3. Urinary incontinence
• Involuntary leakage of urine
• Failure to store urine during the filling
phase
• Abnormality of the bladder detrussor or
the urethral sphincter
• Urine loss may be urethral or extra-
urethral (ectopic urethra, rectovesical or
VVF)
4. Prevalence
• F >> M
• Increase with age : 50-70
– 25% : premanopausal women
– 40% : women >65 years
– 15% : men >65 years
Of all urinary incontinence
• Stress incontinence: 50%
• Urge incontinence: 11%
• Mix incontinence: 36%
5. What are the types of incontinence
• Stress urinary incontinence:
– Urine leakage on effort , exertion , sneezing or coughing
– Occur when bladder pressure exceed urethral pressure under a
condition of increase abdominal pressure
• Urge urinary incontinence:
– Leakage accompanied by, or immediately precede by urgency (a sudden
strong desire to void)
– A function of uncontrolled detrusor contraction that overcome urethral
resistence
• Mix urinary incontinence:
– Leakage associated with urgency , and also with effort of exertion ,
sneezing or coughing
– Treatment should focus on predominant symptom
• Overflow incontinence:
– Leakage of urine when bladder is abnormally distended with large
residual volume
– Esp in men with chronic retention
6. Normal baseline
• Frequency:
– More than 8 voids during the daytime
– IPSS: frequency > Q2 hour
• Nocturia?
– Nocturia: two or more voiding during sleeping
time
• Normal void volume: 200-400ml per void
• Normal RU: < 150ml
9. Anatomy
• Bladder
– Detrusor Muscle
• Smooth muscle – thin and highly distensible
• 3 layers – run in different directions
– Internal Sphincter
• A component of detrusor muscle
• Involuntary
• At bladder base
15. What are the DDx for UI of
elderly?
• DIAPPERS (Delirium, Infection, Atrophic
vaginitis, Pharmaceuticals, Psychological
condition, Excess urine output, Reduced
mobility, Stool impaction)
• Atrophic vaginitis does not by itself cause UI
and should not be treated solely for the
purpose of decreasing UI alone
16. What are the DDx of nocturia?
• Nocturnal polyuria
• Primary sleep problem (including sleep
apnoea)
• Conditions resulting in a low voided volumes
(e.g. elevated post-voiding residual)
– Bladder diary (frequency-volume chart)
17. What are the most common types of
UI in frail / older persons?
• Urgency UI, stress UI, and mixed UI (in frail /
older Women)
• Concomitant detrusor underactivity with an
elevated PVR in the absence of outlet
obstruction, a condition called detrusor
hyperactivity with impaired contractility
(DHIC)
• No published evidence that antimuscarinics
are less effective or cause retention in persons
with DHIC
19. What are the indications for UDS?
1. Previous surgery for stress incontinence
2. Clinical suspicion of detrussor overactivity
3. Voiding dysfunction
4. Unclear clinical diagnosis before surgery
5. Presence of neurological clinical features
• I will perform UDS in all pt before surgery
because 10% of pt with SI with have DO and
20% of pt with DO with SI
20. Advantage of video-UDS?
• Better evaluation of bladder neck descent
& urethra
• Quantifying anterior wall prolapse more
accurately
21. Urodynamics
Goals
• To duplicate patient’ symptom
• Determine the etiology of incontinence
• Evaluate detrusor function
• Determine degree of pelvic floor prolapse
• Identify urodynamic risk factors for
development of urinary tract deterioration
22. Pre-UDS preparation
• Dedicated room with urodynamic equipment & fluroscopy
• Procedure: 40-60min
• Get ready all equipment
• Urine C/ST or dipstick to rule out UTI
• Pre UDS Flow rate
• Insertion Fr 6-8 biluminal catheter into bladder measure
RU + Pves
• Insertion Fr 6-8 single lumen catheter into rectum Pabd
• Line connected to UD transducer
• Flushed line with NS to exclude all bubbles
• All system zero to atmospheric pressure
• Reference point: superior edge of the pubic symphysis
• Initial cough test to ensure good subtraction
23. UDS procedure
• Patient in sitting or supine position
• Filling rate:
– normal 50-100ml/min
– 30ml/min in neuropathic bladder
• Quality control by asking pt to cough every 1 min
• Ask pt to continuously suppress bladder
contraction
• Valsalva or repeat cough stress incontinence
• Any DO (spontaneous or provacative)
• Voiding phase when MCC reach
25. Interpretation
Filling phase:
• Infused volume & rate
• First desire
• Normal desire
• Strong desire
• Cystometric capacity
Look for:
• Detrussor overactivity
• Stress incontinence
• Compliance?
Provacative manoeuvres:
• Cough and Valsalva
Voiding phase:
• Pdet
• Pdet at Qmax
• Qmax
• Vol voided
• RU
• BN: open and descend
26. Urodynamics
Urinary flow rates
• Two components to
flow: Bladder and
Urethra
• Detrusor
pressure/urinary flow
rate study
– To disinguish between
obstruction and
impaired detrusor
contractility
International Continence Society Nomogram
Gender Age (yr)
Flow
Rate
(ml/sec)
Males <40 >22
40–60 >18
>60 >13
Females <50 >25
>50 >18
28. Definition
• Maximum cystometric capacity :
– Bladder volume at strong desire to void
• Normal detrusor function:
– Little or no pressure increase during filing , no
involuntary phasic contraction despite provocation
• Detrusor overactivity;
– Involuntary detrusor contractions during filling:
spontaneous or provoked
– Phasic DO: phasic contraction
– Terminal DO: single contraction at MCC
– High pressure DO: Max Pdet >40cmH2O
– Overactivity volume: bladder volume at 1st
DO
29. Definition
• Detrusor compliance:
– Relationship btw change in bladder volume & change
in detrusor pressure
– C = change in vol / change in pdet (ml/cmH2O)
– Low compliance: <20ml/cmH20
• Beak volume:
– Bladder volume after which a sudden significant
decrease in detrusor compliance is observed
• Urethral sphincter acontractility:
– No evidence of sphincter contraction during filling, at
high bladder volume or during abdominal pressure
increase
30. Urodynamics
Leak Point Pressure
• Measures urethral sphincter function
• Valsalva leak point pressure
– To assess sphincter function in patients with stress
incontinence
– <60 cm H20 – intrinsic sphincter deficiency
• Detrusor leak point pressure
– To assess sphincter function in patients with low
compliance
– >40 cm H20 can have deleterious effects on upper
tracts
31. Urodynamics
Voiding cystourethrography
• Site of bladder outlet obstruction
• Integrity of sphincter mechanism
• Presence of Vesicoureteral reflux
• Presence of bladder/urethral diverticulum
• Presence of bladder wall trabeculations
32. Urodynamics
Sphincter Electromyography
• For:
– Integrity of the micturation reflex
• Neurogenic bladder dysfunction
• Learned voiding dysfunction
– External urethral sphincter contractions in the absence of
neuro or anatomic defects – 2%
33. Tracing of an investigation from 2 different individuals
What is this investigation? (2)
What is shown in each tracing? (2)
Q67
34. • Ambulatory UDS
– When conventional CMG does not reproduce
symptoms and treatment will be affected
• Left tracing showed urine leakage (the spike
indicated rise in temperature from
temperature sensitive napkin)
• Right tracing is normal (the drop in
temperature coinciding with rise in Pdet
indicated removal of pants /dress for normal
voiding in toilet) (1)
35. What is urethral pressure profile?
• Measurement of the intraluminal urethral pressure
• It involves using a 2 lumen catheter , one lumen for infusing
water at a rate enough to keep the urethra wall away from the
catheter fenestrations (2ml/min) and the other lumen is used
for pressure measurements
• The catheter is withdrawn at a rate of 2mm/sec.
• The maximum urethral pressure would normally be at the
external urethral sphincter mechanism.
• A maximum pressure >20mm water would exclude intrinsic
sphincter deficiency as the cause for stress urinary incontinence
36. What is abdominal / valsalva leak point
pressure?
• Relation to stress incontinence in non-neuropathic
female pt
• Abdominal/ leak point pressure is the inravesical
pressure at which urine leakage occurs due to increase
abdominal pressure in the absence of detrusor
contraction
• McGuire reported that when such pressure is
– >90cm water urethral hypermobility
– <60cm water sphincter insufficiency ISD (type 3 GSI)
• IDS: Suburethral tape or artificial sphincter insertion are
more appropriate procedures to colposuspension
37. What is detrussor LPP?
• Use in relation to pt with neurological disease
• This is the lowest detrusor pressure at which leakage
occurs in the absence of increased intra-abdominal
pressure or detrussor contraction
• It therefore refers to the detrusor pressure during
bladder filling and is an indirect measure of the
bladder compliance and urethral resistance.
• McGuire : risk of upper tract dilatation and
nephropathy was significantly higher when the DLPP
Is >40cm water
39. History
1. Type of incontinence (stress, urge, mix)
2. Onset? Duration ? Progression ?
3. Frequency and severity of symptom
4. Associated LUTS (storage or voiding)
5. Bowel function
6. Pad use & QOLs
7. Drinking habit
8. Medical Hx:
• Recurrent UTI
• Gyn hx: pregnancy, menopause, HRT, contraceptive
• Hx of pelvic surgery or RT
• DM , Neurological disease (MS, SCI, CVA, Pakinsonism)
9. Drug history: diureterics, anticholinergics , Antidepressant
10. Smoking & alcohol history
11. Int’l Consultation of Incontinence Questionnaire – short form (ICIQ-
SF)
12. Previous treatment , desire for further txn & expectation
40.
