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Joseph Lee

Bernie Haylen

Oliver Daly

Christopher Maher

UGSA MUS sling workshops

Managing intraop & post op complications 2016

Preamble

Pathophysiology & Etiology of SUI

Epidemiology

Assessment of UI

Management of SUI

Enhorning’s Theory & Hammock Theory

Conservative & Surgery

Management of intra & post operative complications

Case discussions

SUI surgery – challenging issues of perception Retropubic SUI surgery – intra op & post op issues

Bladder Perforation

Needle wont pass

Mesh in Sulcus

Haemorrhage

Voiding Dysfunction after MUS

Recurrent Urinary tract infection

Pain after MUS

De novo Urgency

Failed MUS, recurrent SUI

Recurrent SUI after Mesh Excision

Persistence of OAB

Bladder Perforation Bladder Perforation

• Follow traditional steps

• Drain bladder & deviate bladder

• Infiltrate 40ml cave, 20ml vagina & Mark exit site

• Keep hand piece horizontal, avoid deviation

• 70 degree cystoscopy, flush out hematuria

• Abandon procedure if unable to have clear view

– (don’t re-place & hope)

• More fine control on initial vertical pass

• Drop shoulder & elbow

Bladder

puncture

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Bladder Perforation – Retropubic MUS RCTs

0

5

10

15

20

25

30

%

03 03 05 05 05 05 05 06 06 06 06 07 07 08 08 08 08 09Year

0.7

Spacr 41

IVS 50

TVT 50

Rechberger

Mansoor

TVT 102

TVT 58

IVS 54

Sparc 58

SUSPEND Lim

TVT 43

Andonian

Tseng

TVT 31

Sparc 31

TVT 105

Sparc 130

Enzelsberger

Na

Ryu

TVT 80

TVT 48

Agarwala

TVT 92

IVS 87

Meschia

TVT 147

Sparc 153Lord

TVT 89

Liapis

TVT 131Riva

ISTOP 88

David-Montefiore

Sparc 50

Wang

TVT 90

Porena

TVT 231

TVT 158

Andonian

TVT 72

Meschia

Zullo

TVT 265Laurikainen

TVT 187

TVT 170

Barry

Barber

TVT 138Schierlitz

TVT 208

TVT 127

Araco

Teo

TVT 349Taumussino

TVT 164Karateke

Lynx 48

IVS 398

Rechberger

8 4 9.2 1.6 3.3 6.6 23 24 0.0 12.9 7.6 6.2 0.0 3.3 3.4 1.9 6.5 1.5 9.5 3.4 2.1 13.8 4 11 8.50.7 7 7 2.7 0.0 3.3 4 6 6.5 3.7

Average 6.04%

JL 2009

Bladder Perforation rate is dependant on size of RCTs

Perforation rate

Sam

ple size RCT

0

50

100

150

200

250

300

350

400

450

0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00%

Average rate 6%

RCT – MUS: Scatter Plot Sample size vs Bladder Perforation

Perforation rates of RPMUS RCTs dependent on sample size

Independent risk factors for bladder perforation

OR Significance 95% C.I.

Previous Caesarean Section 3.7 p<0.05 1.2 - 11.5

Previous Colposuspension 3.2 p<0.05 1.2 - 12.7

BMI < 30 5.9 p<0.01 1.7 - 20.6

Local anaesthesia 5.9 p<0.001 2.6 - 13.7

Rectocele 6.2 p<0.001 2.1 - 17.8

Perforation rates of RPMUS related to experience

This occurs in surgeons who performed <50 slings

Retropubic MUS trocar passage

HUG the symphysis

- Handle DOWN

- Drop elbow

- Point upwards, finger in vagina

- Dont shove towards shoulder

Retropubic SUI surgery – intra op & post op issues

Bladder Perforation

Needle wont pass

Mesh in Sulcus

Haemorrhage

Voiding Dysfunction after MUS

Recurrent Urinary tract infections

Pain after MUS

De novo Urgency

Failed MUS, recurrent SUI

Recurrent SUI after Mesh Excision

Persistence of OAB

• WHY

• Are you in right space

• Are you hitting bone

• Enough infiltration (20ml each side)

• Was tip sharp (make sure plastic tip sits snug)

• Video, cadaver training, preceptorship

Needle wont pass

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• Check after each trocar passage

• Was plastic ends cut? – retrieve, review defect before re-do

• Drop handle more?

• Mobilise vaginal flaps, re suture over

Vaginal angle injuries/perforation

• Small amount of bleeding not uncommon

• generayl, bleeding will stop when closing vaginal skin

• Eg cystoscopy suggest perivesical hematoma

• More hematoma with RP route (cf TO)

• generous infiltration eg 60ml

• Mark skin, keep midline

Hemorrhage on needle passage

Floseal after SPARC

56yo non obese Brisk bleeding after sleev removed

Spinal anaesthesia

Inf border ramus

Midurethral – space laterally

Sparc device to deploy tape

Check cystoscopy

Digital compression two 10m interval

Bladder filled 600ml + 10m bimanual

compression

FloSeal + 10m Bimanual

EBL 300ml

Floseal use have been described for retropubic bleeding due to trocar passage

Retropubic SUI surgery – intra op & post op issues

Bladder Perforation

Needle wont pass

Mesh in Sulcus

Haemorrhage

Voiding Dysfunction after MUS

Recurrent Urinary tract infections

Pain after MUS

De novo Urgency

Failed MUS, recurrent SUI

Recurrent SUI after Mesh Excision

Persistence of OAB

• Best predictor – uroflow, Valsalva Voiders

• Expectations

• SPC vs Urethral

• 2 weeks to re-loosen

• Imaging – position, compression

• Division midline vs lateral

Voding dysfunction after MUS Prediction of post op voiding after RPMUS

Dawson IUJ 2007; 18:1297–1302, Haylen BJU 1989; 64:30-8

Incidence of VD @6m post op – 22/267 (8%) require ISC

there is almost a threefold greater

likelihood of needing ISC in women

with a QaveCent of 10 than in

those with a QaveCent of 80

average voiding flow rate centile score showed the strongest association with post-TVT voiding

dysfunction, the likelihood of needing ISC increasing as the centile score fell

Liverpool AUFR Nomogram

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Retropubic SUI surgery – intra op & post op issues

