decision making with the usi patient neuman menahem 13 th turkish ob/gyn annual meeting antalya -...
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Decision making with the USI patient
Neuman Menahem
13th Turkish Ob/Gyn Annual meeting Antalya - 2015
Disclosure: Menahem Neuman is consultant for Serag-Wiessner.
Urogynecology Service, Western Galilee MC, Nahariya, the Faculty of medicine, Bar-Ilan University, Safed, Israel.
Decision making with the USI patient
• Diagnosis
• Pre treatment consultation
• Surgery
• Complication
• Failure
• Follow-up
Menahem Neuman
Decision making with the USI patient
• Diagnosis
• Pre treatment consultation
• Surgery
• Complication
• Failure
• Follow-up
Menahem Neuman
Diagnosis
• History taking, pelvic exam.
• Cystoscopy? US? Cytology?
• Urodynamics?
Menahem Neuman
Decision making with the USI patient
• Urodynamics?• Curr Opin Obstet Gynecol - 2014, van Leijsen
• Preoperative urodynamics do not improve outcome
in women with complaints of stress incontinence
• The routine use in women with uncomplicated stress
incontinence should no longer be advised.
• Preoperative urodynamic evaluation should only be
used to answer a specific clinical question
Menahem Neuman
Decision making with the USI patient
• Urodynamics in Korea?
• Korean J Urol – 2014, Agarwal A
• Statistically significantly better treatment outcomes
in the urodynamic group
Menahem Neuman
Decision making with the USI patient
• Rachaneni, Latthe: BJOG. 2015
• A systematic review and meta-analysis.
• Urodynamics does not improve outcomes
• With careful office evaluation!
Menahem Neuman
Decision making with the USI patient
• Meschia, Cardozo, Int Urogynecol J 2015
• The role of urodynamic studies before
prolapse surgery is a hotly debated.
There is no evidence that the outcome
of surgery is altered by prior UDS.
Menahem Neuman
Decision making with the USI patient
• USI
• USI predominance
• Combined
• Others
Menahem Neuman
Decision making with the USI patient
• USI
• USI predominance
• Combined
• Others
Menahem Neuman
Decision making with the USI patient
• Diagnosis
• Pre treatment consultation
• Surgery
• Complication
• Failure
• Follow-up
Menahem Neuman
Consultation
• Medical?
• Physiotherapy?
• Surgery!
Menahem Neuman
Decision making with the USI patient
Physiotherapy?
Menahem Neuman
Berghmans, N Engl J Med - 2013
Surgery, as compared with physiotherapy, results in higher rates of subjective improvement and subjective and objective cure at 1 year.
Decision making with the USI patient
• Diagnosis
• Pre treatment consultation
• Surgery
• Complication
• Failure
• Follow-up
Menahem Neuman
Surgery
• Injectable?
• RP Open Colpo-Suspension?
• TVT
Menahem Neuman
Surgery
• Injectable?
• RP Open Colpo-Suspension?
• TVT SMUS?
• SMUS-RP?
• SMUS-TOT?
• Mini SMUS?
Menahem Neuman
Menahem Neuman
The Mid-Urethra Concept
Pubo-urethral ligaments Zacharin 1968, DeLancey 1994
Menahem Neuman
The Mid-Urethra Concept
Functional AspectsMaximal urethral closure pressure at mid-urethra Ulmsten 1976
Menahem Neuman
Ulf Ulmsten - TVT Classic
Over 1000 papers
6% Bladder penetration
5% P/O BOO
Intestinal / vessel injuries
TVT
Menahem Neuman
Menahem Neuman
Menahem Neuman
Over 150 papers
3% of P/O BOO
Thigh pain – 30%
Bladder & Urethral injuries, Field infection, Bleeding
SUI treatment evolvement: TVT-O
Menahem Neuman
Is TVT better than TVT-O?
Novara et al. Eur Urol, 2010Menahem Neuman
Is outside-in better?
Mahduvrata et al. Eur J Obstet Gynecol Reprod Biol, 2012
Menahem Neuman
Menahem Neuman
Decision making with the USI patient
• SIMUS (Mini-Slings)?
Menahem Neuman
Are mini slings better?
Abdel-Fattah et al. Eur Urol, 2011
Eran Schreter and Menahem Neuman
7 years after anti-incontinence mini Mid-Urethral
Sling (MUS) procedure: Patient’s own perspective
and follow-up data
Turkish-Israeli Urogyne MeetingJerusalem - 2015
33% had recurrence of rUSI, mostly after 5 years.
7 years after mini MUS
Decision making with the USI patient
Menahem Neuman
TVT for USI with ISD
Minerva Chir. 2014, Kokanalı
TVT is effective (83%) and safe for USI with ISD.
However, ISD patients with low maximal urethral
closure pressure should be informed preoperatively
about possible poor outcomes
Decision making with the USI patient
Menahem Neuman
TVT for USI with ISD
Int Urogynecol J. 2012 , Choo
With our long-term results, TVT is an effective
treatment even in women with ISD (82%).
ISD patients with low VLPP should be counseled
carefully about TVT outcome
Decision making with the USI patient
Menahem Neuman
Management of recurrent stress urinary
incontinence after failed MUS: a survey of
members of the IUGA
• Int Urogynecol J. 2015, Robinson D, Cardozo L
•Members of IUGA prefer RPS in most patients and
UBA with absent urethral hypermobility and ISD
Decision making with the USI patient
Menahem Neuman
Management of recurrent stress
urinary incontinence in the US
Neurourol Urodyn. 2015 , Zimmern
•6% of women with rUSI were retreated within 5
years, mostly with injection therapy or autologous
fascial sling
Decision making with the USI patient
Menahem Neuman
The surgical management of rUSI: a systematic
review
Acta Obstet Gynecol Scand. 2015, Nikolopoulos
There is a wide spectrum of surgical interventions for
secondary treatment of SUI. A common characteristic
is a lower success rate compared with those reported
following primary procedures.