41. Physical examination?
1. General: Obesity (BMI)
2. Abdominal: bladder
3. Pelvis :
– Supine and left lateral with Sims speculum
– Inspection: oestrogen status of introitus, any prolapse
– “ stress test “ ask pt to cough to show leakage
– If leakage +ve place index & middle finger on either side of bladder neck
and ask her to cough again if no leakage (Marshall’s test +ve) good
support of BN will correct incontinence
– Q-tip test (see below)
– Sims speculum : cystocele or rectocele, anterior wall prolapse
4. Perineum: sensation , anal tone, bulbocavernosis reflex
5. Lower limb neurological exam
6. Assess voluntary pelvic floor muscle function by vaginal or rectal
examination before teaching pelvic floor muscle training (PFMT)
42. What is Q-tip test?What is Q-tip test?
• Introduce a lubricated cotton-tipped
applicator into urethra
• Angle > 30 degree on straining
hypermobility of the urethra
43. What are the investigation?
1. Urine test (C/ST, cyto)
2. FRRU
3. 3 days voiding diary (frequency-volume chart –
quantifying frequency, volume, types and timing of
drinks, nocturia, number of incontinence episodes)
4. Pad test (weight)
5. Renal USG or Cr if neurological features
6. Symptoms scores**:
• Bristol Female LUTS-SF
• ICIQ-UISF (4Q: When/How often/much/border you leak?)
• Pelvic floor impact questionnaire
• QoL: Kings’ Healthcare questionnaire
45. What is the pad test?
• 1 hour pad test
– 500ml fluid
– A set of exercise over next hour
– Positive if >1.4g
• 24-hour test
– Normal daily activity
– Positive if >8g
46. Urinary incontinence
Turner-Warwick & Chapple
• Standard ICS 1-hour Pad tests
• Before the test: drink 500 ml of plain water
• Test can be started without the preliminary voiding
• All women were given pre-weighed pads
• First 15 minutes: Sit or rest
• Half hour exercise: simply walking around, incl stairs of 1 FOS
• Last 15 minutes: standard ICS provocation ex.
– Standing up from sitting, 10 times
– Coughing vigorously, 10 times
– Running on the spot, 1 min
– Bending and pick up small object from floor, 5 times
– Washing hands in running water for 1 min
• The pad would then be re-weighed
• A pad gain >1.4 gm was considered a positive pad test
47. What is the classification of SUI?
Blaivas – based on degree of rotational descent
Type O No urine leakage demonstrated despite typical
Hx elicited
Type I Urethral
hypermobility
≤2cm descent of bladder neck during
valsalva
Type II Urethral
hypermobility
>2cm descent of bladder neck during
valsalva
IIa BN above inferior border of pubic symphysis
IIb BN below inferior border of pubic symphysis
Type III ISD Open non fxn BN/Prox urethra but no monility
(Stove-pipe urethra)
Dx by VLPP < 60cmH20
48. Stress Incontinence
Classification
• Type 0
– History of stress incontinence without
objective incontinence on urodynamic testing
– Bladder neck and urethra closed at rest
– Bladder neck and urethra open during stress
49. Stress Incontinence
Classification
• Type I
– Bladder neck and
urethra closed at rest
– Bladder neck and
urethra open and
descend during stress
– Descent less then 2
cm
– No evidence of
cystocele
51. Stress Incontinence
Classification
• Type IIB
– Bladder neck and
urethra closed and
below the symphysis
pubis at rest
– May or may not
descend during stress,
but urethra opens
53. What is the name of this classification? (1)
What is it used to quantify? (1)
54. • Pelvic Organ Prolapse Quantification (POPQ) classification (1)
• To quantitatively describe the severity of pelvic organ prolapse
– Presentation: prolapsed pelvic organ with obstructive voiding pattern
56. Vaginal Prolapse
Classification
• Stage 0 —no prolapse is demonstrated.
• Stage I —the most distal portion of the prolapse is more than 1
cm above the level of the hymen.
• Stage II —the most distal portion of the prolapse is 1 cm or less
proximal or distal to the hymeneal plane.
• Stage III —the most distal portion of the prolapse protrudes
more than 1 cm below the hymen but protrudes no farther than
2 cm less than the total vaginal length (i.e., not all of the vagina
has prolapsed).
• Stage IV —vaginal eversion is essentially complete.
57. What are the risk factors in pelvic organ
prolapse?
• Childbirth : increase with the number of
children
• Unclear whether Caesarean section
(CS) prevents the development of POP
though most studies indicate CS carries
less risk than vaginal delivery for
subsequent pelvic floor morbidity
58. What is the POP surgery?
• Asymtomatic cystocoeles do not require surgery
• Symptomatic cystocoeles-anteriorrepair if grade 2 + Use a pessary when
needed
• If associated stress incontinence
– Grade 1: colposuspension / sling
– Grade 2: colposuspension / sling +/- anterior repair
– Grade 3: colposuspension / sling + anterior repair
– Grade 4: colposuspension / sling + hysterectomy
• Central (enterocoele)
– Protrusion of small bowel into vaginal lumen
– Repaired by enterocoelerepair, sacrospinousfixation, or sacrocolpopexy
• Posterior (rectocoele)
– Protrusion of anterior rectal wall into vaginal lumen
– Often symptomatic with bowel dysfunction
– Repaired by rectocoele repair
• The overall relapse rate at 2 years is reported to be 20-30%
60. 1. What is urethral position1. What is urethral position
theory?theory?
• First theory
• Kelly, (Bonney, Enhorning) 1961
• Urethral position theory
• Urethra should remain above the pelvic floor
so that abdominal pressure can equally
transmit to and close the urethra
61.
62. 2. What is ISD?
• Intrinsic sphincter deficiency (ISD)
• Mc Guire in 1980
• Weakness of the sphincter itself
• Valsalva leak point pressure (VLPP)
– VLPP: < 60cmH20 ISD
– VLPP : > 90 cmH20 : anatomical cause of SUI
– VLPP: 60-90 cm H20 Mixture of problem
63. What are the causes of ISD?
• Inadequate urethral compression
– Previous urethral surgery
– Ageing, menopause
– Radical pelvic surgery
– Anterior spinal artery syndrome
• Deficient urethral support:
– Pelvic floor weakness
– Childbirth
• In males:
– Post RRP or TURP
64. 3. What is Hammock Theory?
• Delancey’s theory (1994)
• Urethra is resting on supportive layer of
endopelvic fascia and anterior vaginal wall
• Reinforced by the lateral attachment to arcus
tendineus fascia and levator muscle
66. 4. What is Integral Theory?
• Petros and Ulmsten 1990
• Laxity of the anterior vaginal wall & pubo-
urethral ligament to mid urethra
• Hypermobility of BN & dissipation of
urethral pressure incontinence
67. 5. What is trampoline theory?
• Incorporates all of the theories
• Female pelvis – outer ring
• Pelvic musculature and ligaments are the
springs
• SUI – multifactorial
• All of the above are compromised to some
extent
68.
69. What is the treatment upon different theories?
TheoryTheory TreatmentTreatment
Change ofChange of
UrethrovesicalUrethrovesical
angle/ hypermobilityangle/ hypermobility
(Kelly, Boney,(Kelly, Boney,
Enhorning)Enhorning)
RetropubicRetropubic
suspension/ Kelleysuspension/ Kelley
PlicationPlication
ISDISD Bulking agentBulking agent
injectioninjection
Hammock TheoryHammock Theory Mid-urethral SlingMid-urethral Sling
Integral TheoryIntegral Theory Mid-urethral slingMid-urethral sling
70. Treatment of stress urinaryTreatment of stress urinary
incontinenceincontinence
71. What are the treatment options of stressWhat are the treatment options of stress
urinary incontinence?urinary incontinence?
• Non-surgical
– Lifestyle modification – weight reduction and stop smoking, fluid
management
– Usage of incontinence pad
– PFEx / bladder retraining
– Medication: duloxetine, oestrogen therapy
• Surgical
– Occlusive
• Bulking agents
• AUS
– Supportive
• Suburethral sling
• Pubovaginal sling
• Retropubic suspension : colposuspension , MMK
72. What is pelvic floor muscle training?
• Defined as : any program of repeated voluntary pelvic floor
muscle contractions taught by a health care professional
(Kegel)
• At least 3 months
• Rationale For Pelvic Floor Exercises
– Strengthen pelvic floor musculature & thus urethral support
– Regain normal unconscious activation of pelvic floor muscle
during increased abdominal pressure
73. What is pelvic floor muscle training?
• No PFMT regimen has been proven most effective
• Long slow contractions and short sharp pull-up
• A representative strengthening program for PFMT suggests:
– 15 near-maximal contractions
– 10 sec for each contraction with equivalent rest period
– Repeated 3 cycles per day
– 30-50 daily contractions
• Biofeedback: the use of any method of training a patient to
gain control of and strengthen the pelvic muscles
– Palpation only (by trainer/patient)
– Vaginal cones
– Visual aids, EMG activity
• Passive PFMT: Electrical and Magnetic stimulation
74. What is pelvic floor muscle training?
• Success more likely in patients with milder degrees
– ~60% success
• To assess efficacy:
– Anterior displacement of urethra
– Elevation of perineum
– Posterior displacement of clitoris
75. What is this device? (1)
What is it used for? (2)
Q50
76. • Vaginal cone / vaginal weighted cones (1)
• A form of biofeedback for patients in pelvic
floor muscle training (2)
77.
