Glup montecchio incontinenza&prolasso_meschia
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Glup montecchio incontinenza&prolasso_meschia

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GLUP Montecchio 24-9-10

GLUP Montecchio 24-9-10

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  • Urodynamics must reproduce patient’s symptoms to be of any value

Glup montecchio incontinenza&prolasso_meschia Glup montecchio incontinenza&prolasso_meschia Presentation Transcript

  • In God we trust, all others must have data
  • Incontinenza & Prolasso Michele Meschia - Giancarlo Vignoli
  • Aims of urodynamics
    • To reproduce the patient’s symptomatic complaints
    • To provide a pathophysiological explanation for the patient’s problems
  • Role of urodynamics
    • 25-30% of women with SUI do not have urodynamic
    • stress incontinence
    • Glazener 1996
    • In almost half of the patients with OAB symptoms there
    • is no detrusor overactivity on urodynamics
    • Rosenzweig, 1992
  • Stress incontinence & Urodynamics
    • Indications:
    • - Always when surgery is planned
    • In particular when:
    • mixed urge and stress symptoms
    • associated voiding problems
    • pt with neurologic disorders
  • Use cystometry if appropriate
    • Multi-channel filling and voiding cystometry is recommended before surgery if:
      • detrusor overactivity suspected
      • previous surgery has been done for stress UI or anterior compartment prolapse
      • symptoms suggest voiding dysfunction
    NICE guidelines 2006
    • Design of the Value of Urodynamic Evaluation (ValUE) trial:
    • A non-inferiority randomized trial of preoperative
    • urodynamic investigations.
    • Background :
    • UDS are routinely obtained prior to surgery for SUI despite a lack of evidence that UDS have an actual impact on outcome
    • Primary aim :
    • to determine whether women with symptomatic uncomplicated SUI without pre-op UDS have non-inferior treatment outcomes when compared to women with pre-op UDS
    • Secondary aims :
    • to determine how often physicians use pre-op UDS results to alter clinical and
    • surgical decision-making
    • to compare the amount of improvement in incontinence outcomes
    • to determine the incremental cost and utility of performing UDS compared with
    • not performing UDS
    • Methods : UDI and PGI-I responses will be use to measure the primary outcome at 12 months
    Nager CW, Brubaker L et al. On behalf of the Urinary Incontinence Treatment Network, Contemp Clin Trials 2009
    • Anytime ISD is suspected (higher risk of recurrence)
    • Previous incontinence or prolapse surgery
    • Hypo-mobile or fixed urethra
    • Severe incontinence with minimal efforts
    When are urethral pressure profilometry and leak point pressure measurements useful for evaluation of incontinence?
    • MUCP: poor sensitivity and specificity
    • VLPP : poor reproducibility; techniques not standardized
    • Some evidence they can predict outcomes
    • ICI 2009
  • “ Urodynamic investigation should be part of the diagnostic workup in patients with POP who are candidates for surgical repair”
  • Genital Prolapse
  • Frequency / Urgency: 85% Voiding dysfunction: 34-62% Difficulty empting: 49% Incomplete voiding: 62% Hesitancy: 34% POP and urinary symptoms 237 women with POP Urinary incontinence: 73% Stress: 13% Urgency: 5% Mixed: 76% Ellerkmann, 2001
  • OAB and POP Digesu et al, 2007 Symptoms and diagnoses before and 1 year after POP surgery Symptoms Pre-op Post-op P Frequency 100% 41% 0.02 Urgency 100% 30% 0.001 Urge incont. 62% 17% 0.001 Diagnoses Pre-op Post-op DO 61% 34% Mixed incont 30% 23% Normal urod. 9% 33%
  • Postoperative resolution of urinary retention in patients with advanced POP Inclusion criteria Postvoid residual volume > 100 ml Urodynamics with voiding study (POP reduced) Results 89% had normal PVR after surgery Pre-op voiding study as predictor of  post-op PVR 66% sensitivity; 46% specificity 12% positive predictive value 93% negative predictive value FitzGerald, 2000
  • POP and SUI
    • Women with severe pelvic organ prolapse may be continent because of urethral kinking or compression
    • Without prolapse reduction only 3.7% of women with III-IV stage prolapse demonstrate urodynamic stress incontinence (Visco et al, 2008)
    • OSUI can be suspected if the patient reported a history of SUI which has disappeared with the exacerbation of POP
  • Incidence of post-op SUI
    • 11% within 3 months of anterior colporraphy with and without VH (Stanton et al, 1982)
