th 13 Turkish Ob/Gyn Annual meeting Antalya - 2015 Decision making with the USI patient Neuman Menahem Urogynecology Service, Western Galilee MC, Nahariya, the Faculty of medicine, Bar -Ilan University, Safed, Israel. Disclosure: Menahem Neuman is consultant for Serag-Wiessner.
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 predominance • Combined • Others Menahem Neuman
Decision making with the USI patient • 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? 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. Menahem Neuman
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
The Mid-Urethra Concept Pubo-urethral ligaments Zacharin 1968, De. Lancey 1994 Menahem Neuman
The Mid-Urethra Concept Functional Aspects Maximal 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 Menahem Neuman
TVT Menahem Neuman
Menahem Neuman
SUI treatment evolvement: TVT-O Over 150 papers 3% of P/O BOO Thigh pain – 30% Bladder & Urethral injuries, Field infection, Bleeding Menahem Neuman
Menahem Neuman
Is TVT better than TVT-O? Menahem Neuman Novara et al. Eur Urol, 2010
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
Turkish-Israeli Urogyne Meeting. Jerusalem - 2015 7 years after anti-incontinence mini Mid-Urethral Sling (MUS) procedure: Patient’s own perspective and follow-up data Eran Schreter and Menahem Neuman
7 years after mini MUS 33% had recurrence of r. USI, mostly after 5 years.
Decision making with the USI patient 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 Menahem Neuman
Decision making with the USI patient 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 Menahem Neuman
Decision making with the USI patient 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 Menahem Neuman
Decision making with the USI patient Management of recurrent stress urinary incontinence in the US Neurourol Urodyn. 2015 , Zimmern • 6% of women with r. USI were retreated within 5 years, mostly with injection therapy or autologous fascial sling Menahem Neuman
Decision making with the USI patient The surgical management of r. USI: 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. Menahem Neuman
Decision making with the USI patient Surgical treatment of r. USI: 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. Menahem Neuman
Decision making with the USI patient Results of primary versus recurrent surgery to treat stress urinary incontinence in women Int Urogynecol J. 2015 , Heesakkers Recurrent surgery to treat r. SUI 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 Menahem Neuman
Turkish-Israeli Urogyne Jerusalem Meeting - 2015 Pain reduction after Anti Incontinence operation with medial needle trajectory & a shortened sub mid urethral sling implant Gilad Reut and Neuman Menahem Neuman
Pain reduction after TVT-A Ø Needle trajectory medially remote according with FF (IUJ 2012) Ø A Trans - Obturator sub mid urethral short sling implant (12 Cm, TVT-Abbrevo, J&J)
Pain reduction after TVT-A 102 Pts were included: Ø Early P/O thigh pain: 6 Pts (6%), all mild. Ø At 3 Yrs: Ø Chronic pain: 5 Pts – all mild Ø OAB : 11 Pts (13%) Ø POP: 9 Pts (11%), mild Ø SUI: 2 Pts (2. 5%), mild 14% 12% 10% 8% 6% PAIN 4% OAB 2% POP 0% SUI PAIN Menahem Neuman OAB POP SUI
Decision making with the USI patient Vaginal delivery following TVTS J Obstet Gynaecol Res. 2013, Tommaselli The patient remained continent throughout the gestation and in the following 24 months Menahem Neuman
Decision making with the USI patient 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 %). Menahem Neuman
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 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 Menahem Neuman
Decision making with the USI patient 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 Menahem Neuman
Decision making with the USI patient 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 Menahem Neuman
Decision making with the USI patient 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 Menahem Neuman
Decision making with the USI patient 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 Menahem Neuman
Decision making with the USI patient Impact of incontinence surgery on sexual function: a systematic review J Sex Med. 2012 , Jha Coital incontinence is significantly reduced following continence surgery Menahem Neuman
Decision making with the USI patient 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 Menahem Neuman
Decision making with the USI patient Robotic Burch colpo-suspension Int Urogynecol J. 2015 Francis Robotic Burch colpo-suspension can be completed in a safe and effective Why? Menahem Neuman
Decision making with the USI patient Low-cost TVTO for the treatment of USI using ordinary polypropylene mesh Int Urogynecol J. 2015 El. Shenoufy 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 Menahem Neuman
Decision making with the USI patient 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 Menahem Neuman
My own choice of Anti-incontinence operations: TOT, inside out TVT-RP for r. USI & ISD SIMUS (Mini sling) when vaginal wall tissue is poor Para urethral injectables – for the very friable Pts Menahem Neuman
mneuman@netvision. net. il Menahem Neuman
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