78. Pessary
• Intravaginal device that support the pelvic
organs
• Knobs that sit under the urethra to
increase urethral support
• Require regular cleaning
• Cx: vaginal discharge and erosion
• Similar efficacy as tampons in reducing
urinary frequency and stress incontinence
79. What are the possible medication?
• Duloxetine hydrochloride (Yentreve)
• Combine norepinephrine + SSRI
• 20mg BD
• Act on Onuf’s nucleus increase activity of pudendal
nerve increase urethral muscle tone
• Efficacy: 30%
• Meta-analysis: Decrease incontinence episode,
increase QOL
• Limited use due to side effect: nausea, dizziness,
constipation , dry mouth , insomnia , somnolence &
asthenia
• Not recommended as 1st
or 2nd
line treatment due to SE
(Grade A)
80. Any hormonal treatment of UI?
• A systematic review concluded that oestrogen therapy
may be effective in alleviating OAB symptoms and local
administration may be the most beneficial route of
administration
• It is possible that urinary urgency, frequency and urgency
incontinence are symptoms of urogenital atrophy in older
post-menopausal women which may be controlled by
low-dose (local) vaginal oestrogen
• However, oestrogens (with or without progestogens)
should not be used to treat UI, as they are shown to
have a higher risk of stress and urge incontinence than
placebo [Heart & estrogen/ progestin Replacement
Study 2001]
81. How about DDAVP?
• Polyuria is defined as a 24 hour urine production of 3 litres or more
• ICS therefore defines nocturnal polyuria as a nocturnal urine
production that exceeds 33% of the 24 hour urine production
depending on age
• Desmopressin (DDVAP) was found to be well tolerated and
resulted in a significant improvement in UI compared to placebo in
reducing nocturnal voids and increasing the hours of undisturbed
sleep
• Quality of life (QOL) also improved
• Hyponatraemia - 10%
– Mild headache, anorexia, nausea, and vomiting to loss of consciousness,
seizures and death
– Increase with age, cardiac disease and a high 24-hour urine volume
82. If urodynamic SUI is confirmed, What
are the next steps?
• Full range of non-surgical treatments
• Retropubic suspension procedures
• Bladder neck/sub-urethral sling operations
• Limited bladder-neck mobility, consider using
bladder neck sling procedures, injectable
bulking agents and the artificial urinary
sphincter
84. What is Bulking agent ?What is Bulking agent ?
• Indications:
1. ISD - VLPP < 60 cmH2O
2. high risk , elderly patients
3. Multiple failed procedure
4. Mild to moderate SUI
• Success rate:50%, effect not long lasting, may require >1 injection
• Procedure:
– Injection Tx
– Cystoscopic, LA multiple submucosal injection at prox. Urethra or bladder
neck
– Aim to appose mucosa and close lumen
– Inject material periurethrally to provide additional submucosal bulk
• Agents:
– non absorbable: silicon (Macroplastique best – permanent and no significant
risk of migration), PTFE (Teflon) Ca hydroxyapatite
– Absorbable: bovine collagen, hyaluronic acid + dextronomer, autologous fat
• Comp: urgency, AUR, haematuria, UTI, migration of bulking agent
85. Surgery
• Conventional teaching
– Hypermobility of Urethra - Repositioning
• Colposuspension - Primary Procedure
• MMK, VOS
– ISD - Obstruction
• Sling - Secondary Procedure
• AUS
• Alternative teaching:
– All patient have ISD
– All operation cause obstruction
– Sling solved all these problmes
– Repositioning of other structures
88. What is pubovaginal sling?
• Indication:
– ISD, Type III SUI with minimal urethral mobility
– Failed anti-incontinence procedure (previous retropubic
suspension)
– Type I SI: Obese , COPD, Athletes
• Stripe of autograft fascia placed at the bladder
neck and fixed across the rectus muscle
• 90 % had significant improvement in 6 months
– Gormley J Urol AUA abstracts 1996, 2002
• Comparable cure rate between two procedures
89. What are the complication?
1. Bleeding retroperitoneal haematoma (0.5
%)
2. Retention or obstructed voiding-variable
(8%)
3. De novo urge 10-20 %
4. Urethral erosion - rare
5. Wound issues-variable
6. Death-none
90. Procedure
• Dorsal lithotomy position
• Foley catheter
• Allis clamp with upward traction to expose ant vaginal wall
• Midline incision over anterior vaginal wall
• Dissection: lateral over peri-urethral fascia
• Enter retropubic space at level of BN
• Detached urethropelvic ligament from arcus tendineus
• Free adhesion bluntly or sharply
• 2x6/12cm sling prepare
• O-PDS suture place in corners of slings for transfer to SP incision
• 2x incision just above pubic symphysis
• Insertion of Raz-Peyrera ligature carrier from incision deliver under
complete fingertip guidance into the vaginal incision
• End of PDS passed into the ligature carrier and brought back up to
abdominal incision
• Cystoscopy : exclude bladder perforation / intravesicle suture transfer
• To avoid tying the suture too tyte , not > 30degree of scope from movment
• Wound closure
• Vaginal pack for hemostasis
93. Q. Equipment
• A. What condition is this piece of equipment
used to treat?
• B. What material is implanted?
94.
95. Q.
• A. Urodynamic stress urinary incontinence (1)
• B. Tension free vaginal tape made of prolene
mesh (1)
96. What is mid-urethral sling?
• 1995: Tension-free vaginal tape by Ulmsten
• Objective cure rate > 90% in 10 year FU
• MUSS become new gold standard for surgical treatment of
female SUI
• +ve surgical outcome & low morbidity
• Mechanism of action
1. Dynamic kinking of the urethra with stress
2. Reinforce functional pubourethral ligaments, thereby securing proper
fixation of the midurethra to the pubic bone
3. Reinforce the suburethral vaginal hammock
4. Prevent hypermobiliy of BN from opening the mid-urethra
• Midurethra closing pressure of <20cm water is a predictor of stress
related surgery failure
97. Indications
• Urethral hypermobility
• Urodynamic SUI (No UI or DO)
• Extended :
– Complex SUI (minimal hypermobility, lower LPP,
Mixed UI)
– Obese & elderly pt
– Together with organ prolapse
– Previous failed surgery
• For ISD Pubovaginal sling is a better option
98. What are the contra-indications for
MUS?
1. Urethrovaginal fistula
2. Urethral diverticulum
3. Intra-operative urethral injury
4. Untreated urinary malignancy
99. Types of slingTypes of sling
• Classic (bladder neck/prox urethral position)
– Natural
– Rectus fascia (“the original sling”)
– Fascia lata ( auto or allograft – N.B. CJD)
– Synthetic
– (Monofilament) polypropylene (prolene) mesh or tape (early 1970’s)
– Dacron : Mersilene (multifilament polyester): “gauze hammock-sling”
– Gore-tex (PTFE: vascular grafts; 1988)
• Tension-free vaginal tapes (TVT; 1996)
(mid-urethral position with little or no tension)
– First described with polypropylene mesh
• Suprapubic Arch Sling (SPARC)
(similar mid-urethral position)
100. What are the materials of sling?
• Synthetic mesh : 4 type:
– Type 1: macroporous, monofilament (Prolene)
• Type 1 mesh are better:
– Relative resistant to infection & inflammation
– Early and sustained filling with fibrous
connective tissue & capillaries
– Promote tissue host in-growth with integration
anchoring mesh within tissue
– Inflammation reduce with time
• Thus all commercially available MUSS are
now made from type 1, uncoated mesh
101. Antomical approach
• Retropubic:
– “bottom-to-top” : Trocar from mid-urethral incision endopelvic
fascia retropubic space suprapubic exit point (e.gTVT)
– “Top-to-bottom”: e.g SPARC (2001)
• Transobturator:
– Delorme 2001: thru the obturator foramen
– Avoid passage thru retropubic space decrease bladder,
bowel, vessel injury
– Decrease in voiding dysfunction
– Less OT time, no cystoscopy require
– Trocar passage btw vaginal incision obturator membrane
obturator internus muscle groin incision below adductor
muscle insertion
– “outside-in”: Transobturator tape (TOT) AMS, Bard TOT
– “inside-Out”: TVT-O
102. TVT: Procedure
• Dorsal lithotomy position, Foley
• Mark abdominal percutaneous puncture and mid-urethral vaginal
wall incision
• Midline ant vaginal wall incision at level of mid urethra
• Dissect vaginal wall off laterally to develop space btw vaginal wall &
urethral & paraurethral tissue
• Until the junction of pubic ramus & urethropelvic complex is reach
• 2x 5mm stab incision over top of pubic symphysis 2.5cm from
midline on either side
• Passage of needle carrier (antegrade or retrograde fashion)
– Bladder should be empty
– Patient position so that symphysis pubis is in a vertical plane (reverse
Trendelenburg position)
– Use the catheter guide thru foley & displace the BN away from the side of
the carrier passage to decrease bladder injury
– Avoid too lateral direct (injury to ilioinguinal n or Inf epigastric vessels)
• Sling stabilized urethra should ensure at least 30-45 degree of
urethral hypermobility
• Cough test for urethral leakage
103.
104. Who are the suitable candidates for TOT?
Where suprapubic route is not preferred
• Transplant
• Neobladder
• Obese patients
• Multiple prior retropubic surgery
• Patient’s choice
105. Procedure of TOT
• Safer approach with less bowel and bladder
injury
• Dorsolithotomy position
• Thigh at right angle to pelvis for better access to
obturator foramen
• 1cm incision ant vaginal wall at mid-urethra
• Inner thigh incision: 2cm lateral to thigh crease
and 2cm ant to level of urethral meatus
106. Procedure : Out-In (TOT)
• Develop periurethral pocket to level of the
internal obturator membrane
• Medial rim of obturator foramen in pinched btw a
vaginal finger and on the inner thigh near the
stab wound
• Curved device passed from inner thigh site
skin muscle fascia onto the vaginal finger
and then rotated into the vagina
• Cystoscopy to exclude perforation
• Sling material attached curved device and
brought out to the thigh area
• Repeat on contralateral side
107.
