Overview of Surgical Management of SUI:

Sling Selection, Outcomes, and Adverse Events

Eric S. Rovner, M.D.Professor of UrologyMedical University of South CarolinaCharleston, South Carolina

Treatment Options for SUI

• WAWA• Behavior

– Pelvic floor exercises

• Drugs???• Pessary/Devices

• Surgical repair– Bulking agents

             

Prepubic sling

Which one ??Which one ??IF ALL WERE EQUIVALENT:IF ALL WERE EQUIVALENT:

-experience of surgeon-experience of surgeon

-patient factors:-patient factors:-wishes and willingness to accept risks-wishes and willingness to accept risks

-other: convalescence, pain, etc-other: convalescence, pain, etc

BUT ALAS THEY ARE NOT ALL EQUIVALENT:BUT ALAS THEY ARE NOT ALL EQUIVALENT:

-Operations are not……..-Operations are not……..

-efficacy, durability, recovery, etc.-efficacy, durability, recovery, etc.

-Patients are not………...-Patients are not………...

-types of SUI, anatomy, prior surgery, etc.-types of SUI, anatomy, prior surgery, etc.

“I leak when I cough”

Autologous Fascial Sling*Courtesy of Jerry G. Blaivas, MD

Algorithm for surgical treatment of SUI*:

SURGERY for SUI SURGERY for SUI 19951995• Injectables (collagen)• Abdominal (retropubic) suspensions

-Burch

-MMK-Richardson-etc.

• Vaginal-Needle suspensions (Raz, etc.)-Slings: fascia, synthetics, vaginal wall sling-Anterior colporraphy (Kelly plication)

+/- Laparoscopy

Surgery for SUI: 2011• Midurethral Tapes

– Transvaginal (TVT, etc.)• “Minislings”

– Suprapubic• Commercial (SPARC, Uretex, etc.)• Non-commercial “home made” versions

– Raz ($10 TVT)– Rackley (PVT)

– Transobturator• Outside in/Inside out

• Injectables: Contigen, Durasphere, Macroplastique, Coaptite, etc• RP suspensions: Burch , etc.• Slings (bladder neck)

xNeedle BNSAnterior repair (Kelly)

ESR Operations to treat SUI (in 2011)

• Retropubic suspension (rarely)

• Injectables

• Autologous pubovaginal slings

• Vaginal tapes– Transobturator (outside in)– Retropubic

Why Not One Surgery for Everybody w/SUI?Patient variables in selecting surgery

• Prior failed SUI surgery– Erosion, extrusion, BOO, etc.– Retropubic (Burch, MMK, etc.)

• Physical examination– Anterior vaginal wall/urethral mobility– Prolapse– “extreme” habitus

• Urodynamics– Intrinsic urethral function (ISD)

• Urethral “disease”– Diverticulum, fistula, etc.

• Patient disease/morbidity– +/- vaginal atrophy (XRT, etc.)– Steroids– Immune status– Diabetes– Other

SUI Surgery 2011

• Midurethral synthetic sling is a good choice……

EXCEPT……

SUI Exceptions

• Urethral diverticulum • Urethrovaginal fistula• Other urethral pathology (stricture)• Severe irreversible atrophy or XRT

Autologous pubovaginal sling

Other exceptions

• Unwilling or unable to have surgery:– Injectable

• Other RP surgery (w/o ISD) or can’t do lithotomy:– Burch

So, who gets which MUS?

• Midurethral sling– TOT– Retropubic– Mini-sling

transobturator vs. retropubic sling

Do they work equally well for ISD????

-Low VLPP?

-Poor urethral mobility?

Are they equally safe/effective in redo cases?

-prior RP anti-incontinence surgery

Choice of Surgery for SUI

IdeallyIdeally…..– Evidence based

• Prospective, RCT’s– Equivalent inclusion/exclusion criteria

– Uniform patient population for each subpopulation with SUI

» Urodynamics, mobility, habitus, prior surgery, etc.

– Factors:• Efficacy, durability, cost, safety, convalescence, etc.

Choice of Surgery for SUI

Reality…….Reality……. – Non-evidenced based

• Poor quality literature

– Commercial bias

– Mostly anecdotal

– Surgeon “preference”

AUA SUI Guidelines Update

Reviewed SUI literature since last Guidelines and updated the document

Dmochowski, et al, JU 183:1906, 2010

AUA SUI Guidelines Update 2010

Literature search 1994-2005*

436 papers suitable for efficacy/safety outcomes

155 papers only complications data usable

Index patient: healthy female +/- prolapse willing to undergo surgical correction of SUI

*AUA Best Practices update coming to include TOT

TOMUS

N= 597 randomized to TOT or retropubic MUSRetropubic MUS= TVT (Gynecare)

TOT= Monarc (AMS) or TVT-O (Gynecare)

OutcomesObjective criteria

Negative CST, negative 24 hour pad test, no re-Tx

Subjective criteriaNo sx’s SUI, negative 3 d diary, no re-Tx

Adverse events

Null hypothesis: no difference = <12% between groups

Success

Objective success81% RP

78% TOT

Subjective success62% RP

56% TOT

“I am not certain why humans or animals are continent of urine and feces and I am not convinced that anyone really knows.”

–J. Berry, 1961(Berry Prosthesis)

Rx of Urinary Incontinence

Continence= urethral closure forces > bladder expulsion forces

Bladder

Urethra

All therapies either All therapies either ↑ urethral or ↓ bladder forces↑ urethral or ↓ bladder forces

Rovners algorithm for SUI Surgery

• This is my approach– Mostly NON-EVIDENCE-BASED*

• Literature can be cited where available

*to the extent of the quality of evidence in the literature to support any approach

Rovner’s Algorithm Assumptions:

• Patient is “index” patient– Has SUI, is healthy, desires surgical Rx, etc.

– No XRT/fistula/UD

– Can get into lithotomy position

• Patient willing to have any approach

• Surgeon equally skilled in all approaches

• No prolapse > Stage II

• No detrusor abnormalities– Compliance, etc.

Index patient w/ SUI

Prior surgery?Yes No

Obstructed? NoYes

Urethrolysis +/- PVS

Mobility?Yes No

Prior RP surgery?

Yes

No

TOTLow “pressure”

urethra?

Yes

PVS (+/- RP UT)

No

TOT, or RP UT or PVS

Urethrolysis +/- PVS (or RP UT)

Index patient w/ SUI

Prior surgery?Yes No

Mobility?Yes

Yes

No

No RP UT (+/- PVS)

Low “pressure” urethra?

RP UT Or TOT

RP UT (+/- PVS)

Hooray !!!!!

!!

The “perfect” therapy for SUI*• Effective (high immediate success rate)• Durable • Simple, fast and easy to perform (reproducible)• Applicable for ALL types of SUI

– And all patients with SUI (primary and redo cases, body habitus, etc.)

• For Surgery: minimally invasive – Local (or no) anesthesia– Small (or no) incisions– Outpatient procedure– Short convalescence and return to normal activities– Minimal (or no) pain

• Low (or no) morbidity and complications• Inexpensive: patient, healthcare facility, healthcare system, etc

*theoretical

The Perfect Result (“Cure”)

• Dry (pad test, per patient, PE, etc)• Resolution of all voiding sx’s• No new voiding symptoms• No pain• Minimal utilization of resources

– eg, cost, convalescence, LOS, etc

• Patient is ecstatic (QoL, questionnaire, etc)• No complications

– eg, fistula, prolapse, dyspareunia, UTIs, etc

Permanently