Intrinsic Sphincter Deficiency

1
Intrinsic Sphincter Deficiency Slings

• Nader Gad
• MBChB, MChGO, FRCOG, FRANZCOG
• Consultant Senior Lecturer in OG
• Royal Darwin Hospital, Darwin, Australia

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Definition of ISD

• SLPP less than 60 cmH2O
• MUCP less than 20 cmH2O
• Type III Stress Incontinence (Proximal urethra
  open at rest)

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Classification of SUI
Clinically During UDA Bladder neck proximal urethra During Rest Bladder Neck Proximal urethra During Stress Cystocele
Type 0 No SUI is seen Probably due to momentary voluntary contraction of External Urethral sphincter closed at rest At or above inferior Margin of SP Descend open None
Type I Closed at rest Above inferior Margin of SP Open Descend less than 2 cm None or Small Cystocele
Type IIA Closed at rest Above inferior Margin of SP Open Rotational descent characteristic of cysto-uretherocele Present
Type IIB Closed At or below inferior Margin of SP Open May be further descent
Type III Open at rest Proximal urethra no longer function as sphincter
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Causes Of ISD

• Previous Pelvic Surgery
• Anti-incontinence surgery
• Urethral diverticulectomy
• Radical Hysterectomy
• Urethrotomy
• Resection or incision of vesical neck
• Aging Hypo-oestrogenic States
• Pelvic Irradiation
• Neurologic Conditions
• Myelodysplasia
• Anterior spinal artery syndtome
• Lumbosacral neurologic conditions
• Shy-Drager syndrome

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Treatment of ISD

• McGuire et al(1978 )were the first to note that
  ISD present in
• 75 of women of patients who failed in multiple
  surgeries for SUI
• 13 with no previous anticontinence surgery
• Difficult to determine is it cause or effect?

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Treatment of ISD

• Sand et al (1987)
• High failure rate of Burch colposuspension in
  women with low MUCP compared to those with MUCP
  more than 20cm H2O
• Failure rate of Burch at 3 months FU
• Low MUCP 54
• Normal MUCP 18

7
Treatment of ISD

• Most data show simple elevation of the bladder
  neck is ineffective
• Recommend more obstructive procedure

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Treatment of ISD

• Proximal Suburethral slings (Traditional)
• Mid-Urethral Tension-free Slings
• TVT
• TOT
• 3. Artificial sphincter
• 4. Urethral Bulking Procedures

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Proximal Suburethral Slings

• First introduced by Giordano in 1907 using
  Gracilis muscle flap
• Aldridge in 1942, developed the Fascial sling
• The principle
• Create a hammock underneath bladder neck to
  prevent descent and provide a backboard at UVJ
  against which the urethra is compressed during
  increase of intra-abdominal pressure

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Types of Proximal Slings
Biologic Synthetic
Fascia lata Mersilene
Rectus fascia Nylon
Gracilis muscle flap Marlex
Pyramidalis muscle flap Gore-tex
Round ligament Silastic
Ox dura mater Polypropylene mesh
Porcine small intestine submucosa
Cadaver fascia
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Patient most un-suitable

• History of irradiation
• Previous sling erosion
• Having surgery on the urethra at the same time
  (e.g., urethral diverticulectomy)
• Having POP surgery at the same time

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Proximal Urethral slings

• Overall success for SUI ISD at 5 years 80
  90
• Summitt et al (1990)
• Sling procedure success rates were
• 93 in ISD HMBN
• 20 in ISD no HMBN

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Common Complications of Proximal Suburethral
Slings

• Longer recovery
• Has the highest rate of retention 2-37

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TVT ISD

• Rezapour (2001) First report on 49 women
• F-U for 3-5 years
• 74 completely cured
• 12 improved
• 14 no improvement
• Majority more than 70 years old MUCP less
  than 10 cmH2O

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TVT ISD

• Overall Success rate 55 74
• (less than the 80-90 with PSUS)
• Some experts advise when TVT in ISD
• tape is placed in immediate proximity with
  urethra (still without tension) instead of aiming
  for a ¼ inch gap

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TVT Complications

• Voiding difficulties
• Recurrent UTI
• Bladder perforation (5-10)
• Erosion (3 5 )
• Vascular injury
• Bowel injury
• Haematoma
• Nerve injury
• Death (6 reported deaths by September of 2002)

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TOT Slings

• It leaves the sling in a more horizontal or
  hammock-like rather than U-orientation
• Less operative time
• Avoid risk of injury to bladder (only few
  reported cases) bowel major vessels

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TVT vs TOT (Monarc)Miller et al (2006)

• Retrospective study of 145 women Comparing TOT
  (Monarc) vs TVT under GA or Spinal anaesthesia
• Monarc was nearly 6 times more likely to fail
  at 3 months after surgery in women with
  borderline MUCP (42 cm H2O or less)
• In this study women with MUCP 20cmH2O or less
• were exclusion criteria of TOT but not TVT

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Failure Rate TVT vs TOTMiller et al 2006
TVT (60) Monarc (85)
All (145) Objective Subjective 3 14 9 16
MUCP 42 or less (81) Objective Subjective 3 13 16 23
MUCP more than 42 (64) Objective Subjective 4 16 2 6
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TVT vs TOT vs Sling Jeon et al (2008)

