overview of surgical management of sui: sling selection, outcomes, and adverse events eric s....
TRANSCRIPT
Overview of Surgical Management of SUI:
Sling Selection, Outcomes, and Adverse Events
Eric S. Rovner, M.D.Professor of UrologyMedical University of South CarolinaCharleston, South Carolina
Treatment Options for SUI
• WAWA• Behavior
– Pelvic floor exercises
• Drugs???• Pessary/Devices
• Surgical repair– Bulking agents
Prepubic sling
Which one ??Which one ??IF ALL WERE EQUIVALENT:IF ALL WERE EQUIVALENT:
-experience of surgeon-experience of surgeon
-patient factors:-patient factors:-wishes and willingness to accept risks-wishes and willingness to accept risks
-other: convalescence, pain, etc-other: convalescence, pain, etc
BUT ALAS THEY ARE NOT ALL EQUIVALENT:BUT ALAS THEY ARE NOT ALL EQUIVALENT:
-Operations are not……..-Operations are not……..
-efficacy, durability, recovery, etc.-efficacy, durability, recovery, etc.
-Patients are not………...-Patients are not………...
-types of SUI, anatomy, prior surgery, etc.-types of SUI, anatomy, prior surgery, etc.
“I leak when I cough”
Autologous Fascial Sling*Courtesy of Jerry G. Blaivas, MD
Algorithm for surgical treatment of SUI*:
SURGERY for SUI SURGERY for SUI 19951995• Injectables (collagen)• Abdominal (retropubic) suspensions
-Burch
-MMK-Richardson-etc.
• Vaginal-Needle suspensions (Raz, etc.)-Slings: fascia, synthetics, vaginal wall sling-Anterior colporraphy (Kelly plication)
+/- Laparoscopy
Surgery for SUI: 2011• Midurethral Tapes
– Transvaginal (TVT, etc.)• “Minislings”
– Suprapubic• Commercial (SPARC, Uretex, etc.)• Non-commercial “home made” versions
– Raz ($10 TVT)– Rackley (PVT)
– Transobturator• Outside in/Inside out
• Injectables: Contigen, Durasphere, Macroplastique, Coaptite, etc• RP suspensions: Burch , etc.• Slings (bladder neck)
xNeedle BNSAnterior repair (Kelly)
ESR Operations to treat SUI (in 2011)
• Retropubic suspension (rarely)
• Injectables
• Autologous pubovaginal slings
• Vaginal tapes– Transobturator (outside in)– Retropubic
Why Not One Surgery for Everybody w/SUI?Patient variables in selecting surgery
• Prior failed SUI surgery– Erosion, extrusion, BOO, etc.– Retropubic (Burch, MMK, etc.)
• Physical examination– Anterior vaginal wall/urethral mobility– Prolapse– “extreme” habitus
• Urodynamics– Intrinsic urethral function (ISD)
• Urethral “disease”– Diverticulum, fistula, etc.
• Patient disease/morbidity– +/- vaginal atrophy (XRT, etc.)– Steroids– Immune status– Diabetes– Other
SUI Surgery 2011
• Midurethral synthetic sling is a good choice……
EXCEPT……
SUI Exceptions
• Urethral diverticulum • Urethrovaginal fistula• Other urethral pathology (stricture)• Severe irreversible atrophy or XRT
Autologous pubovaginal sling
Other exceptions
• Unwilling or unable to have surgery:– Injectable
• Other RP surgery (w/o ISD) or can’t do lithotomy:– Burch
So, who gets which MUS?
• Midurethral sling– TOT– Retropubic– Mini-sling
transobturator vs. retropubic sling
Do they work equally well for ISD????
-Low VLPP?
-Poor urethral mobility?
Are they equally safe/effective in redo cases?
-prior RP anti-incontinence surgery
Choice of Surgery for SUI
IdeallyIdeally…..– Evidence based
• Prospective, RCT’s– Equivalent inclusion/exclusion criteria
– Uniform patient population for each subpopulation with SUI
» Urodynamics, mobility, habitus, prior surgery, etc.
– Factors:• Efficacy, durability, cost, safety, convalescence, etc.
Choice of Surgery for SUI
Reality…….Reality……. – Non-evidenced based
• Poor quality literature
– Commercial bias
– Mostly anecdotal
– Surgeon “preference”
AUA SUI Guidelines Update
Reviewed SUI literature since last Guidelines and updated the document
Dmochowski, et al, JU 183:1906, 2010
AUA SUI Guidelines Update 2010
Literature search 1994-2005*
436 papers suitable for efficacy/safety outcomes
155 papers only complications data usable
Index patient: healthy female +/- prolapse willing to undergo surgical correction of SUI
*AUA Best Practices update coming to include TOT
TOMUS
N= 597 randomized to TOT or retropubic MUSRetropubic MUS= TVT (Gynecare)
TOT= Monarc (AMS) or TVT-O (Gynecare)
OutcomesObjective criteria
Negative CST, negative 24 hour pad test, no re-Tx
Subjective criteriaNo sx’s SUI, negative 3 d diary, no re-Tx
Adverse events
Null hypothesis: no difference = <12% between groups
Success
Objective success81% RP
78% TOT
Subjective success62% RP
56% TOT
“I am not certain why humans or animals are continent of urine and feces and I am not convinced that anyone really knows.”
–J. Berry, 1961(Berry Prosthesis)
Rx of Urinary Incontinence
Continence= urethral closure forces > bladder expulsion forces
Bladder
Urethra
All therapies either All therapies either ↑ urethral or ↓ bladder forces↑ urethral or ↓ bladder forces
Rovners algorithm for SUI Surgery
• This is my approach– Mostly NON-EVIDENCE-BASED*
• Literature can be cited where available
*to the extent of the quality of evidence in the literature to support any approach
Rovner’s Algorithm Assumptions:
• Patient is “index” patient– Has SUI, is healthy, desires surgical Rx, etc.
– No XRT/fistula/UD
– Can get into lithotomy position
• Patient willing to have any approach
• Surgeon equally skilled in all approaches
• No prolapse > Stage II
• No detrusor abnormalities– Compliance, etc.
Index patient w/ SUI
Prior surgery?Yes No
Obstructed? NoYes
Urethrolysis +/- PVS
Mobility?Yes No
Prior RP surgery?
Yes
No
TOTLow “pressure”
urethra?
Yes
PVS (+/- RP UT)
No
TOT, or RP UT or PVS
Urethrolysis +/- PVS (or RP UT)
Index patient w/ SUI
Prior surgery?Yes No
Mobility?Yes
Yes
No
No RP UT (+/- PVS)
Low “pressure” urethra?
RP UT Or TOT
RP UT (+/- PVS)
Hooray !!!!!
!!
The “perfect” therapy for SUI*• Effective (high immediate success rate)• Durable • Simple, fast and easy to perform (reproducible)• Applicable for ALL types of SUI
– And all patients with SUI (primary and redo cases, body habitus, etc.)
• For Surgery: minimally invasive – Local (or no) anesthesia– Small (or no) incisions– Outpatient procedure– Short convalescence and return to normal activities– Minimal (or no) pain
• Low (or no) morbidity and complications• Inexpensive: patient, healthcare facility, healthcare system, etc
*theoretical
The Perfect Result (“Cure”)
• Dry (pad test, per patient, PE, etc)• Resolution of all voiding sx’s• No new voiding symptoms• No pain• Minimal utilization of resources
– eg, cost, convalescence, LOS, etc
• Patient is ecstatic (QoL, questionnaire, etc)• No complications
– eg, fistula, prolapse, dyspareunia, UTIs, etc
Permanently