managing urethra at the time of prolapse surgery

8/6/2019 Managing Urethra at the Time of Prolapse Surgery

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Managing urethra at theManaging urethra at thetime of prolapse surgerytime of prolapse surgery

Prof Dr Mohamed ShafikProf Dr Mohamed ShafikAlexandria UniversityAlexandria University


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DilemmaDilemma

SUI may occur following prolapse repair How often?

Following which type of prolapse repair? Can we predict who will get it?

What should we do about it?

No consensus on the optimal managementNo consensus on the optimal management


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Prolapse & SUIProlapse & SUI

If preoperative SUI ( symptomatic and/orurodynamic) and prolapse

Most would repair cystocele and sling

But what about.No preoperative SUI & prolapse- 10-30 % of patients at risk of de novo SUI

Despite lack of level 1 evidenceto support this approach !!!


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Evidence in literatureEvidence in literature

3rdInternational Consultation on Incontinence:

Lev

el IEv

idence:None supporting any type of Rx in this scenario

Level II Evidence:

Incontinence & voiding dysfunction may follow POP surgeryand these outcomes are variable and unpredictable


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Slings & Grade IV CystoceleSlings & Grade IV Cystocele

We all agree that a sling should be done if thepatient has:

- Subjective and objective stress incontinence- Urodynamic stress incontinence- Occult incontinence ( demonstrated after reduction of the

prolapse)

The question is to sling or not in a dry patientwithout clinical, urodynamic or occultincontinence.


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All patients with high gradeAll patients with high grade

cystocele should also have a slingcystocele should also have a sling


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why should we do slings?why should we do slings?

Prevents the 5-30% of secondary SUI No reliable preoperative testing can

predict the functional status of theurethra

Minimal morbidity of the distal poly-propylene sling

- Low urinary retention rate ( < 4-7%) Reduced incidence of 2ry cystocele

(19% vs. 34)

Level I Evidence that a urethral supporting procedureshould be done as part of the repair of

vaginal vault prolapseBrubaker, 2006, NEJM


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Stress incontinence (SUI) &Stress incontinence (SUI) &Grade IV cystoceleGrade IV cystocele

Repair of G IV cystocele lead to 13-35%denovo SUI

Richardson DA et.al (1983); Borsted E, et. Al (1989); Bump R C,et.al. (1988)

We agree that a sling should be done ifthe patient has preoperative clinical,

urodynamic or occult stress urinaryincontinence

What to do if no preop. SUI


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Stress incontinence (SUI) &Stress incontinence (SUI) &

Grade IV cystoceleGrade IV cystocele

Can be predict which patients should have a

sling? Do concomitant sling procedures increase

risk of complications?

Should we perform a sling in every patient? Is there other rationale to do a concomitant

sling in the dry patient?


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Should we perform a sling in every patient?

Is there other rationale to do a concomitantsling in the dry patient?


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Preoperative reduction methodsPreoperative reduction methods

Detection rate of SUI with prolapsereduction varied significantly

SUI with prolapse reduction at 300 mls- Pessary 6% (5 of 88)

- Manual 16%(19 of 122)- Forceps 21% (21of 98)

- Speculum 30%(35 of 118)


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RCT: Prolapse repair +/RCT: Prolapse repair +/-- BurchBurch

Preoperative negative stress test withprolapse reduced:

-- With Burch:With Burch: 1717% had postop.SU

I% had postop.SU

I-- Without Burch:Without Burch: 3535% had postop. SUI% had postop. SUI

Regardless of preoperative result of

reduction stress test: post op scores weresignificant worse if Burch procedure was notdone ( 6% vs. 24%)


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Risk of obstruction and stressRisk of obstruction and stress

incontinenceincontinence The risk of intervention for obstruction after

sling procedures is 8.5%

The risk of intervention for stressincontinence in patients without clinical,

urodynamic or occult stress incontinencewithout sling was 8.3%


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Do concomitant sling proceduresDo concomitant sling proceduresincrease risk of complications ?increase risk of complications ?


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Yes we do agree that slings canYes we do agree that slings canlead to significant complicationslead to significant complications

Studies only with TVT midurethral slingsLiang CC, et.al. (2004); Mechia M, et.al.(2004), Groutz A,

et.al.(2004)- De-novo urge incontinence: 10-16%

- Urinary retention: 2-10% (not with TOT)

It would we be great to have a sling procedurethat is effective, with minimal complications ofretention, erosion or overactive bladder


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Is there other rationale to do aIs there other rationale to do aconcomitant sling in the dry patientconcomitant sling in the dry patient

Suburethral sling placement associated withreduction in rate of post operative cystocele

recurrence (42% vs. 19%)Goldberg RP, et. al. (2001)

Transvaginal bladder neck slings repair were

associated with reduction in risk ofrecurrent cystocele

Gandhi S, et.al.(2005)


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Stress incontinence (SUI) &Stress incontinence (SUI) &Grade IV cystoceleGrade IV cystocele

Can be predict which patients should have asling? NoNo

Do concomitant sling procedures increaserisk of complications?

DependsDepends

Should we perform a sling in every patient?Yes, I think soYes, I think so


YesYes


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To sling with prolapse repairTo sling with prolapse repair

Reduction of prolapse cant predict whichpatient will have postop incontinence

5-20% of the patients with grade IV cystocelerepair will develop 2ry incontinence regardlessof your preoperative assessment

Sling help to prevent recurrent cystocele

Why submit the patient to a second

surgery?


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To sling with prolapse repairTo sling with prolapse repair

Sling placement is a minimally invasive procedure withno more than 10 min over

Sling has a high success rate to cure stressincontinence with rare/no postop. retention

If you have rare complications, you could do a

prophylactic sling to prevent the 5-20% postop.incontinence

It is all about your personal experience


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managing urethra at the time of prolapse surgery

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