Recurrent Urinary Incontinence Judith Goh FRANZCOG CU Ph

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Recurrent Urinary Incontinence Judith Goh FRANZCOG CU Ph. D Professor Griffith University Urogynaecologist Greenslopes

Recurrent Urinary Incontinence Judith Goh FRANZCOG CU Ph. D Professor Griffith University Urogynaecologist Greenslopes Private Hospital Brisbane, Australia

Topics to cover • Why surgical failure? • What to do?

Topics to cover • Why surgical failure? • What to do?

Urinary Incontinent procedures • Ideal patient – Urodynamic stress incontinence only – Normal uroflowmetry

Urinary Incontinent procedures • Ideal patient – Urodynamic stress incontinence only – Normal uroflowmetry – Normal bladder capacity – No overactive bladder – No previous incontinence procedures

Urinary Incontinent procedures • Ideal pre-operative situation – Initial conservative management • • Exclude

Urinary Incontinent procedures • Ideal pre-operative situation – Initial conservative management • • Exclude pathology, infection Bladder diary Pelvic floor rehabilitation Education regarding diet, fluids, bowels, weight control etc – Compliance – Treat overactive bladder symptoms – Confirm diagnosis

Surgical Failure

Surgical Failure

Surgical Failure: Contributing Factors • • • Failure of surgical technique Incorrect original diagnosis

Surgical Failure: Contributing Factors • • • Failure of surgical technique Incorrect original diagnosis Incorrect procedure Patient related factors Onset of new problems

Surgical Failure: 1. Failure of surgical technique • Suture, mesh, tissue failure, pull out

Surgical Failure: 1. Failure of surgical technique • Suture, mesh, tissue failure, pull out of material – Permanent vs dissolvable materials • Position of material, tension – 3 rd generation “mini” mid-urethral slings – learning curve • Number of sutures – eg Burch colposuspension – more than 1 suture each side

Surgical Failure: 2. Incorrect diagnosis • Detrusor overactivity – History of pure stress/activity urinary

Surgical Failure: 2. Incorrect diagnosis • Detrusor overactivity – History of pure stress/activity urinary incontinence 10 -15% due to detrusor overactivity • Overflow incontinence • Fistula

Surgical Failure: 3. Incorrect procedure • Anterior repair – Poor results for urinary incontinence

Surgical Failure: 3. Incorrect procedure • Anterior repair – Poor results for urinary incontinence vs incontinent procedures – Randomised trial of anterior repair vs Burch colposuspension • Colombo BJOG 2000 • Low closure pressure, valsalva LLP – Higher success with retropubic slings

Surgical Failure: 4. Patient related factors • Age – higher risk of failure with

Surgical Failure: 4. Patient related factors • Age – higher risk of failure with increasing age • Barber et al Am. JOG 2008; Sharp et al. Curr Op Urol 2006 • Over 75 years of age cf 65 -74 years – 12 months follow up of 1356 continent procedures – More post-op urge incontinence (20% vs 12. 6%) – More failures to treat USI (10. 5% vs 7. 2%) – More outlet obstruction (10. 5% vs 6. 6%) • Anger J et al 2007 J Am Geriatr Soc

Surgical Failure: 4. Patient related factors (cont) • Concurrent detrusor overactivity – 2 -8

Surgical Failure: 4. Patient related factors (cont) • Concurrent detrusor overactivity – 2 -8 year follow up lower success rates in women with mixed symptoms • Holmgren et al Obstet Gynecol 2005 • Scar, previous incontinent surgery (some may not know)

Onset of new problems or recurrent of old? WHAT TO DO?

Onset of new problems or recurrent of old? WHAT TO DO?

Predictors of DO following incontinent surgery • 305 women, mixed incontinence – 31. 5%

Predictors of DO following incontinent surgery • 305 women, mixed incontinence – 31. 5% resolution of DO (no difference in BMI, recurrent surgery, concomitant hysterectomy or repair • Persistent DO risk factors – – Age Nocturia ≥ 2 Low UCP Bladder neck slings – Gamble et al Am. JOG 2008

Predictors of recurrent incontinence following surgery 162 women (retropubic or transobturator) – 73 mixed,

Predictors of recurrent incontinence following surgery 162 women (retropubic or transobturator) – 73 mixed, 1 year follow up – Recurrent any incontinence 42%, recurrent USI 16. 5% • Risk for any incontinence – Age, pre-op urge incontinence/anticholinergics – Lower functional bladder capacity – Concurrent surgery for POP • Risk for recurrent USI – Age – Lower bladder functional capacity • Barber et al Am. JOG 2008

Other risk factors: Closure pressures • Higher risk failure with Burch cf sling –

Other risk factors: Closure pressures • Higher risk failure with Burch cf sling – Max UCP < 20 cm H 20 or VLLP < 60 • ? Transobturator vs retropubic sling – 145 women, retrospective: Monarc 6 x more likely to fail cf TVT if MUCP < 42 cm H 20 (Miller et al Am. JOG 2006) – 240 randomised patients, 1 year follow up, TVT vs TVTO • Significantly high failure with TVTO (33%) in more severe incontinence (Araco Int Urogynecol J 2008) – Melbourne (MUCP < 20 cm H 20) • Repeat surgery 1/82 TVT vs 9/82 Monarc (p<0. 05)

