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Overview of Surgical Management of SUI: Sling Selection, Outcomes, and Adverse Events

Overview of Surgical Management of SUI: Sling Selection, Outcomes, and Adverse Events. Eric S. Rovner, M.D. Professor of Urology Medical University of South Carolina Charleston, South Carolina. Treatment Options for SUI. WAWA Behavior Pelvic floor exercises Drugs??? Pessary/Devices

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Overview of Surgical Management of SUI: Sling Selection, Outcomes, and Adverse Events

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  1. Overview of Surgical Management of SUI:Sling Selection, Outcomes, and Adverse Events Eric S. Rovner, M.D. Professor of Urology Medical University of South Carolina Charleston, South Carolina

  2. Treatment Options for SUI • WAWA • Behavior • Pelvic floor exercises • Drugs??? • Pessary/Devices • Surgical repair • Bulking agents

  3. AUTOLOGOUS PUBO-VAGINAL SLING TVT Outside-in Inside-out Spiral sling Transobturator Sling Prepubic sling Retropubic tape “Minisling” Colposuspension MIDURETHRAL SLING

  4. Which one ?? IF ALL WERE EQUIVALENT: -experience of surgeon -patient factors: -wishes and willingness to accept risks -other: convalescence, pain, etc BUT ALAS THEY ARE NOT ALL EQUIVALENT: -Operations are not…….. -efficacy, durability, recovery, etc. -Patients are not………... -types of SUI, anatomy, prior surgery, etc.

  5. Algorithm for surgical treatment of SUI*: “I leak when I cough” Autologous Fascial Sling *Courtesy of Jerry G. Blaivas, MD

  6. SURGERY for SUI 1995 • 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

  7. 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) x Needle BNS Anterior repair (Kelly)

  8. ESR Operations to treat SUI (in 2011) • Retropubic suspension (rarely) • Injectables • Autologous pubovaginal slings • Vaginal tapes • Transobturator (outside in) • Retropubic

  9. 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

  10. SUI Surgery 2011 • Midurethral synthetic sling is a good choice…… EXCEPT……

  11. SUI Exceptions • Urethral diverticulum • Urethrovaginal fistula • Other urethral pathology (stricture) • Severe irreversible atrophy or XRT Autologous pubovaginal sling

  12. Other exceptions • Unwilling or unable to have surgery: • Injectable • Other RP surgery (w/o ISD) or can’t do lithotomy: • Burch

  13. So, who gets which MUS? • Midurethral sling • TOT • Retropubic • Mini-sling

  14. 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

  15. Choice of Surgery for SUI Ideally….. • 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.

  16. Choice of Surgery for SUI Reality……. • Non-evidenced based • Poor quality literature • Commercial bias • Mostly anecdotal • Surgeon “preference”

  17. AUA SUI Guidelines Update Reviewed SUI literature since last Guidelines and updated the document Dmochowski, et al, JU 183:1906, 2010

  18. 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

  19. TOMUS N= 597 randomized to TOT or retropubic MUS Retropubic MUS= TVT (Gynecare) TOT= Monarc (AMS) or TVT-O (Gynecare) Outcomes Objective criteria Negative CST, negative 24 hour pad test, no re-Tx Subjective criteria No sx’s SUI, negative 3 d diary, no re-Tx Adverse events Null hypothesis: no difference = <12% between groups

  20. Success Objective success 81% RP 78% TOT Subjective success 62% RP 56% TOT

  21. “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)

  22. Bladder Urethra Rx of Urinary Incontinence Continence= urethral closure forces > bladder expulsion forces All therapies either ↑ urethral or ↓ bladder forces

  23. 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

  24. 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.

  25. Index patient w/ SUI Prior surgery? Yes No Obstructed? Yes No Mobility? Urethrolysis +/- PVS Yes No Prior RP surgery? Urethrolysis +/- PVS (or RP UT) Yes No Low “pressure” urethra? TOT Yes No PVS (+/- RP UT) TOT, or RP UT or PVS

  26. Index patient w/ SUI Prior surgery? Yes No Mobility? Yes No Low “pressure” urethra? Yes No RP UT (+/- PVS) RP UT (+/- PVS) RP UT Or TOT Hooray !!!!!!!

  27. 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

  28. 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

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