108. Procedure : In-Out (TVT-O)
• Develop tunnel under vaginal wall to the level of
internal obturator fascia by dissecting at 45 degree
to the vertical plane
• Perforate fascia
• Place guide into the tunnel and thru the fascia
• Spiral instrument with sling attached is passed via
the groove of the guide through the foramen and
rotated while bring the handle of the device into a
vertical position
• Tip pass out through the inner thigh stab wound
• Sling pulled thru the thigh incision while spiral
device is back out
• Repeat on contralateral side
• No need for cystoscopy
109.
110.
111. What are the results of TVT?
• Consistent short and long term results
• Longest FU series by Nilsson 2008 (11.5yr)
– Success (objective Cure) rate: 90% at 11 years
– Subjective cure (Patient Global impression of
improvement PGI-I) : 77%
failure rates if :
• advancing age at the time of procedure
• intrinsic sphincter deficiency
112. What is the result of TOT?
• Liapis , 4 yr result of TVT-O: cure rate :
82%
• Waltergny , 3 yr result of TOT: cure rate :
88%
113. MUS vs Pubovaginal sling (for ISD)
• Novara , EU 2010
• similar effective in continence rate
• PV sling has
– more associate with storage LUTS
– less intraoperative bladder perforations
114. What are the result of TVT VS
colposuspension?
• Meta-analysis Novara EU 2010:
• TVT vs Burch has:
1. Better efficacy in terms of cure rate
2. Shorter OT time
3. Less blood loss
4. Faster recovery
5. Shorter time to return to normal activities
6. Less reoperation rate but more risk of bladder
perforation
115. TVT vs TOT
• Systemic review and meta-analysis
[Novara EU 2010]
• Similar efficacy
• TVT vs TOT: TVT has
– Higher intraop complication: bladder and
vaginal perforations, hematoma
– More storage LUTS
– Longer operation time
– Less post-operative pain groin and thigh pain
116. TOT vs TVTO
• no difference btw the two TOT (i.e TVT-O
and Monarc)
117. • Multicenter , randomized equivalence trail [2010]
• TVT vs TOT/TVT-O in women with SUI
• 597 women
• Result: TVT vs TOT
– Treatment success (obj) at 12m: Equivalent (80%vs
77.7%)
– Treatment success (sub) at 12m: Equivalent (62%vs 55%)
– TVT has higher voiding dysfunction (2.7% vs 0) , bladder
perforation & UTI
– TOT has higher neurological sym (leg pain and groin
numbness ) (9.4% vs 4%)
– No difference in urge incontinence , satisfaction with result
and QOL
TOMUS
118. The First 5-yr FU data of TVT vs TVT- O:
[Angioli et al , Rome Italy, EU 2010]
• Both surgical technique are safe with similar result of objective cure
rate (72%) & low complication rate (16%) btw the two gp after 5 yr of
FU
• Most prevalent complication:
– 1. urge incontinence (5%) , 2. dyspareunia (3%) & 3. incontinence
during intercourse (6%)
• Complications of sling surgery:
– Intraoperative complication:
• 1. Bleeding: 6%
• 2. urinary tract injury: urethra (1%), bladder (5% in TVT), ureter (rare), Vaginal
(4%), Bowel (rare)
• Post-op complication:
– 1. Voiding dysfunction and urinary retention (2-4%)
– 2. Vaginal extrusion and urinary tract erotsion (0-2%)
– 3. Sexual dysfunction
– 4. Others: refractory thigh or groin pain , chronic pelvic or perineal pain,
surgical site infection
120. Mx of complications of TVT?
• Vaginal or urethral erosion
– remove the tape
– Urethral defect can be repaired with Martius fat if significant
defect
– Rectus sling can be inserted later if patient is incontinent
• Bladder perforation
– endoscopically remove the tape using laser / cystostomy
• TVT with complete obstruction in 1st
3 days:
– Reoperated
• Continued obstructive symptoms beyond 3 months
– require consideration of takedown
• TVT with large PVR could be dealt with by division of tape
121. What are the complications of TOT?
• Thigh/groin pain 16%
• De novo urgency 4%
• Urinary retention 2%
• Vaginal erosion 2%
• Urethral perforation 1%
• Vaginal perforation 1%
• Bladder perforation 0.5%
122. What to do if bladder perforation
noticed during TVT insertion?
• Cystoscopy at end of procedure should
always allow early recognition of problem
• Reposition needle/suture immediately
• Conservative management with drainage
of bladder X1/52 and cystogram prior to
removal of catheter
123. Dealing with complication
• Bleeding:
– Bed rest and prolonged use of vaginal pack
– Insert foley posterior to packing with 80ml
balloon
– Surgical exploration (rare)
• Post-op Pain:
– Pain killer
– Avoid suture over portion of the rectus muscle
to prevent nerve entrapment
124. Dealing with complications
• Urinary retention:
– Any associated voiding symptoms?
– Period of CISC (up to 3 months)
– VUD: hypersuspended urethra & high
pressure low flow
– For mid urethral sling: incise sling early
– Bladder neck sling: can delay until 3m
– Transvaginal urethrolysis (rarely)
125. De novo detrusor instability-De novo detrusor instability-
• Must be distinguished from recurrent
SUI (surgical failure)
• Preoperative prediction is very difficult
but consideration must be given to
preoperative bladder capacity and
urodynamic evaluation
• May require removal of sling
126. Erosion/infectionErosion/infection
• This most serious complication may be
vaginal or urethral
• Thankfully rare perhaps related to
excessive tension
• Increased with synthetic slings but can
occur with natural material
• Often requires removal of
sling/urethrolysis
128. Retropubic suspension:
1. Burch Colpocystourethropexy
2. Marshall-Marchetti- Krantz (MMK)
vesico-urethral suspension
• Base on Enhorning theory:
– Urethral height within the pelvis determines
continence
– Urethra must be restore to intra-abdominal
position
129. Indications & contraindications
• Indications:
1. Significant urethral hypermobility
2. failed suburethral sling or conservative mx
3. Requires concomitant abdominal surgery (dysterectomy ,
colpopexy, enterocele)
4. Limited vaginal capacity / mobility
• Contraindications:
1. True Type III incontinence (i.e ISD)
2. Fixed proximal urethra with no hyper mobility
130. What is Burch colposuspension?What is Burch colposuspension?
• Result: 1 yr 90%/ >10yrs 70%
• Aim of surgery: elevate and fix BN and prox.
urethra in retropubic position
• To allow vaginal wall to be elevated and attached to
the lateral pelvic wall where the formation of
adhesions over time secures its position
• Paravaginal fascia is exposed and approximated to
the iliopectineal (Cooper's) ligament of the
superior pubic rami
• Change of vesicourethral angle
131.
132. What are the complications of
colposuspension?
1. Retropubic hemorrhage
2. Infection , recurrent cystitis (1%)
3. Bladder injury
4. Enterocele / rectocele (bladder moved ant more
space at posterior)
5. Voiding dysfunction AROU
6. De-novo Urgency
7. Dyspareunia
• Less bladder injury by more re-operations than TVT
134. What is Marshall-Marchetti-Krantz
(MMK) procedure?
• Sutures are placed either side of the urethra around
the level of the bladder neck and then tied to the
hyaline cartilage of the pubic symphysis
• Result: Short-term success is about 90%, but declines
over time (30% at 10 years)
• Complications: osteitis pubis (3%), typically
presenting up to 8 weeks post-op with pubic pain
radiating to the thigh
• Treatment is with simple analgesia, bed rest, and
steroids
135.
136. • Osteitis Pubis
• X-ray show hazy
border of symphysis
with possible lytic
lesion
138. What is OAB?
• International Continence Society 2002
• “OAB is a symptom syndrome of urgency with or without
urge incontinence, usually associated with frequency and
nocturia in the absence of UTI or obvious pathology”
• Idiopathetic detrussor overactivity:
– A urodynamic evidence of involuntary detrussor contractions
without an underlying cause
– Can be spontaneous or provoked
• Neurogenic DO: cause by (SCI, MS, CVA , etc)
139. How common is OAB?
• Affect 10-15% of women
• 25% resolved over 1 year
• Most have symptoms for many years
• Exclude: UTI/ stone/ Ca bladder
140. Risk factors for OAB?
1. Increasing age
2. Female sex
3. Obesity
4. Impaired functional status
5. Depression
6. Recurrent UTI
7. DM
8. Neurological disorder
9. Post-surgery for stress incontinence
10.Bladder symptom in childhood
141. Patient present with frequency , urgency
and nocturia ? Approach?
History
• When did the symptoms first appear?
• Are there any exacerbating factors?
• Are there any associated obstructive symptoms or proven
urinary infections?
• How many (if any) pads does she have to wear throughout the
day?
• Is this problem affecting her quality of life?
• Is there any history of neurological disease? Gait, visual,
memory
• Has she had any previous pelvic operations?
• Is she a smoker?
• Does she drink excessive amounts of caffeinated beverages?
• What medication is she taking?