• Retrospective study of 253 women with ISD defined
  as LPP less than 60 cmH2O or MUCP less than 20
  cmH2O
• - PVS 87
• TVT 94
• TOT 72
• TOT (polypropylene Iris, Dowmedics Co, Korea,
  Outside in )
• Regional of General Anaesthesia

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TVT vs TOT vs SlingJeon et al (2008)

• Cure rates after 2 years
• PVS 87
• TVT 87
• TOT 35
• Cure rate after 7 years
• PVS 59
• TVT 55

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TVT vs TOT vs SlingJeon et al (2008)
Complications PVS (n87) TVT (n94) TOT (n72) P value
Bladder injury 1 (1.2) 0 0 0.6
De novo urgency 14 (16) 14 (15) 13 (18) 0.9
Voiding dysfunction (one month or longer) 18 (19) 17 (18) 8 (11) 0.75
V.D. Requiring surgery 0 3 (3.1) 1 (1.4) 0.26
Recurrent UTI 2 (2.3) 6 (6.4) 0 0.06
Mesh Erosion - 1 (1.1) 1 (1.4) 1
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Darwin Experience

• Retrospective study of my First 25 cases of the
  TVT-O procedures (JJ)
• Procedure were completed in all women under
  sedation and local anaesthesia
• Outcome of the procedure
• Complication intra- post-operative
• Success rate Subjective Cough test
• Any difference in outcome when ISD present?

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Darwin Experience

• ISD was defined as valsalva or cough LPP less
  than 60 cmH2O and/or MUCP 20 cm H2O or less
• Women with ISD were given the option to chose
  between TVT vs TVT-O
• TVT have a higher cure rate than TVT-O in women
  with ISD
• TVT has the potential risk of bowel or major
  blood vessels injury

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Patients studied
Public 7 28
Private 18 72
GP referral 20 80
Specialist Ref 5 20
Age 39 66 years 39 66 years
Parity 1 6 1 6
Presence of SUI In All women 100
Urgency 9/25 36
Urge incontinence 5/25 20
Frequency 6/25 24
Nocturia 5/25 20
Previous surgery for SUI 3/25 12
Previous Hysterectomy 10/25 40
Previous POP repair 6/25 24
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UDA Findings
Presence of POP 15/25 60
HMBN 21/25 84
ISD 10/25 40
HMBN ISD 6/25 24
ISD alone 4/25 16
DI 2/25 8
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ISD

• Of the ten women with diagnosis of ISD
• a. 5 women (50) had MUCP lt 20cm H2O
• 4 women had leakage on valsalva
• the remaining patient had leakage on Cough LPP of
  less than 60 cm H2O, this patient was the only
  patient lost to follow up.

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Sedation

• Bolus of 1-2 mg midazolam
• Then propofol 1 infusion at a rate of
  20-40mls/hour titrated to effect
• A small bolus of propofol (10-30mg) and/or
  alfentanil (100 200mcg) may be used when
  required in some patients during penetration of
  Obturator membranes.

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Local Anaesthesia

• The local anaesthetic agent used was a total of
  80 100 ml of 0.25 prilocaine with adrenaline
  (1200,000)

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Local Anaesthesia

• Administration of local anaesthesia to
• the area of the suburethral vaginal incision
• paraurethral lateral dissection
• expected tape passage through the Obturator
  foramen and muscles and the exit on the skin of
  the inner upper part of the thigh on both sides.

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Cough Test

• Once tape is inserted, cessation of all sedation
• Bladder is filled to a volume similar to that
  when SUI was demonstrated during UDA
• Cystoscopy performed
• When patient is awake enough, operative table is
  tilted head up about 30 degrees
• patient is instructed to cough strongly and the
  tape is very slowly adjusted to the point when
  urinary leakage just stops

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Operative Short-term Complications
Intra-operative complications 0 0
Short term Urinary retention 0 0
Short Term DI 1/25 4 One woman had 2 episode of nocturnal enuresis on the 2nd and 7th postoperative and day that resolved by the time she was reviewed 5 weeks later
Short term postoperative complications 2/25 8 2 patients (8) developed significant pain in the upper thigh that resolved by 6 weeks post surgery
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Hospital Stay
AM list 7 28
Discharge of AM list on same day 6/7 86
PM List 18 72
Discharged on the same day 2/18 11
Discharged next morning 14/18 78
Discharged within 48 hours 2/18 11
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Follow-up
Duration of FU Mean 4 52 weeks Average 13.3 weeks
Duration to Audit Mean 7 156 weeks Average 53 weeks
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Long Term Outcome
Urinary retention 0 0
Urgency 2 8 Two woman developed mild urgency
Other complications 1 4 Pain in the vagina required excision of part of the tape
No further SUI 24/24 100
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August 2008Anast et al from Missouri, USA

• TOS (Trans-Obturator Sling) placement a
  outside-in (ObTape Coloplast Surgical,
  Humeleback, Denmark)
• 124 patients had leakage on valsalva
• 29 had low VLPP (Less than 60 cmH2O)
• 71 had higher VLPP

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August 2008Anast et al, Missouri, USA
At a mean of 12 month Low VLPP (29) High VLPP (71)
Subjective Cure rate 93 79
Bladder perforation (6 patients) 3 6
Complication rate 11 29
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Conclusion

• TVT-O under local anaesthesia and sedation with
  the Cough Test in Theatre is very effective and
  safe surgical treatment of SUI in women with or
  without ISD.
• Shortcomings of the Study
• Retrospective
• Small number of the patient in this study
• Relatively short term follow up period