Recurrent Urinary Incontinence Judith Goh FRANZCOG CU Ph
- Slides: 31
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?
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 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: 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 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 incontinence 10 -15% due to detrusor overactivity • Overflow incontinence • Fistula
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 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 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?
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, 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 – 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: – 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 • 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, bladder neck – Fistula – Infection, malignancy – Voiding difficulty • Urodynamics +/- cystoscopy
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 – 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 – Division sling/suture • Remove bladder/urethral pathology • Repair fistula
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 in retropubic space – Bleeding: plexus, obturator vessels – Injury to bladder, urethral
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: 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 • 1 mild urge incontinence • Moore et al Int Urogynecol J 2007
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 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, 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 • Patient risk factors – Counselling – Realistic expectations • Repeat incontinence – Diagnosis • Repeat surgery – Data to suggest retropubic slings may improve results
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