Urinary incontinence and Urinary incontinence and female urologyfemale urology

Edmond

Outline

• Urinary incontinence• Urodynamics• OAB• Stress urinary incontinence• Interstitial cystitis• Prolapse• Urethral diverticulum• VVF• Augmentation cystoplasty

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)

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%

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

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

Pathophysiology

• An interaction between bladder and sphincter• Bladder abnoramlities:

– Detrussor overactivity (idiopathetic, neurogenic) – Low bladder compliance

• SCI, interstitial cysitis, radiation cysititis, hysterectomy

• Sphincter abnormalities: – Extrinsic: Urethral hypermobility

• Weakness of pelvic floor muscle (urethral support)

– Intrinsic: Intrinsic sphincter deficiencey (ISD)• Urethral masculature , blood flow ,innervation

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

Anatomy

• Urethra– Sphincter

• Striated muscle – voluntary

– Male• 15-20 cm• Prostatic, Membranous, anterior

Anatomy

• Urethra– Female

• 3-4 cm – muscular, short tube

• Striated Sphincter– Poorly defined outer

circular layer– Longitudinal layer

shortens with voiding

• Submucosal vasculature—rich vascular plexus

– Forms a seal at rest

• Squamous epithelium – distal urethra

– Sensitive to estrogen

Neurologic

• Sympathetic – Hypogastric Nerve– T10-L2– Forms the pelvic plexus with the

parasympathetics– Beta vs Alpha

• Parsympathetic – Pelvic Nerve– S2-S4– Detrusor contraction, Bladder neck, Levator ani

Neurologic

• Somatic– Pudendal Nerve

– S2-S4 Onuf’s nuclus (anterior horn)– Striated sphincter, anterior levators, superficial perineal

muscles

– Pontine micturation center– Receives cortical input from frontal lobes – inhibitory– Afferent stretch input from detrusor– Cerebellar input for coordinated voiding

– Sacral mictruation center– Communicates with pons for the mictruation reflex

– Lesions

Risk factor for urinary incontinence

1. White race2. Age: menopause (50)3. Female4. Childbirth: particularly vaginal5. General: smoking, caffeine, obesity, poor mobility6. Fluid intake7. Infection (UTI)8. DM9. Pelvic , perineal and prostate surgery10.RT11.Neurological disease: CVA, Parkinsonism, MS, SCI 12.Anatomoical disorder: VVF, ectopic ureter, urethral

diverticulum13.Medication

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

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)

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

Urodynamics study

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

Advantage of video-UDS?

• Better evaluation of bladder neck descent & urethra

• Quantifying anterior wall prolapse more accurately

UrodynamicsGoals

• 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

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

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

Interpretation

Trace: • Pves• Pabd• Pdet• Pdet = Pabd – Pves• Volume infuse• Volume rate :

50ml/min

Quality control: • Baseline pressure:

Pdet 0-6cmH20• Coughing : good

subtraction and biphasic waveform on Pdet

• Any artefacts?

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

UrodynamicsUrinary 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 >2240–60 >18>60 >13

Females <50 >25>50 >18

UrodynamicsCystometrography

• Graphic measure of bladder pressure during filling

• To assess:– Detrusor activity– Sensation– Capacity– Compliance

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

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

UrodynamicsLeak 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

UrodynamicsVoiding cystourethrography

• Site of bladder outlet obstruction

• Integrity of sphincter mechanism

• Presence of Vesicoureteral reflux

• Presence of bladder/urethral diverticulum

• Presence of bladder wall trabeculations

UrodynamicsSphincter 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%

Tracing of an investigation from 2 different individuals What is this investigation? (2) What is shown in each tracing? (2)

Q67

• 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)

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

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

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

Urinary incontinence in femaleUrinary incontinence in female

History1. Type of incontinence (stress, urge, mix)2. Onset? Duration ? Progression ?3. Frequency and severity of symptom4. Associated LUTS (storage or voiding) 5. Bowel function6. Pad use & QOLs7. Drinking habit8. 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 , Antidepressant10. Smoking & alcohol history11. Int’l Consultation of Incontinence Questionnaire – short form (ICIQ-

