decision making with the usi patient neuman menahem 13 th turkish ob/gyn annual meeting antalya -...

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

Menahem Neuman

mneuman@netvision.net.il