many Stresses/Many Solutions

Dr. Robert Nordland, FACOG



IncontinenceOver 13 million people in the US

experience incontinence.

85% of them are women.



Types of Urinary IncontinenceOverflow incontinence

Urge incontinence

Stress incontinence

Functional incontinence



Types of Urinary Incontinence



Causes of Urinary IncontinenceDamage to pelvic floor

Child birth trauma

Hormone deficiencies

Spinal cord injury

Stroke

Urinary tract infections



Stress IncontinenceThe involuntary loss of

urine during coughing,

laughing, sneezing or other activities that

increase abdominal

pressure



Stress Incontinence-ISD

INTRINSIC SPHINCTER DEFICIENCY

The urethral sphincter is

unable to close and generate

enough resistance to retain

urine, especially during stress

maneuvers.



Stress Incontinence-ISD

HYPERMOBILITY

The bladder neck and

urethra are significantly

displaced with anincrease in abdominal

pressure



Pathophysiology of GSUIDefects in the Support Structure

Pubourethral ligaments

Suburethral vaginal hammock(endopelvid fascia)

Connective tissue (collagen fibers) interconnecting theabove structures

Defects in Both Instrinsic andExtrinsic Urethral Function:

DenervationDevascularization

Aging



Dr. Neale¶s QuoteThe art of urogynaecology is to 'marry' the right

operation to the right patient, Meaning '... after the

right patient has been selected for operation, the

right operation must be selected for the patient.¶

Richard Neale

Current Opinion in Obstetrics and Gynecology 1995, 7:400-403



Goal of SurgeryRestore and/or reinforce the pubourethral

ligaments

Restore and/or reinforce the suburethralvaginal hammock.

Reinforce the paraurethral connective

tissue.



K

elly Plication Procedure



Marshall-Marchetti-K rantz

Morbidity6

Abdominal incision

Hernia

Osteitis pubisPermanent retention

Obstruction

1949, original ³pin-up´ procedure

Peri-urethral tissue sutured to the pubic symphysis

84-92% success rate for stress incontinence6



Burch Retropubic UrethropexyTechnical advantages over M-M-K

Supportive tissue lateral to urethra sutured

to Cooper's ligament

79-88% success rate for stress incontinence5



Artists Diagram of a Fascial Sling



Sling Materials for Midurethral

SurgeryMersilene-6 patients

Prolene-10 patients

Biopsies obtained at the end of 2 years

Results: Mersilene had a significant

inflammatory reaction as compared to

ProleneUlmsten, Falconer, Soderberg, et al, International Urogynocol Journal, 2001



TVT Tension Free Vaginal TapeLocal anesthetic

No catheters

Out-patient



TVT Tension Free Vaginal Tape

PROLENE* polypropylene mesh (Tape)

No fixation

Trans-vaginal approach



Mid-Urethral Entry



Mid-Urethral Spacing



ProphalacticTVT as Combined

Therapy for Severe Prolapse

30 consecutive continent women withsevere prolapse and occult SUI(+stress test)

All patients had hyper-mobility(no ISD)

One year follow-up with CMG at 3 monthintervals

0 developed postop symptomatic SUI

3(10%) asymptomatic patients had positivetests

9(30%) had detruser instability before

surgery that persisted in 6(66%) post-op



Combined Therapy(Cont.)

Postop de novo detruser instability found in

4 other patients

None of the patients had recurrent prolapse

None had bladder outlet obstruction

Conclusion, preliminary results indicate

prophalactic TVT encouraging for severe

prolapse surgery

Gordon et al, Urology, 58, 2001



Intrinsic Sphincter

Deficiency(ISD) treated by TVT4 year(mean) follow-up of 49 patients

36(74%) completely cured

6(12%) significantly improved

7(14%) no improvement

Ulmsten, Rezapour, Falconer-Upsala Univ., Int. Urogynecol J., 2001



Long Term Results with TVT for

Mixed and Stress IncontinenceQuestionnaire returned from 760 patients out of 970 who

had TVT 2-8 years previous

Excluded 17 as unclassified, and 51 as de novo-

580(83.8%) with stress and 112(16.2%) mixed

Results: Stress cure rate of 85%, mixed cure rate of 60%

up to 4 years then declined to 30% after 4 years due to

urge

Holmgren et al, Sweden, Ob/Gyn, Vol. 106, July 2005



Anesthesia(s) Effect on

Voiding after TVTRetrospective study of 173 cases(data only

from 163) comparing general anesthesia vs.