Bladder Perforation

Needle wont pass

Mesh in Sulcus

Haemorrhage

Voiding Dysfunction after MUS

Recurrent Urinary tract infections

Pain after MUS

De novo Urgency

Failed MUS, recurrent SUI

Recurrent SUI after Mesh Excision

Persistence of OAB

Less evidence

• Check flow, residual, upper tracts

• Is sling tight?

• Reverse vaginal atrophy

• Exclude intravesical mesh or non-absorbable suture in vaginal

• Hiprex 1mg BD w VitC 500-1000mg BD

• Low dose rotating antibiotics

• Cranberry, D-Mannose, PM Lactobaccilus

Recurrent UTI after MUS

• Avoid mesh in adductor muscle

• Outside in needle diameter narrower than inside out

• MRI to locate position

• Injection with Local/Steroids prior to removal

• MRI – on Hip joint? Referred pain

• Retropubic easier to remove than transobturator

Pain after RP/TO Sling

• Exclude obstruction: uroflow, residual

• Pre-op UDS?

• Exclude UTI, intravesical mesh

• Routine approach to OAB

• Antimuscarinics: Ditropan, Oxytrol, Vesicare, Enablex, Detrusitol

• beta3 agonist: Betmiga

• Good Bladder Habits, Bladder training

De Novo Urgency after MUS

pUUI

<0.00010.38 – 0.750.54Concomitant POP surgery

0.0240.39 – 0.940.61Transobturator MUS

<0.00011.02 – 1.041.03Age (per year increase)

0.0061.10 – 1.781.41*Baseline urgency

symptoms severity

<0.00011.39 – 3.012.04Urodynamic USI & DO

p value95%CI ORpersistent Urgency

0.0050.087-0.970.33

0.0271.24 - 34.136.49

0.0081.18 – 2.931.86

<0.00011.38 – 2.561.88

0.0041.28 – 3.702.18

p value95%CIOR

Apical POP

USI & DO

Prev SUI

surgery

Apical POP

surgery

Who has persistence U/UUI

*baseline degree of bothersome urgency: 0=nil, 1=occasional, 2=daily

*Baseline

urgency severity

The mean age was 60.6±12.8 years.

The mean follow-up was 218.1±105.3 weeks.

The overall subjective rate for pU & pUUI was 40.3% & 32.30% respectively.

No difference Urgency between retro MUS and obturator tapes

Ford 2016

Retropubic SUI surgery – intra op & post op issues

Bladder Perforation

Needle wont pass

Mesh in Sulcus

Haemorrhage

Voiding Dysfunction after MUS

Recurrent Urinary tract infections

Pain after MUS

De novo Urgency

Failed MUS, recurrent SUI

Recurrent SUI after Mesh Excision

Persistence of OAB

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• Review by urogynaecologist

• Review diagnosis ?ISD

• Imaging – position, compression

• Repeat UDS

• If urethra rigid = poorer outcomes

• Injectables or MUS or PVS

• Prev Colpo: if hypermobile = MUS

• Sling on Sling feasible

• RP confer 70% subj cure for repeat MUS

J Urol 2010; 183:241-2461

Recurrent SUI – prev SUI surgery Repeat Midurethal Sling on prev MUS

7% (1112) repeat MUS. Overall subj cure 85% (primary 86% vs 62%

repeat p<0.001)

Repeat group has more ISD (31% vs 13%, p<0.001)

Amongst repeat, RP has higher subj cure (71% vs 48% [TO] p=0.04)

Repeat group has more post op urgency & UUI (30%,22% vs 14%,5%

p<0.001)

Stav 2009

• Superficial Dyspareunia / persistent discharge or “Hispareunia”

• <5mm: conservative, Estrogen

• Wide excision, flaps, antibiotics

• Following excision Recurrent SUI rate 20-50%

• Advise against Concomitant SUI surgery

Mesh Exposure UGSA RANZCOG Position statement on MUS

https://www.ranzcog.edu.au/news/1356-ranzcog-ugsa-supports-the-use-of-mid-urethral-

slings-in-the-surgical-management-of-female-stress-urinary-incontinence.html

24th Mar 2014

https://www.ranzcog.edu.au/doc/position-statement-on-midurethral-slings-c-gyn-32.html

UGSA RANZCOG Position statement on MUS

https://www.ranzcog.edu.au/doc/position-statement-on-midurethral-slings-c-gyn-32.html

RANZCOG & UGSA supports use of MUS

SUI is common & burdensome

MUS is efficacious, effective and had

Become the operation of choice in

Australia, UK, USA & Europe

FDA safety communications on

Transvaginal mesh do NOT include MUS

MUS does comes with adverse events.

Evidence for its efficacy & effectiveness is

robust

Questions