142. What test?
• Basic blood test
• Urine : Dipstick and culture
• FR + RU
• Bladder diary
• If suprapubic pain or hematuria USG &
FC
143. Investigation
1. Validated questionnaires
– ICIQ -SF(Abram, ICS )
2. Bladder diary
1. Volume of fluid intake
2. Incontinence episode
3. Number of pad use
4. Urinary frequency
5. Void urine volume (functional bladder capacity)
144. Differential diagnosis?
Urological:
• Detrussor overactivity
• UTI
• Urethral syndrome
• Urethral diverticulum
• IC
• Ca bladder
Gyn:
• Cystocele
• Pelvic mass
• Vaginitis
• Urethritis
• Urethral caruncle
• Atrophy
146. Need UDS diagnosis ?Need UDS diagnosis ?
• No
1. OAB is so prevalent that the urodynamic facilities may
be overwhelmed
2. UDS are relatively invasive and costly and may not
always confirm the presence of DO
3. Conservative and drug therapies are safe and relatively
inexpensive
Yes when:
1. Initial treatment fails
2. Complex neurological disease suspected
3. Before surgery
147. What is the treatment ladder forWhat is the treatment ladder for
OAB?OAB?1. Lifestyle modification:
– Decrease caffeinated drinks
– Stop smoking
– Weight loss [PRIDE study]
2. Bladder re-training : 6m
3. PFMT : 3 months is recommended
4. Pharmacological (efficacy 60%)
5. Intravesical instillation therapy
6. Botox, botulinum toxin A Injection (efficacy 70% for 6 months)
7. Neuromodulation (50% cure rate, 25% improvement, 25% failure
rate)
8. Augmentation cystoplasty (50% cure rate, 25% significant
improvement, 25% failure rate)
9. Urinary diversion in refractory case
Urodynamics require
148. What is bladder training?
• Principles:
– Central control can be relearned as the same way in infancy
• Time voiding: urinate according to a schedule, rather
than response to urge
• When patient feels the urge diverse the attention to
other things within a pre-setted time
• Deep breathing, mental calculation, squeezing of pelvic
floor muscle
• Prolong the presetted time sequentially before going to
void
• Aim to decrease urgency and frequency (2-3hr)
149. Role of PFE in Urge incontinence?
• Cochrane review: [Dumoulin 2010]
– More effective than no treatment , placebo or
inactive control treatments in women with mix
or urgency incontinence
150. Other measures?
• Electrical stimulation of the PFM
– Apply electrical current to pelvic floor muscle
to induce a passive contraction
– Insufficient evidence to recommend its use
• Extracorporeal magnetic stimulation:
– Patient sit on magnet chair
– No solid data
151. What is anti-cholinergics?
• Anticholingergics are competitive muscarinic receptor antagonist
• High binding affinity to muscarinic receptor that mediate the
contraction of bladder (M2 & M3)
• Reduce spontaneous detrusor msucle activity
• Decrease detrusor pressure + increase RU
• M2 – most abundant in detrusor
• M3 – functionally important receptor
• Most drugs – non-elective
– Tertiary amine good GI absorption while quaternary amine has less CNS side
effect
• Vesicare/solifenacin – selective M2 and M3 receptor antagonist
• Emselex/darifenacin – selective M3 receptor antagonist
• Proceed CMG if failed anti-cholinergics before invasive procedure
152. Antimuscarinic AgentsAntimuscarinic Agents
• Tertiary (^lipophilicity, ^ Pass into CNS)
o Oxybutynin Ditropan® (XR form and transdermal form a/v)
o Tolterodine Detrusitol® Detrol® (Relatively low lipophilicity,
functional selectivity for bladder over salivary gland, XR form
a/v)
o Atropine (if used, usu. Intravesical for neurogenic DO)
o Propiverine Detrunorm® (Equal efficacy, fewer S/E than
oxybutynin)
o Darifenacin Enablex® (M3 selective)
o Solifenacin Vesicare® (M2 and M3)
• Quaternary (less CNS effect)
o Trospium Sanctura® (Non-selective)
o Propantheline Pro-Banthine® (Non-selective)
153.
154. Are they all the same?
Agency for Healthcare Research and Quality
(AHRQ) evidence report [2009]
• No one drug was definitively superior to another
• Extended release (both oxybytynin & tolterodine)
were better than immediate release in
decreasing the number of urgency incontinence
episode
• Medication improve QOL & reduce distress due
to leakage (vs placebo)
• 15% withdrawal due to side effect
• Work best in combination with behavior therapy
156. Tissue Distribution Potential Adverse Events
Muscarinic Receptor Distribution andMuscarinic Receptor Distribution and
Potential Adverse Events With AntagonistPotential Adverse Events With Antagonist
UseUse
Eye
M3 Decreased lacrimation
Decreased
accommodationSalivary
glands
M3
Xerostomia
(dry mouth)
Heart
M2-M3
Cardiovascular
Intestine
M2-M3
Constipation
Urinary retention
Bladder
M2-M3
• M2 reverses sympathetically-mediated smooth muscle relaxation
• M3 causes detrusor contraction
Brain
M1-M5
Decreased cognitive
function
Short-term memory loss
Altered sleep cycle
157. What is intravesical Instillation-Capsiacin &
Resiniferatoxin (RTX)?
• Vanilloids
• Capsiacin-extracts from hot chili pepper
• RTX- extract from an African Plant -1000 times
more potent
• Target in vanilloid receptors located in membrane
of unmyelinated C fibre of bladder mucosa
• More effective in Neurogenic Detrusor
Overactivity
• Need repeated instillation
• Longest duration for one dose 3 months
158. What is the drawback of
intravesical Instillation?
• Not available in most western country
• Need to do under general anesthesia
• Irritating effect last for 1-2 weeks post op
• Repeated instillation , but some patients
has no effect even on second instillation
160. The photo illustrates a type of treatment increasing
being used in Urology
How does it work in details? (3)
Q17
161. Botulinum toxin: MOA
• Botulinum toxin is a neurotoxin derived from Clostridium botulinum
• Normally acetylcholine (Ach) release from presynaptic nerve
terminal at neuromuscular junction (NMJ) requires its exocytosis via
a protein complex called SNARE protein
• BoNT/A (Botulinum toxin A), after being introduced in the NMJ, can
be endocytosed into the presynaptic nerve terminal via its heavy
chain docking onto receptors
• Botulinum toxin consists of a light chain attached to a heavy chain via
a disulfide bond with an associated zinc atom
• Inside the presynaptic nerve terminal, BoNT/A light-chain then
cleaves a specific protein (SNAP-25) on the SNARE protein complex
which results in failure of exocytosis and release of acetylcholine into
the NMJ reversible parapysis of the detrusor muscle
• Further, there is evidence that BoNT/A has an effect on the sensory /
afferent pathway at P2X receptors of type C nerve decrease
urgency
162. • There are 7 serotypes of botulinum toxin
• Different BoNT (A,B,C1,D,E,F,G) have different protein targets in
the SNARE protein complex
• Only botulinum toxins type A and B are used for clinical purposes, A
more potent
• Available formulation of BoNT/ A
– Botox (allergan , USA)
– Dysport (Ipesn, UK)
– Xeomin (Merz, Germany)
• (SNARE : Soluble N-ethylmaleimide sensitive factor Attachment
protein Receptor)
• (SNAP-25 : SyNaptosomal Associated Protein of 25kD)
163. What is intravesical Botulinum Toxin A?
• Intravesical Botulinum Toxin A
• Botox® (5 times more potent than Dysport)
– Dosage: 100–300 U
– Reversible as axons regenerates in 3-6months
– More effective in neurogenic detrusor overactivity
• Administration:
– LA / GA
– Flexible or rigid cystoscopy
– Intradetrusor injection and sparing of the trigone
– 300 U diluted in 30 mL saline and injected at 30 sites
( 10U/ml )
– Trigone-sparing to avoid reflux
164. What is intravesical Botulinum Toxin A?
• Efficacy:
– Better than placebo in decreasing incontinence, inproving
QOL & maximum bladder capacity
– Good response rate within 1-2 week
– 70% response with mean duration of 6-9 months
– Repeated injection will be needed
• Adverse effects: well tolerated mostly
1. UTI 5 %
2. Haematuria 5 %
3. Transient urinary retention 1%
4. Need to self-catheterize 15-20%
5. Systemic absorption (muscle paralysis resp. failure, dry
mouth, flu-like, malaise)
165. What is intravesical Botulinum Toxin A?
• Contraindication of Botox:
1. Myasthenia Gravis
2. Pregnancy
3. Breast feeding
4. Bleeding diathesis
5. Eaton Lambert Syndrome
• Reported uses in Urology:
– OAB: NDO and IDO
– (DSD, Chronic prostadynia, retention due to
acontractile bladder)
170. Sacral neurostimulationSacral neurostimulation
• Indications:
– intractable OAB
– Fowler’s syndrome (more effective)
• MOA:
– Continuous mild electrical activity to stimulate sacral afferent (S3)
– Modulate local neural reflexes & inhibit bladder contraction
– Also affect signals from higher brain centres in control
• GA or LA delivery
• Two stages
– Test implant at S3 foramina (>50% symptoms improvement 2nd
stage)
– Permanent electrode into S3 and pulse generator in a pouch superficial to
posterior superior iliac crest
• Efficacy: 75% in refractory idiopathic DO
• Battery live – 7 years (need revision)
• Complications: Pain (site or LL )infection, bleeding and migration ,
explantation (10%)
• Note: S3 can be stimulated peripherally by means of posterior tibial
nerve
172. Augmentation cystoplasty
• How does it work?
