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Intrinsic Sphincter Deficiency & Slings

Intrinsic Sphincter Deficiency & Slings. Nader Gad MBChB , MChGO , FRCOG, FRANZCOG Consultant & Senior Lecturer in O&G Royal Darwin Hospital, Darwin, Australia. Definition of ISD. SLPP less than 60 cmH2O MUCP less than 20 cmH2O

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Intrinsic Sphincter Deficiency & Slings

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  1. Intrinsic Sphincter Deficiency & Slings Nader Gad MBChB, MChGO, FRCOG, FRANZCOG Consultant & Senior Lecturer in O&G Royal Darwin Hospital, Darwin, Australia

  2. Definition of ISD • SLPP less than 60 cmH2O • MUCP less than 20 cmH2O • Type III Stress Incontinence (Proximal urethra open at rest)

  3. Classification of SUI

  4. Causes Of ISD • Previous Pelvic Surgery • Anti-incontinence surgery • Urethral diverticulectomy • Radical Hysterectomy • Urethrotomy • Resection or incision of vesical neck • Aging & Hypo-oestrogenic States • Pelvic Irradiation • Neurologic Conditions • Myelodysplasia • Anterior spinal artery syndtome • Lumbosacral neurologic conditions • Shy-Drager syndrome

  5. Treatment of ISD • McGuire et al(1978 )were the first to note that ISD present in : • 75% of women of patients who failed in multiple surgeries for SUI • 13% with no previous anticontinence surgery Difficult to determine is it cause or effect?

  6. Treatment of ISD • Sand et al (1987): • High failure rate of Burch colposuspension in women with low MUCP compared to those with MUCP more than 20cm H2O • Failure rate of Burch at 3 months FU: • Low MUCP: 54% • Normal MUCP: 18%

  7. Treatment of ISD • Most data show simple elevation of the bladder neck is ineffective • Recommend more obstructive procedure

  8. Treatment of ISD • Proximal Suburethral slings (Traditional) • Mid-Urethral Tension-free Slings: • TVT • TOT 3. Artificial sphincter 4. Urethral Bulking Procedures

  9. Proximal Suburethral Slings • First introduced by Giordano in 1907 using Gracilis muscle flap • Aldridge in 1942, developed the Fascial sling • The principle: Create a hammock underneath bladder neck to prevent descent and provide a backboard at UVJ against which the urethra is compressed during increase of intra-abdominal pressure

  10. Types of Proximal Slings

  11. Patient most un-suitable • History of irradiation • Previous sling erosion • Having surgery on the urethra at the same time (e.g., urethral diverticulectomy) • Having POP surgery at the same time

  12. Proximal Urethral slings • Overall success for SUI + ISD at 5 years = 80 – 90% • Summitt et al (1990) Sling procedure success rates were: • 93% in ISD + HMBN • 20% in ISD + no HMBN

  13. Common Complications of Proximal Suburethral Slings • Longer recovery • Has the highest rate of retention: 2-37%

  14. TVT & ISD • Rezapour (2001) First report on 49 women: • F-U for 3-5 years: • 74% completely cured • 12% improved • 14% no improvement: Majority more than 70 years old & MUCP less than 10 cmH2O

  15. TVT & ISD • Overall Success rate: 55 – 74% (less than the 80-90% with PSUS) • Some experts advise when TVT in ISD: tape is placed in immediate proximity with urethra (still without tension) instead of aiming for a ¼ inch gap

  16. TVT Complications • Voiding difficulties • Recurrent UTI • Bladder perforation (5-10%) • Erosion (3 – 5 %) • Vascular injury • Bowel injury • Haematoma • Nerve injury • Death (6 reported deaths by September of 2002)

  17. TOT & Slings • It leaves the sling in a more horizontal or hammock-like rather than U-orientation • Less operative time • Avoid risk of injury to bladder (only few reported cases) bowel & major vessels

  18. TVT vs TOT (Monarc)Miller et al (2006) Retrospective study of 145 women Comparing TOT (Monarc) vs TVT under GA or Spinal anaesthesia : Monarc was nearly 6 times more likely to fail at 3 months after surgery in women with borderline MUCP (42 cm H2O or less) In this study women with MUCP 20cmH2O or less were exclusion criteria of TOT but not TVT

  19. Failure Rate TVT vs TOTMiller et al 2006

  20. TVT vs TOT vs Sling Jeon et al (2008) • Retrospective study of 253 women with ISD defined as: LPP less than 60 cmH2O or MUCP less than 20 cmH2O - PVS: 87 • TVT: 94 • TOT: 72 TOT (polypropylene; Iris, Dowmedics Co, Korea, Outside – in ) • Regional of General Anaesthesia

  21. TVT vs TOT vs SlingJeon et al (2008) • Cure rates after 2 years: • PVS: 87% • TVT: 87% • TOT: 35 % • Cure rate after 7 years: • PVS: 59% • TVT: 55%

  22. TVT vs TOT vs SlingJeon et al (2008)

  23. Darwin Experience • Retrospective study of my First 25 cases of the TVT-O procedures (J&J) • Procedure were completed in all women under sedation and local anaesthesia • Outcome of the procedure: • Complication: intra- & post-operative • Success rate: Subjective & Cough test • Any difference in outcome when ISD present?

  24. Darwin Experience • ISD was defined as valsalva or cough LPP = less than 60 cmH2O and/or MUCP = 20 cm H2O or less • Women with ISD were given the option to chose between TVT vs TVT-O: • TVT have a higher cure rate than TVT-O in women with ISD • TVT has the potential risk of bowel or major blood vessels injury

  25. Patients studied

  26. UDA Findings

  27. Sedation • Bolus of 1-2 mg midazolam • Then propofol 1% infusion at a rate of 20-40mls/hour titrated to effect • A small bolus of propofol (10-30mg) and/or alfentanil (100 – 200mcg) may be used when required in some patients during penetration of Obturator membranes.

  28. Local Anaesthesia • The local anaesthetic agent used was a total of 80 – 100 ml of 0.25% prilocaine with adrenaline (1:200,000)

  29. Local Anaesthesia • Administration of local anaesthesia to: • the area of the suburethral vaginal incision • paraurethral lateral dissection • expected tape passage through the Obturator foramen and muscles and the exit on the skin of the inner upper part of the thigh on both sides.

  30. Cough Test • Once tape is inserted, cessation of all sedation • Bladder is filled to a volume similar to that when SUI was demonstrated during UDA • Cystoscopy performed • When patient is awake enough, operative table is tilted head up about 30 degrees • patient is instructed to cough strongly and the tape is very slowly adjusted to the point when urinary leakage just stops

  31. Operative & Short-term Complications

  32. Hospital Stay

  33. Follow-up

  34. Long Term Outcome

  35. August 2008Anast et al from Missouri, USA • TOS (Trans-Obturator Sling) placement a outside-in (ObTape –Coloplast Surgical, Humeleback, Denmark) • 124 patients had leakage on valsalva: • 29% had low VLPP (Less than 60 cmH2O) • 71% had higher VLPP

  36. August 2008Anast et al, Missouri, USA

  37. Conclusion • TVT-O under local anaesthesia and sedation with the Cough Test in Theatre is very effective and safe surgical treatment of SUI in women with or without ISD. • Shortcomings of the Study: • Retrospective • Small number of the patient in this study • Relatively short term follow up period

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