Decision making with the USI patient
Menahem Neuman
Surgical treatment of rUSI: a systematic review and
meta-analysis of RCT’s
Eur Urol. 2013, Abdel-Fattah
No difference in patient-reported and objective cure
rates between RP-TVT and TO-TVT in the surgical
treatment of women with R-SUI.
Decision making with the USI patient
Menahem Neuman
Results of primary versus recurrent surgery to treat
stress urinary incontinence in women
Int Urogynecol J. 2015 , Heesakkers
Recurrent surgery to treat rSUI are do not differ from
results of primary surgery.
Menahem Neuman
Post TOT Thigh pain
Menahem Neuman
Post TOT Thigh pain
Menahem Neuman
Post TOT Thigh pain
Menahem Neuman
Post TOT Thigh pain
Menahem Neuman
Post TOT Thigh pain
Gilad Reut and Neuman Menahem
Menahem Neuman
Turkish-Israeli Urogyne Jerusalem Meeting - 2015
Needle trajectory medially remote according with FF (IUJ 2012)
A Trans - Obturator sub mid urethral short sling implant (12 Cm, TVT-Abbrevo, J&J)
102 Pts were included:
Early P/O thigh pain: 6 Pts (6%), all mild.
At 3 Yrs: Chronic pain: 5 Pts – all mild OAB : 11Pts (13%) POP: 9 Pts (11%), mild SUI: 2 Pts (2.5%), mild
Menahem Neuman
Decision making with the USI patient
Menahem Neuman
Vaginal delivery following TVTS
J Obstet Gynaecol Res. 2013, Tommaselli
The patient remained continent throughout
the gestation and in the following 24 months
Decision making with the USI patient
Menahem Neuman
Effect of pregnancy and delivery on urinary
incontinence after the smus
Int Urogynecol J. 2015 , Cavkaytar
Four patients had a TVT and 8 had TOT.
Seven women had CS and 5 women VD.
10 were continent after delivery (83.3 %).
Decision making with the USI patient
• Concomitant surgical correction of USI and
anterior vaginal wall prolapse
• Zargham, J Res Med Sci – 2013
• Anterior vaginal wall reconstruction can
improve SUI surgery outcome at 18 months
Menahem Neuman
Decision making with the USI patient
Menahem Neuman
Pelvic organ prolapse in a cohort of women
treated for stress urinary incontinence
Am J Obstet Gynecol. 2014 , Brubaker
Surgeons may counsel women with asymptomatic
stage 2 POP that their prolapse is unlikely to require
surgery in the next 5-7 years
Decision making with the USI patient
Menahem Neuman
A SMUS to reduce SUI after vaginal prolapse repair
N Engl J Med. 2012 , Nygaard
A prophylactic SMUS inserted during vaginal prolapse
surgery resulted in a lower rate of USI but higher rates
of adverse events
Decision making with the USI patient
Menahem Neuman
Prolapse surgery with or without USI surgery : a
systematic review and meta-analysis of RCT’s
BJOG 2014, Roovers
Combination surgery reduces the risk of P/O USI, but
adverse events were more frequent
Decision making with the USI patient
Menahem Neuman
Trans-vaginal prolapse repair with or without the
addition of a SMUS: a randomized trial
BJOG 2015, Roovers
Women with prolapse and co-existing SUI are less
likely to have SUI after trans-vaginal prolapse repair.
Only 17% of the women undergoing POP surgery
needed additional MUS
Decision making with the USI patient
Menahem Neuman
Sexual function in women before and after TVT
Acta Obstet Gynecol Scand. 2014 , Glavind
Most women experience an improvement in sexual life
after a TVT mainly because of absence of incontinence
during sexual activity or absence of fear of
incontinence during sexual activity
Decision making with the USI patient
Menahem Neuman
Impact of incontinence surgery on sexual
function: a systematic review
J Sex Med. 2012 , Jha
Coital incontinence is significantly reduced following
continence surgery
Decision making with the USI patient
Menahem Neuman
Autologous adipose stem cells in treatment of
female stress urinary incontinence
Stem Cells Transl Med. 2014 , Nieminen
The feasibility and efficacy of the treatment were not
optimal
Decision making with the USI patient
Menahem Neuman
Robotic Burch colpo-suspension
Int Urogynecol J. 2015 Francis
Robotic Burch colpo-suspension can be completed in a
safe and effective
Why?
Decision making with the USI patient
Menahem Neuman
Low-cost TVTO for the treatment of USI using ordinary
polypropylene mesh
Int Urogynecol J. 2015 ElShenoufy
Safe with 91% 5-year cure.
It should be considered as a low-cost alternative to
available commercial kits, mainly for public health
systems with few financial resources
Decision making with the USI patient
Menahem Neuman
Surgeon-tailored polypropylene mesh Vs TVT-O
Int Urol Nephrol. 2015 Apr 22. Hassan
Outcome of STM is comparable to TVT-O.
Furthermore, STM is more economic
Decision making with the USI patient
Menahem Neuman
My own choice of Anti-incontinence operations:
TOT, inside out
TVT-RP for rUSI & ISD
SIMUS (Mini sling) when vaginal wall tissue is poor
Para urethral injectables – for the very friable Pts