– Bivalve the bladder and patch the defect
with ileum
1. Impairs bladder contraction
2. Lower detrusor pressure
3. Increase capacity of the bladder
4. Decrease amplitude of contraction
174. Long term complications
1. Need of post-op CISC: 50%
2. Troublesome mucus production : 40g/d
– Infection , stone and blockage
– Bladder washout with acetylcesteine
3. Stone : 15%
4. Bacteriuria (100%) & UTI (10%)
5. Hyperchloraemic metabolic acidosis: 15%
– Reabsorption of ammonium choloride ammonia & HCL acidosis (handle by
kidney)
– Ammonia need to be handle by liver
– Txn: bicarbonate
6. Renal function deterioration
7. Malignancy: > 10 year
– Chronic inflammation , urinary stasis and recurrent UTI
– Adeno Ca in the region of anastomosis
– Bacteriuria reduction of Nitrate to nitrite react with urinary amine N-
nitrosamines (carcinogenic)
8. Bowel change: Diarrhoea (30%), decrease absorption (vit B12, Folic) anemia
9. Perforation (< 1%) : high mortality due to late presentation (25%)
10. Demineralization of bone + fracture : acidosis buffered for Ca
180. What is interstitial cystitis?What is interstitial cystitis?
• Definition:
– Painful bladder syndrome PBS: Chronic (>6w) Suprapubic
pain related to bladder filling, frequency, in the absence of
urinary infection or other pathology
– Interstitial cystis: as above + unspecificed typical
syctoscopic and histological features
– Diagnosis by exclusion
• Epidmemiology:
• F: M = 5:1
• 18 case per 100, 000
• Asso with : allergies , Irritable bowel syndrome,
fibromyalgia, Sjogren’s syndrome, inflammatory bowel
disease
181. What is the pathologenesis?
Multifactorial
1. Infection
2. Mast cell
– Pathognomonic marker
– Estrogen augments mast cell secretion
3. Autoimmunity
4. Defect of GAG
5. Neurogenic inflammation abn sensory activity
6. Stress
7. Female : Commonest age of onset is in fifth decade
182. What is NIDDK definition?
• Only 1/3 patients completely fit this definition
• Anatomatic inclusions
– Hunner’s ulcer – not true ulcer, inflammation which causes deep
rupture through mucosa and submucosa with oozing (waterfall)
on hydrodistension
– Only 20% IC have demonstrable ulcers
• Positive factors
– Pain (suprapubic, perineal, urethral) on bladder filling that is
relieved by emptying
– Glomerulations on endoscopy
• Punctate petechial hemorrhage and observe after hydrodistension
• > 10 per quadrant in ¾ quadrant of the bladder
– Decreased compliance on CMG
– (KCl (0.4mmol/ml) provokes symptoms in 70% of IC patients)
183. What is NIDDK definition?
• Exclusion criteria
– <18 years old
– Infection, radiation, drugs, tumor, stone
– Daytime frequency less than five times in 12 hours
– Nocturia less than twice
– Duration < 12 months
– DI on CMG
– Capacity > 400ml, absence of sensory urgency
184. What are the types of IC according toWhat are the types of IC according to
European Society for the study of IC?European Society for the study of IC?
• Cystoscopic hydrodistension findings
– Normal – 1
– Glomerulation – 2
– Hunner’s ulcer – 3
• Biopsy finding
– Normal – A
– Inconclusive – B
– Positive – C
186. Symptom questionnaire
1. Bladder pain/ Interstitial cystitis Symptom
Score (BPIC-SS)
2. O’Leary Sant (OLS): Interstitial cystitis
symptom and problem Questionnaire
3. Pelvic Pain & Urgency/ Frequency
Patient Symptom Scale (PUF
questionnaire)
187. Diagnosis
• Cystoscopy:
– GA, bladder distended 2x (80-100cmH20) 1-2min
– Inspected for diffuse glomerulations (> 10 per quadrant in
¾ quadrant of the bladder)
– Hunner’s ulcer : pink ulceration
– Bx biopsy as indicated
• Potassium sensitivity test: Riedl’s test
– Bladder filled at 50ml/min to maximal capacity , drained and
record volume
– Instillation of KCL (0.2M KCL) intravesically until MCC
– Reduction > 30% of bladder capacity defective GAG layer
188. What are the treatment options?
• No cure , txn aim to control symptom
• Exacerbations and remissions over the long term
• 50% temporary remission rate
• Support : psychological , IC support group
• Avoidance of trigger – chili, caffeine
• Hydrodistension at 80cmH2O for 1-2 mins
• Surgery:
– Transurethral resection (/laser) of Hunner’s ulcer,
– Denervation procedure : posterior Rhizotomy
– supratrigonal cystectomy
– substitutional cystoplasty or urinary conduit
• Nerve stimulation: Transcutaneous nerve stimulation
(TENS),Sacral nerve stimulation (SNS)
192. • IVU of a lady who was incontinent of urine 5
days after undergoing a hysterectomy. A
cystogram was normal
193.
194. Incontinence
• What is the diagnosis?
– Uretero vaginal fistula
• What are the investigations?
• Give two ways in which the problem could be
managed.
197. Incontinence post Gyn surgery
• History – persistent vaginal watery discharge, recurrent cystitis, surgery of
benign or malignant cause / operation record – any urinary tract injury, past
history of RT / pelvic inflammatory disease / malignancy)
• Physical examination: abd mass, loin pain , speculum – size, site, no. of
fistula, degree of inflammation, vaginal length and introitus size
• Vaginal fluid X creatinine / K
• 3 swab test
– Pyridium stained inner swab > UVF (Bill say no need pyridium)
– Methylene blue stained middle swab > VVF
– Methylene blue stained distal swab > urethrovaginal fistula
– Limitations: false results in VUR
• Upper tract – IVU / CTU with delay phase
– UVF: Hydronephrosis + level of obstruction (99% will not show fistula tract)
• Cystoscopy : will see fistula itself in VVF , RP is contraindicated (sepsis)
• Cystogram: presence and location, lateral view, voiding image, post void
image
• Ureteric stent if continuity preserved / Open reimplantation/ psoas hitch
198.
199. • What are the treatments?
– Conservative treatment
• Prolonged catheter drainage
• Pinpoint fistulas may respond to conservative management
but success rates may be low
– Surgical repair (most cases)
200. What are the pros and cons of early vs
delayed repair of UVF or VVF?
• Argument for early repair (2-3 weeks after injury)
– Post-gynecologic urinary tract fistulas are usually
uncomplicated clean iatrogenic injury
– Large series showing early repair of UVF & VVF can
be safely and successfully undertaken
– Shortened the duration or reduce Cx from fistula
e.g. infection or Cx from stenting/PCN
– Minimizing the patient's discomfort and anguish
– Psychological & Medico-legal issues
201. What are the pros and cons of early vs
delayed repair of UVF or VVF?
• Argument for delayed repair (3-6 mth): Traditional
– reduction of inflammation and edema permits
easier identification of tissue planes and therefore
flap development, less bleeding, and less tension
on the reapproximated suture lines
– Allow time to treat ongoing infection or
inflammation at the level of the vaginal cuff
– (Vesico-vaginal fistula may benefit from pre-
operative topical estrogen)
202. Bill Sir: 2011 tutorial
• Early repair is advocated once sepsis and
UTI is settled
• Preparation before repair
– Improve RFT (drainage)
– Treat sepsis
203. What is the principle of surgical
treatment of VVF?
• Principles of open repair (Success rate >90% in most series)
– Wide exposure of the fistula and surrounding area
– Fistula complicating radiation must be biopsied for
malignancy
– The main factor is to separate the fistulous communication
between the bladder and the vagina
• Complete excision of fistula
(For: assure apposition of vascularized tissues at edges;
Against: large defect, may also include the ureters)
• 10% associated with ureteric injury
– Interpose vascularized graft or flap between the 2 organs
and obtaining a watertight tension-free closure
204. Principle of repair
1. Adequate exposure
2. Debridement of devitalized tissue
3. Removal of foreign body or synthetic material
4. Anatomic separation of involved organ cavities
5. Watertight closure
6. Multilayer closure
7. Tension free non overlapping suture lines
8. Well vascularized flap
9. Adequate urine drainge
10. Maintain hemostasis
11. Avoid infection
205. What is the principle of surgical
treatment of VVF?
• Argument for abdominal approach:
– Familiar to Urologist
– Better exposure in particular multiple VVFs, involving UVF
requiring ureteral reimplantation
– Can repair simultaneous UVF
– Can deal with complex fistula, post RT fistula
– Facilitate the fashion of interposition flap (omentum or
peritoneum)
– No change in vaginal depth or length
• Drawback: need delay of 3-6 months
206. What is the principle of surgicalWhat is the principle of surgical
treatment of VVF?treatment of VVF?
• Argument for vaginal approach:
– Transvaginal usually possible - 92% Raz
– Avoidance of a laparotomy and its associated morbidity
– Short operative time Minimal postoperative pain & blood loss
– Absence of the need for wide opening or bivalving of the bladder
– Approach not compromised by multiple prior abdo or pelvic surgeries
– Concomitant anti-incontinence or prolapse surgery may be performed
– Local interpositional flaps are adjacent (e.g., Martius, peritoneal)
• Drawback:
– Limited exposure
– Tension in closure (Bill)
– risks of vaginal shortening/dyspareunia/vaginal stenosis
207. Bill Sir: 2011
• Transabominal approach (we are urologist!)
• Transperitoneal (**)
– Bladder opened until fistula reached (not
bivalved)
– Fistula tract exposed and excised
– Bladder closure without tension
– Easier in fashioning the edge
– Pedicle omental graft interposition
• Transvesical (extraperitoneal) : not prefer:
– Also need two layer repair (same as
transvaginal)
208. What is the principle of surgical
treatment of VVF?