SF)12. Previous treatment , desire for further txn & expectation

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 reflex5. Lower limb neurological exam6. Assess voluntary pelvic floor muscle function by vaginal or rectal

examination before teaching pelvic floor muscle training (PFMT)

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

What are the investigation?1. Urine test (C/ST, cyto)2. FRRU3. 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 features6. Symptoms scores**:

• Bristol Female LUTS-SF• ICIQ-UISF (4Q: When/How often/much/border you leak?)• Pelvic floor impact questionnaire• QoL: Kings’ Healthcare questionnaire

Voiding Diary• Gives typical urinary habits

– Clinical setting : difficult to communicate and urinate• Record: (24-72 hours)

– Fluid intake, physical activity – Frequency– Void volume– Incontinence episode & associated trigger

• Estimates– 24 hour urine volume– Voiding frequency– Nocturia– Functional bladder capacity

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

Urinary incontinenceTurner-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

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 Urethralhypermobility

≤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

Stress IncontinenceClassification

• 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

Stress IncontinenceClassification

• 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

Stress IncontinenceClassification

• Type IIA– Bladder neck and

urethra open and descend during stress

– Descent greater then 2 cm

– Evidence of cystocele

Stress IncontinenceClassification

• Type IIB– Bladder neck and

urethra closed and below the symphysis pubis at rest

– May or may not descend during stress, but urethra opens

Stress IncontinenceClassification

• Type III: ISD– Bladder neck and

uretha open at rest– Occurs in the absence

of detrusor contraction

What is the name of this classification? (1) What is it used to quantify? (1)

• Pelvic Organ Prolapse Quantification (POPQ) classification (1)

• To quantitatively describe the severity of pelvic organ prolapse – Presentation: prolapsed pelvic organ with obstructive voiding pattern

ICS Pelvic Organ Prolapse Quantification (POPQ)

0IIIIIIIVSTAGE

Vaginal ProlapseClassification

• 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.

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

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%

Theories for development of SUITheories for development of SUI

1. What is urethral position 1. 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

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

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

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

Hammock Theory

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

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

What is the treatment upon different theories?

TheoryTheory Treatment Treatment Change of Change of Urethrovesical Urethrovesical angle/ angle/ hypermobilityhypermobility

(Kelly, Boney, (Kelly, Boney, Enhorning)Enhorning)

Retropubic Retropubic suspension/ suspension/ Kelley PlicationKelley Plication

ISDISD Bulking agent Bulking agent injectioninjection

Hammock TheoryHammock Theory Mid-urethral SlingMid-urethral Sling

Integral TheoryIntegral Theory Mid-urethral slingMid-urethral sling

Treatment of stress urinary Treatment of stress urinary incontinenceincontinence

What are the treatment options of stress What 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

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

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

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

What is this device? (1) What is it used for? (2)

Q50

• Vaginal cone / vaginal weighted cones (1)

• A form of biofeedback for patients in pelvic floor muscle training (2)

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

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)

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]

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

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

Bulking agentBulking agent

What is Bulking agent ?What is Bulking agent ?• Indications:

1. ISD - VLPP < 60 cmH2O 2. high risk , elderly patients3. 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

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

Pubovaginal slingPubovaginal sling

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

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

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

Mid-urethral slingMid-urethral sling

Q. Equipment

• A. What condition is this piece of equipment used to treat?

• B. What material is implanted?

Q.

• A. Urodynamic stress urinary incontinence (1)

• B. Tension free vaginal tape made of prolene mesh (1)

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 stress2. 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

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

What are the contra-indications for MUS?

1. Urethrovaginal fistula

2. Urethral diverticulum

3. Intra-operative urethral injury

4. Untreated urinary malignancy

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)

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

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

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

Who are the suitable candidates for TOT? Where suprapubic route is not preferred• Transplant • Neobladder• Obese patients• Multiple prior retropubic surgery• Patient’s choice

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

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

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

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

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%

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

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

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

TOT vs TVTO

• no difference btw the two TOT (i.e TVT-O and Monarc)

• 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

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

Complications (30%)• Intraoperative:

– Bladder perforation (3%)– Urethral injury (0.5%)– Major vessel injury (1%), bleeding hematoma– Nerve injury (0.5%)– Bowel injury

• Early post-operative: – AROU (lossen tape within 2 week) (10%)– Infection (10%), necrotizing fascitis– Groin pain

• Chronic: – Voiding dysfunction (30%)– Denovo urgency (5%)– Vaginal erosion (1%)– Bladder/ urethral erosion– Pelvic pain/dyspareunia

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

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%

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

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

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)

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

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

Retropubic suspension surgery

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

Indications & contraindications

• Indications: 1. Significant urethral hypermobility 2. failed suburethral sling or conservative mx3. 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

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

What are the complications of colposuspension?