local anesthesiaResults: General anesthesia(lack of cough-

stress test) does not increase chance of post-

op failureMurphy et al, Louisville, Obstetrics and Gynecology, 101, April, 2003



Urinary Retention after TVT1998-600 TVT procedures had 17 patients(2.8%)

with urinary retention more than 1 week post-op

All 17 had sling release procedure(64 days mean post-op)

15 minute procedure with minimal blood loss

Results: 1 urethral injury, 16 remained dry

K lutke et al, Washington U, Urology, 58, 2001



Finnish Study of TVT Complications(1999)38 Hospitals

1,455 Procedures

Bladder Perforation Incidence 38/1000

Blood Loss over 200ml 19/1000

Major Vessel Injury, Nerve Injury, Vaginal Hematoma and

Urethral Lesion 0.7/1000

Minor Voiding Difficulty 76/1000

Laparotomy Required 3.4/1000

ACTA Obstet Gyn Scand 2002; 81



Urethral Erosion After TVT:

Case Report

57 year old with urinary retention 1 year post TVT

Fluroscopy showed dilatation and obstruction

Cysto showed erosion of slingAuthor thought erosion due to urethral tension and

repeated catheterization

Lieb and Das, Albany Medical College, Scand J of Urol & Nephrol, 37, 2003



Management of Vaginal Erosion

of Polypropolene Mesh Slings

90 patients had SPARC between 10/2001-10/2002

3 SPARC and 1 transferred TVT had mesh exposure

6 weeks post-op: 2 asymptomatic, 2 symptomatic

Conservative management 100% cure in 3 months

Therefore, not all erosion need completely removal.

K obashi & Govier, at Virginia Mason U, Seattle, WA, J of Urology, Vol. 169, June 2003



Ilioinguinal Nerve Entrapment

after TVT

Entrapment seen often after herniorrhaphy,inguinal node dissection, and appendectomy

Found entrapment after TVT on 68 year oldfemale and treated with local injections

More likely to occur when trocar extendsinto internal oblique muscle/beyond the

lateral edge of the rectus where nerve runsGeis, Dietl, Germany, Int. Urogynecol J., 13, 2002



TVT Penetrating Urethra:

Case Report

Rarely reported, but could occur more often

than expected

68 year old with pain and voiding disorder found TVT tape penetrating urethra at 14

months post-op

Resolved by transurethral resectionWerner, Switzerland, Obtetrics and Gynecology, Vol. 102, Nov. 2003



Bowel Perforation During TVT-

Case Report

56 year old developed acute abdominal

pain/ required laparoscopy

Found tape passing through loop of smallintestine

Removed and repaired laparascopically

Meschia et al, U of Milan, Int. Urogynecol. J., 13, 2002



Suprapubic Technique



Needles travel in the³ zone of safety´

potentially reduces risk of damage to major vessels and bowel

Suprapubic Approach



TVT versus SPARC

122 consecutive patients had TVT(73) or

SPARC(49)

1/2000-3/2003 Evanston Hospital(retrospectivestudy)

CMG pre-op and 14 weeks post-op

Results: TVT higher subjective

result(86%vs.60%)and objective 95%vs.70%Gandhi et al, Int. Urogynecol J., 17, 2006



SPARC VS. TVT

# of patients SPARC % TVT %

³TVT and SPARC Suburethral Slings: a Case-control Series, Dietz, H.P. et al., Int

Urogynecol J 2004

Cure/Improvements

Subjective

n = 37 SPARC

n = 69 TVT

92 85

³Comparison of SPARC and TVT in Treating Urinary Incontinence´, Gauruder-

B, ICS 2003

Cure/Improvements

Subjective

n = 50 SPARC

n = 50 TVT

87.3 85.9

³Physician Satisfaction with SPARC Suprapubic Sling System: An Opinion-based survey´, Stanford E., J

Pelvic Med Surg, 2005

Opinion-based survey based on completed surveys by 47 urogyns and urologists

76% reported that the SPARC was less difficult to adjust than TVT

90% found the adjustment allowed by SPARC's suture is of at least some benefit

A paired, one-way t-test demonstrated that blood loss with SPARC was 10% less than that of TVT



Transobturator Trochanters



Transobturator AdvantagesClinical efficacy and safety data

Type I Polypropylene mesh

Needle designs

Single-use

Multiple options for every size of patient and physician preference

Standard helix

Large Helix

C-needle

outside-in moves away from obturator nerves and vessels

incontinence and it's management

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