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15/08/2016
1
Joseph Lee
Bernie Haylen
Oliver Daly
Christopher Maher
UGSA MUS sling workshops
Managing intraop & post op complications 2016
Preamble
Pathophysiology & Etiology of SUI
Epidemiology
Assessment of UI
Management of SUI
Enhorning’s Theory & Hammock Theory
Conservative & Surgery
Management of intra & post operative complications
Case discussions
SUI surgery – challenging issues of perception Retropubic SUI surgery – intra op & post op issues
Bladder Perforation
Needle wont pass
Mesh in Sulcus
Haemorrhage
Voiding Dysfunction after MUS
Recurrent Urinary tract infection
Pain after MUS
De novo Urgency
Failed MUS, recurrent SUI
Recurrent SUI after Mesh Excision
Persistence of OAB
Bladder Perforation Bladder Perforation
• Follow traditional steps
• Drain bladder & deviate bladder
• Infiltrate 40ml cave, 20ml vagina & Mark exit site
• Keep hand piece horizontal, avoid deviation
• 70 degree cystoscopy, flush out hematuria
• Abandon procedure if unable to have clear view
– (don’t re-place & hope)
• More fine control on initial vertical pass
• Drop shoulder & elbow
Bladder
puncture
15/08/2016
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Bladder Perforation – Retropubic MUS RCTs
0
5
10
15
20
25
30
%
03 03 05 05 05 05 05 06 06 06 06 07 07 08 08 08 08 09Year
0.7
Spacr 41
IVS 50
TVT 50
Rechberger
Mansoor
TVT 102
TVT 58
IVS 54
Sparc 58
SUSPEND Lim
TVT 43
Andonian
Tseng
TVT 31
Sparc 31
TVT 105
Sparc 130
Enzelsberger
Na
Ryu
TVT 80
TVT 48
Agarwala
TVT 92
IVS 87
Meschia
TVT 147
Sparc 153Lord
TVT 89
Liapis
TVT 131Riva
ISTOP 88
David-Montefiore
Sparc 50
Wang
TVT 90
Porena
TVT 231
TVT 158
Andonian
TVT 72
Meschia
Zullo
TVT 265Laurikainen
TVT 187
TVT 170
Barry
Barber
TVT 138Schierlitz
TVT 208
TVT 127
Araco
Teo
TVT 349Taumussino
TVT 164Karateke
Lynx 48
IVS 398
Rechberger
8 4 9.2 1.6 3.3 6.6 23 24 0.0 12.9 7.6 6.2 0.0 3.3 3.4 1.9 6.5 1.5 9.5 3.4 2.1 13.8 4 11 8.50.7 7 7 2.7 0.0 3.3 4 6 6.5 3.7
Average 6.04%
JL 2009
Bladder Perforation rate is dependant on size of RCTs
Perforation rate
Sam
ple size RCT
0
50
100
150
200
250
300
350
400
450
0.00% 5.00% 10.00% 15.00% 20.00% 25.00% 30.00%
Average rate 6%
RCT – MUS: Scatter Plot Sample size vs Bladder Perforation
Perforation rates of RPMUS RCTs dependent on sample size
Independent risk factors for bladder perforation
OR Significance 95% C.I.
Previous Caesarean Section 3.7 p<0.05 1.2 - 11.5
Previous Colposuspension 3.2 p<0.05 1.2 - 12.7
BMI < 30 5.9 p<0.01 1.7 - 20.6
Local anaesthesia 5.9 p<0.001 2.6 - 13.7
Rectocele 6.2 p<0.001 2.1 - 17.8
Perforation rates of RPMUS related to experience
This occurs in surgeons who performed <50 slings
Retropubic MUS trocar passage
HUG the symphysis
- Handle DOWN
- Drop elbow
- Point upwards, finger in vagina
- Dont shove towards shoulder
Retropubic SUI surgery – intra op & post op issues
Bladder Perforation
Needle wont pass
Mesh in Sulcus
Haemorrhage
Voiding Dysfunction after MUS
Recurrent Urinary tract infections
Pain after MUS
De novo Urgency
Failed MUS, recurrent SUI
Recurrent SUI after Mesh Excision
Persistence of OAB
• WHY
• Are you in right space
• Are you hitting bone
• Enough infiltration (20ml each side)
• Was tip sharp (make sure plastic tip sits snug)
• Video, cadaver training, preceptorship
Needle wont pass
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• Check after each trocar passage
• Was plastic ends cut? – retrieve, review defect before re-do
• Drop handle more?