1. Retropubic hemorrhage 2. Infection , recurrent cystitis (1%)3. Bladder injury4. Enterocele / rectocele (bladder moved ant more

space at posterior) 5. Voiding dysfunction AROU6. De-novo Urgency 7. Dyspareunia• Less bladder injury by more re-operations than TVT

Marshall-Marchetti-Krantz Marshall-Marchetti-Krantz (MMK) procedure(MMK) procedure

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

• Osteitis Pubis• X-ray show hazy

border of symphysis with possible lytic lesion

Overactive bladder syndromeOveractive bladder syndrome

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)

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

Risk factors for OAB?

1. Increasing age2. Female sex3. Obesity4. Impaired functional status5. Depression6. Recurrent UTI7. DM8. Neurological disorder9. Post-surgery for stress incontinence10.Bladder symptom in childhood

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?

What test?

• Basic blood test

• Urine : Dipstick and culture

• FR + RU

• Bladder diary

• If suprapubic pain or hematuria USG & FC

Investigation

1. Validated questionnaires– ICIQ -SF(Abram, ICS )

2. Bladder diary1. Volume of fluid intake2. Incontinence episode3. Number of pad use4. Urinary frequency5. Void urine volume (functional bladder capacity)

Differential diagnosis?

Urological:• Detrussor overactivity• UTI• Urethral syndrome• Urethral diverticulum• IC• Ca bladder

Gyn: • Cystocele• Pelvic mass• Vaginitis• Urethritis• Urethral caruncle• Atrophy

Differential diagnosis?

Medical: • Upper motor neuron

lesion• DM

General: • Excessive fluid intake• Caffeine• Pregnancy• Anxiety

Need UDS diagnosis ?Need UDS diagnosis ?• No1. 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

What is the treatment ladder for What is the treatment ladder for OAB?OAB?1. Lifestyle modification:

– Decrease caffeinated drinks– Stop smoking– Weight loss [PRIDE study]

2. Bladder re-training : 6m3. PFMT : 3 months is recommended4. Pharmacological (efficacy 60%)5. Intravesical instillation therapy6. 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

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)

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

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

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

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)

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

Anticholinergics Side effects: 1. Dry mouth2. Constipation3. Dyspepsia4. Blurred vision5. Drowsiness6. Cognitive & memory

impairment7. Anaphylaxis8. Demnetia9. Cardiac arrhythmias

(prolong QT)

Contraindications:1. MG2. Uncontrolled narrow-

angle glaucoma3. BOO + AROU4. Ulcerative colitis5. Toxic magacolon6. GI obstruction or

atony7. Hypersensitivity to

agent

Tissue Distribution Potential Adverse Events

Muscarinic Receptor Distribution and Muscarinic Receptor Distribution and Potential Adverse Events With Antagonist Potential Adverse Events With Antagonist

UseUse

EyeM3

Decreased lacrimation Decreased accommodationSalivary

glandsM3

Xerostomia (dry mouth)

HeartM2-M3

Cardiovascular

IntestineM2-M3

Constipation

Urinary retention Bladder

M2-M3

• M2 reverses sympathetically-mediated smooth muscle relaxation• M3 causes detrusor contraction

BrainM1-M5

Decreased cognitive functionShort-term memory lossAltered sleep cycle

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

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

Intravesical Botulinum Toxin AIntravesical Botulinum Toxin A

The photo illustrates a type of treatment increasing being used in Urology

How does it work in details? (3)

Q17

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

• 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)

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

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 mostly1. 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)

What is intravesical Botulinum Toxin A?

