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Incontinence and It's Management
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INCONTINENCE
Many Stresses/Many Solutions
Dr. Robert Nordland, FACOG
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IncontinenceOver 13 million people in the US
experience incontinence.
85% of them are women.
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Types of Urinary IncontinenceOverflow incontinence
Urge incontinence
Stress incontinence
Functional incontinence
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Types of Urinary Incontinence
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Causes of Urinary IncontinenceDamage to pelvic floor
Child birth trauma
Hormone deficiencies
Spinal cord injury
Stroke
Urinary tract infections
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Stress IncontinenceThe involuntary loss of
urine during coughing,
laughing, sneezing or other activities that
increase abdominal
pressure
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Stress Incontinence-ISD
INTRINSIC SPHINCTER DEFICIENCY
The urethral sphincter is
unable to close and generate
enough resistance to retain
urine, especially during stress
maneuvers.
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Stress Incontinence-ISD
HYPERMOBILITY
The bladder neck and
urethra are significantly
displaced with anincrease in abdominal
pressure
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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
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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
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Goal of SurgeryRestore and/or reinforce the pubourethral
ligaments
Restore and/or reinforce the suburethralvaginal hammock.
Reinforce the paraurethral connective
tissue.
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K
elly Plication Procedure
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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
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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
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Artists Diagram of a Fascial Sling
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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
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TVT Tension Free Vaginal TapeLocal anesthetic
No catheters
Out-patient
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TVT Tension Free Vaginal Tape
PROLENE* polypropylene mesh (Tape)
No fixation
Trans-vaginal approach
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Mid-Urethral Entry
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Mid-Urethral Spacing
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Suprapubic Technique
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Needles travel in the³ zone of safety´
potentially reduces risk of damage to major vessels and bowel
Suprapubic Approach
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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
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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
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Transobturator Trochanters
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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
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