• Mobilise vaginal flaps, re suture over
Vaginal angle injuries/perforation
• Small amount of bleeding not uncommon
• generayl, bleeding will stop when closing vaginal skin
• Eg cystoscopy suggest perivesical hematoma
• More hematoma with RP route (cf TO)
• generous infiltration eg 60ml
• Mark skin, keep midline
Hemorrhage on needle passage
Floseal after SPARC
56yo non obese Brisk bleeding after sleev removed
Spinal anaesthesia
Inf border ramus
Midurethral – space laterally
Sparc device to deploy tape
Check cystoscopy
Digital compression two 10m interval
Bladder filled 600ml + 10m bimanual
compression
FloSeal + 10m Bimanual
EBL 300ml
Floseal use have been described for retropubic bleeding due to trocar passage
Retropubic SUI surgery – intra op & post op issues
Bladder Perforation
Needle wont pass
Mesh in Sulcus
Haemorrhage
Voiding Dysfunction after MUS
Recurrent Urinary tract infections
Pain after MUS
De novo Urgency
Failed MUS, recurrent SUI
Recurrent SUI after Mesh Excision
Persistence of OAB
• Best predictor – uroflow, Valsalva Voiders
• Expectations
• SPC vs Urethral
• 2 weeks to re-loosen
• Imaging – position, compression
• Division midline vs lateral
Voding dysfunction after MUS Prediction of post op voiding after RPMUS
Dawson IUJ 2007; 18:1297–1302, Haylen BJU 1989; 64:30-8
Incidence of VD @6m post op – 22/267 (8%) require ISC
there is almost a threefold greater
likelihood of needing ISC in women
with a QaveCent of 10 than in
those with a QaveCent of 80
average voiding flow rate centile score showed the strongest association with post-TVT voiding
dysfunction, the likelihood of needing ISC increasing as the centile score fell
Liverpool AUFR Nomogram
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Retropubic SUI surgery – intra op & post op issues
Bladder Perforation
Needle wont pass
Mesh in Sulcus
Haemorrhage
Voiding Dysfunction after MUS
Recurrent Urinary tract infections
Pain after MUS
De novo Urgency
Failed MUS, recurrent SUI
Recurrent SUI after Mesh Excision
Persistence of OAB
Less evidence
• Check flow, residual, upper tracts
• Is sling tight?
• Reverse vaginal atrophy
• Exclude intravesical mesh or non-absorbable suture in vaginal
• Hiprex 1mg BD w VitC 500-1000mg BD
• Low dose rotating antibiotics
• Cranberry, D-Mannose, PM Lactobaccilus
Recurrent UTI after MUS
• Avoid mesh in adductor muscle
• Outside in needle diameter narrower than inside out
• MRI to locate position
• Injection with Local/Steroids prior to removal
• MRI – on Hip joint? Referred pain
• Retropubic easier to remove than transobturator
Pain after RP/TO Sling
• Exclude obstruction: uroflow, residual
• Pre-op UDS?
• Exclude UTI, intravesical mesh
• Routine approach to OAB
• Antimuscarinics: Ditropan, Oxytrol, Vesicare, Enablex, Detrusitol
• beta3 agonist: Betmiga
• Good Bladder Habits, Bladder training
De Novo Urgency after MUS
pUUI
<0.00010.38 – 0.750.54Concomitant POP surgery
0.0240.39 – 0.940.61Transobturator MUS
<0.00011.02 – 1.041.03Age (per year increase)
0.0061.10 – 1.781.41*Baseline urgency
symptoms severity
<0.00011.39 – 3.012.04Urodynamic USI & DO
p value95%CI ORpersistent Urgency
0.0050.087-0.970.33
0.0271.24 - 34.136.49
0.0081.18 – 2.931.86
<0.00011.38 – 2.561.88
0.0041.28 – 3.702.18
p value95%CIOR
Apical POP
USI & DO
Prev SUI
surgery
Apical POP
surgery
Who has persistence U/UUI
*baseline degree of bothersome urgency: 0=nil, 1=occasional, 2=daily
*Baseline
urgency severity
The mean age was 60.6±12.8 years.
The mean follow-up was 218.1±105.3 weeks.
The overall subjective rate for pU & pUUI was 40.3% & 32.30% respectively.
No difference Urgency between retro MUS and obturator tapes
Ford 2016
Retropubic SUI surgery – intra op & post op issues
Bladder Perforation
Needle wont pass
Mesh in Sulcus
Haemorrhage
Voiding Dysfunction after MUS
Recurrent Urinary tract infections
Pain after MUS
De novo Urgency
Failed MUS, recurrent SUI
Recurrent SUI after Mesh Excision
Persistence of OAB
15/08/2016
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• Review by urogynaecologist
• Review diagnosis ?ISD
• Imaging – position, compression
• Repeat UDS
• If urethra rigid = poorer outcomes
• Injectables or MUS or PVS
• Prev Colpo: if hypermobile = MUS
• Sling on Sling feasible
• RP confer 70% subj cure for repeat MUS
J Urol 2010; 183:241-2461
Recurrent SUI – prev SUI surgery Repeat Midurethal Sling on prev MUS
7% (1112) repeat MUS. Overall subj cure 85% (primary 86% vs 62%
repeat p<0.001)
Repeat group has more ISD (31% vs 13%, p<0.001)
Amongst repeat, RP has higher subj cure (71% vs 48% [TO] p=0.04)
Repeat group has more post op urgency & UUI (30%,22% vs 14%,5%
p<0.001)
Stav 2009
• Superficial Dyspareunia / persistent discharge or “Hispareunia”
• <5mm: conservative, Estrogen
• Wide excision, flaps, antibiotics
• Following excision Recurrent SUI rate 20-50%
• Advise against Concomitant SUI surgery
Mesh Exposure UGSA RANZCOG Position statement on MUS
https://www.ranzcog.edu.au/news/1356-ranzcog-ugsa-supports-the-use-of-mid-urethral-
slings-in-the-surgical-management-of-female-stress-urinary-incontinence.html
24th Mar 2014
https://www.ranzcog.edu.au/doc/position-statement-on-midurethral-slings-c-gyn-32.html
UGSA RANZCOG Position statement on MUS
https://www.ranzcog.edu.au/doc/position-statement-on-midurethral-slings-c-gyn-32.html
RANZCOG & UGSA supports use of MUS
SUI is common & burdensome
MUS is efficacious, effective and had
Become the operation of choice in
Australia, UK, USA & Europe
FDA safety communications on
Transvaginal mesh do NOT include MUS
MUS does comes with adverse events.
Evidence for its efficacy & effectiveness is
robust
Questions
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