Decision making with the USI patient

1. 13th Turkish Ob/GynAnnual 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.

2. Diagnosis • Pre treatment consultation • Surgery • Complication • Failure • Follow-up Decision making with the USI patient Menahem Neuman

3. Decision making with the USI patient • Diagnosis • Pre treatment consultation • Surgery • Complication • Failure • Follow-up Menahem Neuman

4. History taking, pelvic exam. • Cystoscopy? US? Cytology? • Urodynamics? Diagnosis Menahem Neuman

5. Urodynamics? • CurrOpin 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 Decision making with the USI patient Menahem Neuman

6. Urodynamics in Korea? • Korean J Urol – 2014, Agarwal A • Statistically significantly better treatment outcomes in the urodynamic group Decision making with the USI patient Menahem Neuman

7. Rachaneni, Latthe: BJOG. 2015 • A systematic review and meta-analysis. • Urodynamics does not improve outcomes • With careful office evaluation! Decision making with the USI patient Menahem Neuman

8. 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. Decision making with the USI patient Menahem Neuman

9. Decision making with the USI patient • USI • USI predominance • Combined • Others Menahem Neuman

10. Decision making with the USI patient • USI • USI predominance • Combined • Others Menahem Neuman

11. Decision making with the USI patient • Diagnosis • Pre treatment consultation • Surgery • Complication • Failure • Follow-up Menahem Neuman

12. Medical? • Physiotherapy? • Surgery! Consultation Menahem Neuman

13. Physiotherapy? Decision making with the USI patient 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

14. Decision making with the USI patient • Diagnosis • Pre treatment consultation • Surgery • Complication • Failure • Follow-up Menahem Neuman

15. Injectable? • RP Open Colpo-Suspension? • TVT Surgery Menahem Neuman

16. Surgery • Injectable? • RP Open Colpo-Suspension? • TVTSMUS? • SMUS-RP? • SMUS-TOT? • Mini SMUS? Menahem Neuman

17. The Mid-Urethra Concept Pubo-urethral ligaments Zacharin 1968, DeLancey 1994 Menahem Neuman

18. The Mid-Urethra Concept Functional Aspects Maximal urethral closure pressure at mid-urethra Ulmsten 1976 Menahem Neuman

19. Ulf Ulmsten - TVT Classic Over 1000 papers 6% Bladder penetration 5% P/O BOO Intestinal / vessel injuries Menahem Neuman

20. TVT Menahem Neuman

21. Menahem Neuman

22. SUI treatment evolvement: TVT-O Over 150 papers 3% of P/O BOO Thigh pain – 30% Bladder & Urethral injuries, Field infection, Bleeding Menahem Neuman

23. Menahem Neuman

24. Is TVT better than TVT-O? Novara et al. Eur Urol, 2010 Menahem Neuman

25. Is outside-in better? Mahduvrata et al. Eur J Obstet Gynecol Reprod Biol, 2012 Menahem Neuman

26. Menahem Neuman

27. SIMUS (Mini-Slings)? Decision making with the USI patient Menahem Neuman

28. Are mini slings better? Abdel-Fattah et al. Eur Urol, 2011

29. Turkish-Israeli Urogyne MeetingJerusalem - 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

30. 7 years after mini MUS 33% had recurrence of rUSI, mostly after 5 years.

31. TVT for USI with ISD Minerva Chir. 2014, Kokanalı TVT is effective (83%) and safe for USI with ISD. However, ISD patients with low maximal urethral closure pressure should be informed preoperatively about possible poor outcomes Decision making with the USI patient Menahem Neuman

32. TVT for USI with ISD Int Urogynecol J. 2012 , Choo With our long-term results, TVT is an effective treatment even in women with ISD (82%). ISD patients with low VLPP should be counseled carefully about TVT outcome Decision making with the USI patient Menahem Neuman

33. Management of recurrent stress urinary incontinence after failed MUS: a survey of members of the IUGA • Int Urogynecol J. 2015, Robinson D, Cardozo L • Members of IUGA prefer RPS in most patients and UBA with absent urethral hypermobility and ISD Decision making with the USI patient Menahem Neuman

34. Management of recurrent stress urinary incontinence in the US NeurourolUrodyn. 2015 , Zimmern • 6% of women with rUSI were retreated within 5 years, mostly with injection therapy or autologous fascial sling Decision making with the USI patient Menahem Neuman

35. The surgical management of rUSI: a systematic review Acta Obstet Gynecol Scand. 2015, Nikolopoulos There is a wide spectrum of surgical interventions for secondary treatment of SUI. A common characteristic is a lower success rate compared with those reported following primary procedures. Decision making with the USI patient Menahem Neuman

36. Surgical treatment of rUSI: a systematic review and meta-analysis of RCT’s Eur Urol. 2013, Abdel-Fattah No difference in patient-reported and objective cure rates between RP-TVT and TO-TVT in the surgical treatment of women with R-SUI. Decision making with the USI patient Menahem Neuman

37. Results of primary versus recurrent surgery to treat stress urinary incontinence in women Int Urogynecol J. 2015 , Heesakkers Recurrent surgery to treat rSUIare do not differ from results of primary surgery. Decision making with the USI patient Menahem Neuman

38. Post TOT Thigh pain Menahem Neuman

39. Post TOT Thigh pain Menahem Neuman

40. Post TOT Thigh pain Menahem Neuman

41. Post TOT Thigh pain Menahem Neuman

42. Post TOT Thigh pain Menahem Neuman

43. 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 Menahem Neuman

44. Pain reduction after TVT-A • Needle trajectory medially remote according with FF (IUJ 2012) • A Trans - Obturator sub mid urethral short sling implant (12 Cm, TVT-Abbrevo, J&J)

45. Pain reduction after TVT-A 102 Pts were included: • Early P/O thigh pain: 6 Pts (6%), all mild. • At 3 Yrs: • Chronic pain: 5 Pts – all mild • OAB : 11Pts (13%) • POP: 9 Pts (11%), mild • SUI: 2 Pts (2.5%), mild Menahem Neuman

46. Vaginal delivery following TVTS J Obstet Gynaecol Res. 2013, Tommaselli The patient remained continent throughout the gestation and in the following 24 months Decision making with the USI patient Menahem Neuman

47. Effect of pregnancy and delivery on urinary incontinence after the smus Int Urogynecol J. 2015 , Cavkaytar Four patients had a TVT and 8 had TOT. Seven women had CS and 5 women VD. 10 were continent after delivery (83.3 %). Decision making with the USI patient Menahem Neuman

48. 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 Decision making with the USI patient Menahem Neuman

49. Pelvic organ prolapse in a cohort of women treated for stress urinary incontinence Am J Obstet Gynecol. 2014 , Brubaker Surgeons may counsel women with asymptomatic stage 2 POP that their prolapse is unlikely to require surgery in the next 5-7 years Decision making with the USI patient Menahem Neuman

50. A SMUS to reduce SUI after vaginal prolapse repair N Engl J Med. 2012 , Nygaard A prophylactic SMUS inserted during vaginal prolapse surgery resulted in a lower rate of USI but higher rates of adverse events Decision making with the USI patient Menahem Neuman