• Interposition grafts/flaps
success rate of fistula closure
1. Provide separation of suture lines
2. Provide added vascularity and lymphatic drainage
• Transvaginal interposition flap
1. Martius Flap (labial fat pad) – most commonly used
2. Labial rotation flap/ Lehoczky flap (labial skin + fat )
3. Gracilis myofascial/ myocutaneous flap
4. Omentum cannot not be used as interposition flap in
transvaginal repair
209. • Abdominal interposition - Free Graft
– Rectus sheath
– Peritoneum
– Bladder mucosa
• Pros: Used when there is no alternative flap e.g. scarred
peritoneum; resected omentum in previous surgery
• Cons: Not vascularized
• Abdominal interposition - Vascularized Flap
– Peritoneal rotation advancement flap
– Omental pedicle flap
• Advantages:
– Omentum provides good interpositional bulk
– Added vascularity and lymphatic drainage
– not irradiated in case of radiation-related fistula
• From either right and left gastroepiploic pedicle
– Rectus abdominis myofascial flap
210. Abdominal repair
• Suprapubic intraperitoneal-extraperitoneal
approach
– Classically described by O’coner
– Bladder bivalve vertically and down to fistula
tract
– Tract dissected out and excised
– Further dissection distally beyond the tract
– Closed separately
211. Vaginal repair
• Create vaginal flap
• Dissection of tract
• Excise tract or not excise tract
• 3 layers closure
– Bladder
– Perivesicle
– vaginal
212. post op mx
• Uninterrupted bladder drainage –
preferably SP drainge for ~2 weeks
• +/- anticholinergic to avoid bladder spasm
• Avoid tampon
• Avoid sexual activity for 3 months
213. outcome
• Over 90% success rate in post surgical fistula
• ~60-70% success rate in post RT
• Complication:
1. Vaginal bleeding
2. Infection
3. Bladder pain
4. Dyspareunia due to vaginal stenosis
5. Graft ischaemia
6. Ureteric injury
7. Fistula recurrence
214. How about UVF?
• Ureteric injury during Gyn surgery: 1 in 1000
• Commonest site of injury : 3
1. Level of Pelvic brim (infundibulopelvic lig, ovarian vessels)
2. Beneath the uterine artery
3. Level of vagina vault before it enters the bladder (cardinal ligaments)
• Presentation
– Prolong ileus
– Watery vaginal discharge
– Persistent drainage of fluid from drains
– Loin pain (type , location)
– Abd mass (urinoma)
– sepsis
– Missed presentation
– Obstruction , urinoma, abscess, fistula, ileus, prolong fever
216. Basic anatomy
• In females, the ureter lies at the base of the broad
ligament and is crossed anteriorly by the uterine artery
just before entering the bladder.
• Ureter crosses the pelvic brim near the bifurcation of the
common iliac artery, where it becomes the “pelvic”
ureter.
• At pelvic brim: ureter is attached to the posterior lateral
pelvic peritoneum running dorsal to ovarian vessels.
• At the midpelvis, it separates from the peritoneum to
pierce the base of the broad ligament underneath the
uterine artery.
• At this point, the ureter is about 1.5 to 2 cm lateral to the
uterus and curves medially and ventrally, tunneling
through the cardinal and vesicovaginal ligaments to enter
the bladder trigone
217. Assessment
• History:
– Indication of surgery (benign or cancer)
– Difficulties encounter (prolonged procedure, bladder ,
adhesions)
– PMH: endometriosis, abd surgery , RT
• PE:
– Abd exam : scar
– Full bladder
– Loin tenderness
– Vaginal exam: look for VVF
218. investigation
• Bld
• Drain?
– Color, amount
– Fluid for Cr (> 300 umol/L+ K)
• Urgent IVU or CTU
– Ureteric dilation and caliectasis
– Opacity vaginal before post void image
– May need oblique or lateral view
• Cystoscopy + Cystogram
– Rule out coexisting VVF
219.
220.
221.
222. Goal of tx
• Preserve renal fx
• Prevent urosepsis
• Resolution of urine leakage
• Management
– Grade I-II injury: placement of ureteral stent / PCN
– Grade III-V: operative treatment
• So drainage the upper tract
– Retrograde stenting if possible
– Antegrade nephrostomy
• Conservative:
– Retrograde stenting
– Observe for spontaneous resolution
223. Timing of repair
• Traditional:
– If dx within few days of injury immediate
repair
– If dx btw 7-14 days delay repair in 3m after
all infection and inflammation settle (7-14 days
is the time of maximal edema and
inflammation )
– If delay need drainage
• Now: earlier repair also gives good result
– Patient can sustain another GA
– But must drain urinoma
– Control sepsis and treat infection
224. Principle of ureteric reconstruction
• Direct uretero-ureterostomy whenever possible
1. Mobilization of ureter with preserving adventitia
2. Debridement of non-viable tissue
3. Spatulation
4. Tension free mucosa-to-mucosa anastomosis
with fine absorbale suture
5. Internal ureteric stent & drain near anastomosis
6. Omental interposition to separate repair from
associated intra-abd injury or suture line
7. Foley to drain bladder to prevent reflus
225. Surgery
• Surgical repair
– When stenting not possible
– No spontaneous resolution
• Partial transaction:
– Primary closure over a stent
– Place drain at site of repair
• Primary ureteroureterostomy:
– Repair with principle over stent
– Directly or together with poas hitch or Boari flap
• If defect too long:
– Autotransplantation of kidney into pelvis
– Ileal interposition
– Permanent PCN
– Nephrectomy
226. Psoas Hitch (Turner-Warwick and Worth 1969)
• Bladder filled with 200-300ml water
• making an incision in the bladder that lies at right angles to the long axis of the
ureter, and this incision is opened out in the same axis as the ureter
• essentially lengthens the bladder, allowing it to reach the ureter, which can be
anastomsed to the bladder without tension.
• Place two stay sutures on either side of the planned incision As the incision is
made, intermittently pull the stay suture apart until you have produced an incision
that is long enough to breach the defect.
• Divide the contralateral superior vesical vessels
• Psoas hitch will need to reach well above the iliac vessels so that it can be
anchored to the psoas minor tendon (take tension off the anastomosis)
• Do not tie the Hitch stitch before uretero-neocystostomy
• Create a hole or a tunnel through which the ureter will be anastomosed to the
bladder.
• Draw the ureter through the tunnel in the bladder
• Uretero-neocystostomy (refluxing [LP] or non-refluxing fashion) over stent
• Close the bladder defect
• Drain outside closure
• Foley for 2 weeks
227.
228. Boari Flap
• Bladder filled with 200-300ml water
• Place suture in inflated bladder around edge of flap
• To bridge a 10-15cm defect
• Base >4cm, ~4x wider than the width of ureter
• Length to base ratio: <3:1
• Fold the flap backward
• Transverse incision to gain more length
• Extra 3cm is need if need a non-refluxing anastomosis
• Anastomosis & close the bladder over stent
• SPC + foley
• Drain
• Foley remove on day 2
• SPC removed on Day 14 after cystogram
229.
230. Transureteroureterostomy
• damaged ureter is swung over to the normal
ureter and the two are anastomosed together
• 1st
check recipient ureter is not injured (RP)
• just above the pelvic brim the ureters are the
closest together (6cm)
• Cut ureter brought to the other side above or
below IMA
• If below watch out for kinking
• Anastomsis in usual way
231.
232. Ileal interposition
• Cases of long segment ureteral destruction
• Should be avoided in patients with GI disease (eg. Crohn’s
• disease) or impaired RFT
• 25cm length of ileum ~20cm proximal to ileocaecal valve
• Ileal segment placed in isoperistaltic orientation
• PCN inserted into ipsilateral kidney to decompress affected kidney
• External, non-suction drains cover both proximal and distal
anastomoses
• Reconstruction wrapped in omentum
• AP after 3 weeks, if no leakage, PCN clamped and reoved
• Urethral catheter removed
233. Surgery: Bill
• According to Bill both PH & BF can reach at most
up to the level of pelvic brim & TUU could not do much
better
• Depend on level of injury
• Above pelvic brim:
• TUU (not better than PH or BF)
• Ileal interposition
• Autotransplantation
• Below pelvic brim
– Uretero-neocystostomy :direct reimplantation
• Should be done at post-lat wall lower down : most immobile part
– Psoas hitch
– Boari Flap: it achieve to same level as PH
– TUU (block by IMA)
235. Special situation
• When a ureter has been injured in a patient who
has under gone a vascular graft procedure, e.g.,
an aortobifemoral graft
• Traditional teaching advocated nephrectomy
because of the potential for graft infection as a
consequence of infection of urine which might
leak from the site of a ureteric anastomosis.
• But renal failure is a major cause of morbidity
after graft surgery
• Thus now the trend is to perform repair &
nephrectomy only in case where urine leakage
detected post-op
236. KUBKUB
• A. What condition is shown on this X-ray?
• B. What is the radiological feature?
• C. What are the causes?
240. What is urehtral diverticulum?What is urehtral diverticulum?
• Blind end sac arising from urethra with transitional cell epithelium
• More common in female with an incidence of 5%
• Causes
– Congenital urethral duplication
– Infection of paraurethral glands (distal 2/3 of urethra)
– Urethral trauma during childbirth
– Mesonephric remnant
• Typical presentation includes the 3 D’s : dysuria, dyspareunia and
dribbling/discharge
• P/E: palpable suburethral mass upon vaginal examination
• Long term complications include stone formation (1-10%), malignancy (very
rare)
• Most common adenoCa, then SCC and TCC
241. What is the name of this device? (1)
What is it used to look for? (2)
Q42
242. • Double-balloon catheter for use during
positive pressure urethrography (1)
• Urethral diverticulum (2)
244. 50/F with LUTS. MRI pelvis shown focusing on her
urethra.
Is this a T1 or a T2 weighted image? (1)
Diagnosis? (2)
Name 2 complications from its corrective surgery (2)
Q43
245. • T2-weighted axial MRI image (water is bright) – gold standard
– Other Ix: positive pressure urethrography
• Complex urethral diverticulum with a stone inside
• Treatment
– Surgical excision of diverticulum
– Urethra repaired over 16F foleycatheter
– Martius fat pad
– Urethrography at 3 weeks
• Complications: Urinary incontinence, urethrovaginal fistula,
recurrence of diverticulum
246. UD tracing of a patient. A special technique is
demonstrated in this UD
What is the technique? (2)
What is the purpose of this technique? (2)
247. • Stop test (2)
• The Pdet iso demonstrated gives some idea
about detrusor contractility (2)
248. Stop Test
• Assessment of detrusor contractility during urodynamic
study
• Once the patient is voiding and when the observer judges
that Qmax has been reached, the patient is asked to stop
voiding.