• Contraindication of Botox:1. Myasthenia Gravis2. Pregnancy3. Breast feeding 4. Bleeding diathesis5. Eaton Lambert Syndrome

• Reported uses in Urology:– OAB: NDO and IDO– (DSD, Chronic prostadynia, retention due to

acontractile bladder)

Meta-analysis: Intravesical botulinum toxin for idiopathic overactive bladder.JUrol2010

Sacral neurostimulationSacral neurostimulation

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

Enterocystoplasty Enterocystoplasty

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

EnterocystoplastyEnterocystoplasty

Contraindications: 1. RT 2. IBD 3. short gut 4. failed to perform CISC 5. significant renal or liver impairment

• Yearly FU: USG /KUB / blood test – R/LFT/VBG/Cl/vit.B12/folate / FC postop 10 years

Long term complications1. 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 deterioration7. 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) anemia9. Perforation (< 1%) : high mortality due to late presentation (25%)10. Demineralization of bone + fracture : acidosis buffered for Ca

What is the treatment for UI in women?

What is the treatment for UI in women?

What are the recommendations for drug therapy?

What are the recommendations for patient care prior to surgery?

Interstitial cystitisInterstitial cystitis

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

What is the pathologenesis?Multifactorial1. Infection2. Mast cell

– Pathognomonic marker– Estrogen augments mast cell secretion

3. Autoimmunity4. Defect of GAG5. Neurogenic inflammation abn sensory activity6. Stress7. Female : Commonest age of onset is in fifth decade

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)

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

What are the types of IC according to What 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

Diagnosis

• History, PE• FVC• FR + RU• Urinanalysis, C/ST• Cytology• KUB• Symptom questionnaire• Pain evaluation

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)

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

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)

IC Oral treatmentIC Oral treatment

1. Pentosanpolysulphate (Elmiron)– 100mg TDS Heparin analogue, 3-6m trial , 30% response

2. Amitryptylline – 75mg QD , effect in 1 week, anticholinergic , antihistamine,

sedatives3. Hydroxyzine

– 25mg nocte, HT antagonist4. NSAID: diclofenac 75mg BD • Cimetidine : 400mg BD , H2 blocker• Dothiapine • Pregabalin

IC Intravesical treatmentIC Intravesical treatment

• Dimethyl sulfoxide (DMSO) 50ml X 50% instillation for 15 mins every 2-4 weeks (response 80%)

• Hyaluronic acid - weekly instillation (response 70%)• Chondroitin sulphate (response 60%)• Heparin 10,000U weekly (response 50%)• Pentosanpolysulphate (Elmiron)

– Work as exogenous GAG layer– response 30%

Genitourinary fistulaGenitourinary fistula

• IVU of a lady who was incontinent of urine 5 days after undergoing a hysterectomy. A cystogram was normal

Incontinence

• What is the diagnosis?– Uretero vaginal fistula

• What are the investigations?

• Give two ways in which the problem could be managed.

VVF : etiology• Traumatic  

– Postsurgical: Abdominal hysterectomy, Vaginal hysterectomy, Anti-incontinence surgery, Anterior vaginal wall prolapse surgery (e.g., colporrhaphy), Vaginal biopsy, Bladder biopsy, endoscopic resection, laser procedures, Other pelvic surgery (e.g., vascular, rectal) 

– External trauma (e.g., penetrating, pelvic fracture, sexual

•  Radiation therapy•  Advanced pelvic malignant disease•  Infectious or inflammatory•  Foreign body (e.g. neglected pessary )

Post hysterectomy VVF

• Iatrogenic bladder injury: 0.5% to 1%• Fistula rate: 0.1 to 0.2%

• Mechanism– Bladder injury pelvic urinoma drained through

vagina vault– Vaginal cuff suture incorporated into bladder tissue

ischemia Tissue necroiss epithelization & fistula

• Risk factors– Prior uterine surgery, endometriosis, pelvic

inflammatory disease, prior irradiation, infection, DM, atherosclerosis

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

• 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)

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

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)