Other risk factors: Closure pressures • TVT vs TOT for Intrinsic Sphincter deficiency: –

Other risk factors: Closure pressures • TVT vs TOT for Intrinsic Sphincter deficiency: – 180 TVT vs 120 TOT (Safye) retrospective – Mean follow up 31 mths – Subjective cure: TVT 78. 3 vs TOT 52. 5% • Gungorduk K et al. Acta Obstet Gynecol 2009

Retropubic vs Mini-slings • Randomised trial • Follow up 6 months: subjective and Uds

Retropubic vs Mini-slings • Randomised trial • Follow up 6 months: subjective and Uds • 71 women – significantly higher failure with mini-slings with no difference in complication rates • Basu M, Duckett J. BJOG 2010

Assessment for Recurrent Urinary Incontinence • History • Urinary diary • Examination – Urethra,

Assessment for Recurrent Urinary Incontinence • History • Urinary diary • Examination – Urethra, bladder neck – Fistula – Infection, malignancy – Voiding difficulty • Urodynamics +/- cystoscopy

New problem • Detrusor overactivity – Worsen or denovo (up to 25 -30% following

New problem • Detrusor overactivity – Worsen or denovo (up to 25 -30% following retropubic incontinent surgery eg Burch, sling • • • Overflow incontinence Urinary tract infection Urethral/Bladder tumour/foreign body • Fistula

Management of New Problem • Detrusor overactivity – Anticholinergics, bladder training, behaviour modification –

Management of New Problem • Detrusor overactivity – Anticholinergics, bladder training, behaviour modification – Note: voiding difficulty may present with OAB symptoms • Infection – If recurrent, check cytology – Urethro-cystoscopy: tumour, foreign body

Management of New Problem • Overflow incontinence/ Voiding difficulty – Clean intermittent selfcatheterisation –

Management of New Problem • Overflow incontinence/ Voiding difficulty – Clean intermittent selfcatheterisation – Division sling/suture • Remove bladder/urethral pathology • Repair fistula

Recurrent USI: Options • Conservative – Physiotherapy, vaginal/urethral devices • Surgery – Success rates

Recurrent USI: Options • Conservative – Physiotherapy, vaginal/urethral devices • Surgery – Success rates usually decrease cf primary surgery – Burch, slings, bulking agents • Diversion, artificial sphincter

Burch Colposuspension • Following failed sling or colposuspension • Risks of surgery – Adhesions

Burch Colposuspension • Following failed sling or colposuspension • Risks of surgery – Adhesions in retropubic space – Bleeding: plexus, obturator vessels – Injury to bladder, urethral

Burch Colposuspension • Repeat Burch (Thakar & Stanton BJOG 2002) – 56 women, 4

Burch Colposuspension • Repeat Burch (Thakar & Stanton BJOG 2002) – 56 women, 4 year follow up – 80% objective cure – No significant complications – 8 needed post repair, 3 needed vault repair – 8 needed further surgery for USI • 7 bulking, 1 TVT

TVT-O after previous surgery • 25 women, 25 mths follow up • Previous surgery:

TVT-O after previous surgery • 25 women, 25 mths follow up • Previous surgery: 7 bulking and surgery • 80% subjective cure – (Biggs et al Int Urogynecol J 2009)

TVT after failed TVT-O • 5 cases, 17 months followup • No recurrent USI

TVT after failed TVT-O • 5 cases, 17 months followup • No recurrent USI • 1 mild urge incontinence • Moore et al Int Urogynecol J 2007

Repeat Mid-Urethral slings • • 29 women, retrospective, 1 year follow up Previous slings

Repeat Mid-Urethral slings • • 29 women, retrospective, 1 year follow up Previous slings (17 retropubic, 12 transobturator) Repeat surgery (13 retropubic, 16 transobturator) Cure rates with repeat surgery – Retropubic (92. 3%), transobturator (62. 5%) • Conclusion: retropubic slings better cure rates for repeat surgery • Lee et al J Urol 2007

Repeat surgery: TVT vs Monarc • 1112 women proven USI – mean 50 mth

Repeat surgery: TVT vs Monarc • 1112 women proven USI – mean 50 mth follow up • 77 failed surgery, proven recurrent USI • 77 women – Rpt retropubic 71% success cf transobturator 48% , p<0. 05) • Stav K et al. J Urol 2010

Bulking Agents • Materials – Collagen, fat, Carbon, Silicone, newer • Methods – Trans-urethral,

Bulking Agents • Materials – Collagen, fat, Carbon, Silicone, newer • Methods – Trans-urethral, peri-urethral – Direct visualisation, imaging, special needle guide • Minimal anaesthesia • Success rates lower, but less risk of voiding difficulty, easy to ‘top-up’

Conclusion • Initial management – – – Multidisciplinary approach Diagnosis Choice of initial surgery

Conclusion • Initial management – – – Multidisciplinary approach Diagnosis Choice of initial surgery • Patient risk factors – Counselling – Realistic expectations • Repeat incontinence – Diagnosis • Repeat surgery – Data to suggest retropubic slings may improve results