• Contraction of the pelvic floor and intrinsic striated muscle
of the urethra, but detrusor is not immediately inhibited and
continues to contract. Isovolumetric contraction Pdet
increases sharply to a new maximum
• After 2 s to 5 s, the patient is asked to continue voiding
• The height of the increase in Pdet is known as the “Pdet
iso” and gives some idea of detrusor contractility.
• This test can be performed only if the patient is able to
interrupt flow instantaneously.
250. Irradiation cystitis
• The longer the patient survive from the
irradiation, the higher chance to suffer from
irradiation cystitis
• Irreversible: increase frequency and severity of
hematuria
• Treatment
– No well documented treatment
– Embolisation
– Surgery in severe cases requiring repeated blood
transfusion
251. Hemorrhagic cystitisHemorrhagic cystitis
• Clot irrigation and catheter drainage
• Continuous bladder irrigation
• Cystosocopy and diathermy
• Alum instillation
• Premarin
• Hyperbaric oxygen
– (70% will benefit from a course of 30 treatments
of HBO)
253. What is urethral syndrome?
• A condition of uncertain etiology that only affects
women
• Presentation: Dysuria , frequency , urgency , SP
discomfort without evidence of infection or uro
abnormality
• DDX: infection , PBS/IC, Urethral diverticulum
• Mx:
– Urethral and endocervial swab for C/ST to exclude STD
– MSU
– Cystoscopy : rule out IC
– Urethrography to rule out diverticulum
• Txn: course of antibiotic for symptom relief
255. MCQ ?T/F
• Regarding Fowler’s syndrome,
1. Typical presentation is dysuria and
frequency
2. EMG is usually abnormal
3. It is associated with polycystic ovaries
4. Neurological examination frequently
identifies subtle deficitis
5. Reported response to SNM has been
poor
256. • F – typical presentation is female of 20-30 years
with AUR
• T - EMG is abnormal needle electromyographic
signals containing both complex repetitive
discharges (sounding like a helicopter or
machine gun fire) anddecelerating bursts
(reminiscent of whale song)
• T – 50% have polycystic ovaries on USG
• F – Usually normal neurologically
• F – response is good with SNM
259. • First described by Prof Clare J Fowler in 1985
• F/ 20-30, present with painless urinary
retention
• 50% associated w/ polycystic ovary syndrome,
ppt factors include gynaecological / other
surgical procedure
• P/E: Normal neurologically. Thickened urethral
sphincter (palpation, TVS)
• During CISC -> tight gripping sensation on
withdrawal of catheter,
Fowler’s Syndrome
260. Fowler’s Syndrome
• EMG findings: both complex repetitive
discharges and decelerating bursts ->
sounds like myotonia -> ephaptic
transmission -> due to failure of relaxation
-> via audio output: reminiscence of whale’s
song
• Example of complex repetitive discharges
• Complex repetitive discharges + Decelerating Bursts
(Sounds like underwater whales)
• More Complex Discharges with background of
decelerating Bursts
• Clearer Decelerating Bursts
261. Fowler’s Syndrome
• Pathogenesis: hormonal associated channelopathy
leading to overactivity of urethral sphincter
• Treatment: poor response to alpha blocker and
botulinum toxin
• Sacral neuromodulation (SNM): afferent
neuromodulation w/ unknown mode of action.
Response: >50% symptoms improvement achieved
in 33-100% of patients. LT FU up to 10 years is a/v.
Good safety profile.
• *2 stage implant vs test implant; *unilateral vs bilateral
262.
263. Ketamin cystitis
• Ketamin: N-methyl-D-aspartate (NMDA)
receptor antagonist
• 1965, first used in humans
• analgesia & dissociative anaesthesia,
provides amnesia to pain
• Rapid onset, short duration of action &
titratable
• Does not depress cardiovascular and
respiratory sys
264. • Illegal drug use
• ‘out of body’ / ‘near death’ feeling
Presentation
• frequency, urgency, dysuria, urge incontinence, painful
• haematuria
• urine culture –ve
• no response to multiple courses of oral antibiotics by GP
Investigation:
• Pelvic pain and frequency/ urgency score (PUF score) > 15
• VUD:
– DO
– Bilateral VUR
– Decrease MCC: < 150ml
– Poor compliance
• FC:
– Mucosal inflammation + glomerulation
• Obstructive uropathy : increase Cr
• USG: bilateral hydronephrosis
• CT: Acute papillary necrosis, LN, thickened ureteric wall
269. What are risk factors in men?
• Age
• LUTS
• UTI
• Functional and cognitive impairment
• Neurological disorders
• Prostatectomy
270. What is the important step of initial
assessment?
• Triage patients with a ‘complicated’
incontinence
– Pain
– Haematuria
– Recurrent infection
– Previous failed incontinence surgery
– Previous pelvic radiotherapy
271. What are the four main groups of
urinary incontinence in men?
• Post-micturition dribble alone
• OAB symptoms: urgency (with or without
urge incontinence, frequency and nocturia
• Stress incontinence, most often after
prostatectomy
• Mixed urgency and stress incontinence,
most often after prostatectomy
272. What is the management approach of post-
micturition dribble ?
• No further assessment is generally
required
• Exert a strong pelvic floor muscle
contraction after voiding or to manually
compress the bulbous urethra directly after
micturition (urethral milking)
273. What are the recommendations of
urinary incontinence in men?
275. What is the treatment approach if failed
above management?
• Sphincter incompetence artificial urinary
sphincter, male sling is alternative
• Intractable OAB symptoms
– Surgical bladder augmentation with intestinal
segments
– Implantation of a neuromodulator
• Detrusor injections with botulinum toxin continue to
show promise in the treatment of symptomatic
detrusor overactivity unresponsive to other therapies
-‘off-label’
• If incontinence is associated with poor bladder
emptying due to detrusor underactivity CIC
276. What are the definitions of post-RP
continence?
• Total control without any pad or leakage
• No pad but loss of few drops of urine
(‘underwear staining’)
• None or 1 pad (‘safety pad’) per day
279. • Evaluation and diagnosis should be performed
• Validated questionnaires should be used to assess symptoms and
impact on quality of life.
• Before surgical treatment, patients should be evaluated with
urethrocystoscopy and urodynamics.
• AMS 800 artificial urethral sphincter is still consider the gold stand for
Post prostatectomy incontinence SUI in men with success rate of > 90%
• Preoperative pelvic floor muscle training (PFMT) may be useful in
increasing early postoperative continence rates. PFMT is also of benefit
in men with persisting SUI >1 yr after surgery.
• Conservative treatment fails after a period of at least 6–12 mo
surgical therapy is recommended.
• Male slings show promising results in patients with persistent mild to
moderate SUI.
• Bulking agents should only be used in highly selected patients due to the
low success rate.
• Due to early high complication rates of the adjustable balloon system,
more data are required for an evidence-based recommendation.
• Currently, stem cell therapy should not be applied.
280. What is interventional treatment for
post-RP incontinence?
• Preop Ix – MSU, FC and VCMG
• Success rates for AUS AMS 800 range 90% (dry or improved)
[Montague]
– Perineal approach better continence rate as compared to
penoscrotal approach (Henry)
– Higher revision rate after radiotherapy , due to a higher
incidence of erosion and infection, possibly caused by
urethral atrophy from radiation-induced vasculitis
– Complications: urethral atrophy – (commonest cause for
revision), cuff erosion (revision), persistent leakage (if DI >
anticholinergic), mechanical failure (revision), reoperation
-10%
281. What other interventional treatment
for post-RP incontinence?
• Male sling - overall minimum success is 60%,
– Mild-to-moderate leakage of urine (1-3 ppd or <500 g/24 hr pad wt),
normal sphincter on urethroscopy, no RT or >6 months post-RT
– Advance™ Sling - Transobturator approach, divide bulbospongiosus
muscle, cut central tendon, repositions bulbomembranous urethra
proximally
• Bulking agents - Macroplastique
– Less effective
– The early failure rate is about 50%
– Beneficial effects decrease with time
• The implantation of compressive adjustable balloon is a new
treatment option – more evidence needed
282.
283. Comparison of sling
InVance Sling:
• Non adjustable bone-
anchoring sling system
• Perineal incision position
under bulbar urethra
• Longest FU 4yr: Pad free 50%
• SE: perineal pain, bone anchor
dislodgement , infection
• If failed AMS
AdVance sling:
• Relocate lax and descended
posterior urethra & sphincter
back to the pre-op position
• Need good mobility of the
sphincter region with 1cm
copative zone
• Dry rate up to 70%(50% with
RT)
• SE: infection , perienal pain ,
explantation rate low
• If failed: consider 2nd
AdVance
sling or AMS
284. Q.
• This film is of a woman with a congenital
thoracolumbar abnormality who underwent
surgery as a child.
285.
286. Q.
• A. What operation was performed?
• B. What was the likely presenting symptom?
287. Q.AUS
• A. AUS (1)
– Usually inserted at bulbous urethra in male
– Deactivate for 6-8week for healing after insertion
– Antibiotic prophylaxis required for dental treatment
• Continence rates 80%
• Expensive
• B. Incontinence
288. AUS: AMS 800
• 3 component:
– Urethral cuff (BN (F) or bulbous urethra (M))
– Scrotal / labial control pump
– Reservoir (preperitoneal retropubic space)
• Indications:
– Post –RRP
– Neuropathic patient with ISD
– Trauma to perineum and pelvis