surgical treatment of stress urinary incontinence dr cecilia cheon consultant, department of obs....
TRANSCRIPT
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Surgical Treatment of Stress Urinary Incontinence
Dr Cecilia Cheon
Consultant, Department of Obs. & Gyn.Queen Elizabeth Hospital, Hong Kong, China
President, HK Urgynaecology Association
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Definition of Urinary Incontinence
Urinary incontinence is the complaint of any
involuntary leakage of urine.
Abram P et al. Neuro Urodyn 02
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Terminology - Symptoms
• Stress urinary incontinence (SUI)
- Involuntary leakage on effort or
exertion, or on sneezing or coughing
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Urodynamic Terminology
• Urodynamic stress incontinence (USI)
- Involuntary leakage of urine during
increased abdominal pressure, in the
absence of a detrusor contraction
- Old term: Genuine stress
incontinence (GSI)
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Impact on Quality of Life
• Embarrassment
• Reduced Self esteem
• Impaired emotional & psychological well-
being
• Poorer sexual relationships
• Impaired social activities and relationships
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Economic Issues
• USA – estimated to be $8.1 billion (Hu,
1984)
• Active evaluation and treatment of nursing
home residents resulted in considerable
cost savings
• Indirect benefit : improve QOL of sufferers,
difficult to quantify
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Stress incontinence : Weakness of the pelvic floor muscles
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Treatment Strategy in women with USI / SUI
Conservative treatment is the first line of treatment for women with SI
International Consultation on Incontinence 01, Paris
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Treatment for SUI
1. General measures
2. Pelvic floor exercises, PFEs
3. Biofeedback
- perineometer, vaginal cones
4. Electrical stimulation treatment
5. Mechanical devices
6. Pharmacological treatment
7. Surgery
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Surgical Treatment
• Paravaginal repair
• Bladder neck suspensions
• Bladder Neck Slings / Midurethral slings
• Periurethral injections
• Artificial sphincter
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Surgical Treatment
benefit risk
Best longterm result
minimalcomplication
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Bladder Neck Suspensions
To use the anterior vagina as a hammock to
elevate the bladder neck
• Needle suspensions
• Retropubic suspensions
- abdominal
- laparoscopic
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Retropubic Suspensions
• Burch’s
• MMK
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Burch’s Colposuspension
Suspension of anterior vagina to the
iliopectineal ligament ( Cooper’s ligamen
t)
Abdominal
Laparoscopic
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Burch Colposuspension
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Burch Colposuspension
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Subjective Cure Rate for Burch’s Operation
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Objective Cure Rate for Burch’s Operation
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Burch’s
Success rate
• 39 trials, 3,301 women
• 1st year 85 – 90%
• 5 year 70%
• No significant difference between open and laparoscopic approach
Lapitan et al, Cochrane Database Systematic Reviews 2008
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Burch’s Colposuspension
Complications
• Detrusor overactivity 5 – 10%
• Voiding difficulty 10 – 15%
• Apical / posterior 5 – 17%
compartment prolapse
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Slings
Sling under the bladder neck or mid-urethra
• Correct hypermobility
• Increase sphincter closure pressure
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Midurethral-slings
• To date, three major slings available
- Tension-free vaginal tape (retropubic
approach) – TVT
- Tension-free vaginal tape
(transobturator approach) – TOT / TVT-O
- Minisling
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The Integral Theory of Continence
• Pelvic organ prolapse mainly caused by
connective tissue laxity in the vagina or its
supporting ligaments
• Stress urinary incontinence is essentially
due to pelvic floor muscle weakness
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The pictorial diagnostic algorithm summarizes the relationships between structural damage in the three zones and urinary and fecal symptoms. Arrows represent directional muscle forces.Anterior zone: external urethral meatus to bladder neck; middle zone: bladder neck to cervix; posterior zone: vaginal apex, posterior vaginal wall, and perineal body.
PRM = m.puborectalis; PCM = pubococcygeus; PUL = pubourethral ligament; ATFP = arcus tendineus fascia pelvis; N = bladder base stretch receptors
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Tension-free Vaginal Tape (TVT)
• Ulmsten et al in 1996 • Treats stress incontinence by
positioning a polypropylene mesh tape underneath the urethra
• Monofilament, macroporous, >75 microns
• Free passage of marophages• In growth of fibroblast• Minimize erosion / infection
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Tension-free vaginal Tape
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Transobturator Tape (TOT)
• Delorme1 in 2001 described the
transobturator (outside-in : TOT)
procedure
• Insert mesh tape under the urethra
through small incisions in the groin area
• eliminates retropubic needle passage
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Transobturator Tape (outside in)
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Transobturator Tape (TOT-O)
• A variation of the technique has been
described in 2003 by de Leval termed the
TOT vaginal tape ‘‘inside-out’’ technique
(TVT-O)
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Transobturator Tape (inside out)
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Imaging
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TVT / TOT / TVT-O Complications
• 3%
• Voiding difficulty, hemorrhage,
hematoma, bladder perforation,
infection
• No report of rejection, erosion or fistula
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Comparison of Mid-urethral sling (TVT) to various procedure
Tension-Free Midurethral Slings in the Treatment of Female Stress Urinary Incontinence: A Systematic Review and Meta-analysis of Randomized Controlled Trials of Effectiveness Giacomo Novara et al. (Italy) 2007
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Comparison of Mid-urethral Sling vs Colposuspension (QEH)
Colposuspension Mid-urethral Sling
No. of patients 222 402
Age 50.74 60.36* (p<0.001)
Bladder injury (%) 0.9 4* (p=0.03)
Days of bladder training (mean) 3.96 3.41
1 year subjective success (%) 82.7 89* (p=0.03)
1 year objective success (%) 89.1 83.4
1 year DO (%) 27.7 30.2
3 years subjective success (%) 76.3 (169) 87.7 (173)* (p=0.007)
3 years objective success (%) 77.1 85.6* (p=0.04)
5 years subjective success (%) 75.8 (95) 89.2 (74)* (p=0.03)
5 years objective success (%) 77.9 91.9* (p=0.01)
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• Today, mid-urethral slings not only have replaced the Burch colposuspension as the gold standard in the treatment of SUI but also are even more often performed than colposuspension
• Easy to perform, superior in terms of operation time, postoperative pain, and hospital stays
• but similar cure rates
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Peri-urethral Injection
Use of injectable bulk forming agents to
increase the urethral closure pressure
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Peri-urethral Injection
Material
• Fat
• Collagen
• Silicone
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Peri-urethral Injection
Advantages
• Safe
Disadvantages
• Low success rate 25 – 60%
• Expensive
• Need to be repeated every 1-2 year
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Artificial Sphincter
• Last resort
• Use when all the other operation have
failed
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Artificial Sphincter
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Conclusions
• 1 in 2 women in HK has urinary symptoms
1 in 3 women has SUI
• Much advances made in the care of
female urinary incontinence
• Effective treatment available which can
significantly improve women’s QoL
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Conclusion
• The concept of the midurethral sling has revolutionized surgical treatment of SUI. Its minimally invasive approach and success rates have led to an increasing acceptance of the technique
• TVT and TOT are both comparable in cure rate• The TOT approach is a potentially safer method
owing to the avoidance of the retropubic space: bladder, vessels, bowel injury
• Pregnancy is not contraindicated and cesarean is not abolute
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• Long-term studies and RCTs are needed
to identify the proper indications for the
various types of slings and to assess
efficacy and complication rates over time.
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