Bill Sir: 2011 tutorial

• Early repair is advocated once sepsis and UTI is settled

• Preparation before repair– Improve RFT (drainage) – Treat sepsis

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

Principle of repair

1. Adequate exposure 2. Debridement of devitalized tissue3. Removal of foreign body or synthetic material4. Anatomic separation of involved organ cavities5. Watertight closure6. Multilayer closure7. Tension free non overlapping suture lines8. Well vascularized flap9. Adequate urine drainge10. Maintain hemostasis11. Avoid infection

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

What is the principle of surgical What 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

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)

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 used2. 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

• 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

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

Vaginal repair

• Create vaginal flap

• Dissection of tract

• Excise tract or not excise tract

• 3 layers closure– Bladder– Perivesicle– vaginal

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

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

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 artery3. 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

Infundibulopelvic Lig

Cardinal lig

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

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

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

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

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

Principle of ureteric reconstruction

• Direct uretero-ureterostomy whenever possible1. Mobilization of ureter with preserving adventitia2. Debridement of non-viable tissue3. Spatulation4. Tension free mucosa-to-mucosa anastomosis

with fine absorbale suture 5. Internal ureteric stent & drain near anastomosis6. Omental interposition to separate repair from

associated intra-abd injury or suture line7. Foley to drain bladder to prevent reflus

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

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

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

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

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

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)

Post-op

• Off foley day 2

• Stent keep for 6 weeks

• IVU at 3m

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

KUBKUB

• A. What condition is shown on this X-ray?

• B. What is the radiological feature?

• C. What are the causes?

Q5 KUB

• Vesicoenteric fistula

• Air in bladder

• Trauma, malignancy and radiation

Urethral diverticulumUrethral diverticulum

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

What is the name of this device? (1) What is it used to look for? (2)

Q42

• Double-balloon catheter for use during positive pressure urethrography (1)

• Urethral diverticulum (2)

Cystogram in lady with recurrent UTI. Diagnosis?

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

• 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

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)

• Stop test (2)

• The Pdet iso demonstrated gives some idea about detrusor contractility (2)

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.

Hemorrhagic cystitisHemorrhagic cystitis

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

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)

Urethral syndrome

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

Fowler’s syndrome

MCQ ?T/F

• Regarding Fowler’s syndrome,1. Typical presentation is dysuria and

frequency2. EMG is usually abnormal3. It is associated with polycystic ovaries4. Neurological examination frequently

identifies subtle deficitis 5. Reported response to SNM has been

poor

• 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

Causes of BOO in women

Causes of BOO in women

• 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

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

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

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

• Illegal drug use• ‘out of body’ / ‘near death’ feelingPresentation• frequency, urgency, dysuria, urge incontinence, painful • haematuria• urine culture –ve• no response to multiple courses of oral antibiotics by GPInvestigation: • 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

Treatment

• X Antibiotic

• X Antimuscurinic

• X Hyaluronic acid

• Abstinence

• Cystoplasty

Urinary incontinence in menUrinary incontinence in men

What are risk factors in men?

• Age

• LUTS

• UTI

• Functional and cognitive impairment

• Neurological disorders

• Prostatectomy

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

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

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)

What are the recommendations of urinary incontinence in men?

What are recommendations for conservative treatment of UI in men post-RP?

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

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

Post-RP incontinence

• 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.

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%

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

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

Q.

• This film is of a woman with a congenital thoracolumbar abnormality who underwent surgery as a child.

http://www.radswiki.net/main/index.php?title=Image:Artificial-urethral-sphincter-001.jpg

Q.

• A. What operation was performed?

• B. What was the likely presenting symptom?

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

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

• Contraindications: – Poor bladder compliance– Untreated detrussor overactivity– Urethral stricture (AUS infection) – Poor cognitive function

• Preparation: – VUD (bladder compliance & ISD)– FC to exclude stricture– Urine c/st

• Success rate: AMS 800– Deactivation for 6-8 weeks for healing– Complete continent: 75%– Socially dry: 90%– Long term continence: 60%

• Complications:” – Infection– Cuff erosion (usually at 1st 6m)– Urethral atrophy (40%) – Persistent leakage– Mechanical failure– Upper urinary tract damage

• High revision rate– 50% only had original sphincter at 10 years– 30% removed for infection/erosion– 20% late mechanical failure