    • 22% 3 months after ant/post colporraphy and cervical amputation (Borstad et al, 1989)
    • At five years: 7.5% rate of surgery for SUI following successful prolapse surgery (Clark et al,2003)
    • Continent patients, no screening for occult SUI, no data on the severity of prolapse
  • Occult Stress Urinary Incontinence 36% to 80% of continent women with POP are at risk to develop SUI after reconstructive surgery (Kleeman et al 2006; Reena et al 2007) These women, considered to have occult stress incontinence, can be identified by performing a barrier test
  • Screening for OSUI
    • 58% POSUI in women with pre-op positive barrier test who underwent ASC without colposuspension (Brubaker et al, 2006)
    • 64.7% of women with positive pre-op pessary test who did not underwent a TVT at the time of prolapse repair developed POSUI (Liang et al, 2004)
  • The Care Trial Women with pre-op positive barrier test were more likely to report POSUI regardless concomitant colposuspension Incidence of post-op SUI Brubaker et al, 2006 Burch No Burch P Total 23.8% 44.1% < .001 Pos barrier test 32% 58% .04 Neg barrier test 21% 38% .007
  • Prolapse reduction
    • A pre-operative negative barrier test result is reliable in predicting patients who will remain stress-continent after prolapse repair (Klukte et al, 2000)
    • A negative pre-op barrier test is associated with 2% post-op SUI (Kleeman et al, 2006)
    • Overall barrier tests have low positive predictive values with pessary having the lowest rate of detection of OSUI: 6%; PPV, 50% (Visco et al, 2008)
  • Role of urodynamics
    • Little evidence to show it is better than barrier methods alone (Roovers et al, 2007)
    • Urethral pressure profile and leak point pressure have poor predictability ( Romanzi et al, 1999)
    • Urodynamics before surgery in women with POP and SUI does not improve cure rates and is not cost-effective relative to basic office evaluation (Weber et al, 2000)
    • When planning concomitant surgery urodynamics is recommended to ascertain coexisting problems such as detrusor overactivity or voiding disorders . (Togami et al, 2010)
    • Detrusor overactivity has been found in up to 30% of patients and persisted in most of them post-op (Araki et al, 2009)
  • Does preoperative urodynamics change the management of prolapse?
    • 53% of women undergoing UDS had an abnormal result with POP reduction
    • 19% had urodynamic SUI
    • 30% had DO either alone or as MI
    • The surgical management was altered in 7% of women who had an additional continence procedure
    Toozs-Hobson, 2008
    • Correct the prolapse first and evaluate afterwards if this procedure has also resolved SUI
    • Correct the prolapse and stress incontinence during the same procedure
    Treatment strategies “ The goal of treatment of SUI and pelvic prolapse is to correct incontinence and prolapse without creating outlet obstruction”
  • Prophylactic bladder neck plication is commonly performed at the time of POP repair OSUI and vaginal surgery Do nothing Bump 1996 Colombo 1997 Meschia 2004 Patient number 29 73 50 Type of study Random Random Random Procedure EPF plic Needle PU lig plic Needle EPF plic TVT Follow-up (mo.) 6 mo 5 y 2 y Cure rate of SUI 93% vs 86% 50% vs 76% 56% vs 92% “ de novo urge” 1% vs 14% 4% vs 2% 4% vs 12%
  • Surgery for POP and SUI Do a sling later on Comparing TVT at the time of POP surgery and TVT 3 months later Results on women randomized to receive TVT after POP surgery
    • 92 women with urodynamic SUI, mostly clinical
    • 28% were cured following POP surgery
    • 72% still had SUI but 1 out of four denied to
    • undergo TVT later on
    Borstad et al, IUJ 2010
  • POP and occult urodynamic SUI Concomitant procedures The high rate of POSUI legitimates the choice of a systematic anti-SUI procedure Groutz 2004 Yamada 2001 Barnes 2002 Chaikin 2000 Klutke 2000 Patient number 100 10 38 14 55 Type of study Prospect Prospect Retrospect Prospect Retrospect Procedure TVT SU sling PV Sling PV sling Burch Follow-up (mo.) 27 mo 51 mo 15 mo 47 mo 3-5 y Cure rate of SUI 98% 99% 93% 86% 96% “ de novo urge” 8% 10% 9.5% 7% 30%
  • POP and SUI surgery
    • No clear evidence of increased rate of complications when compared with TVT alone
    • Prolapse surgery alone
    •  Intraoperative complications
    •  Postoperative voiding dysfunction
    Complications
    • The risk of post-op retention equals the rate of POSUI
    • 7.5% of obstruction requiring surgery
    • 8.3% of POSUI requiring intervention
    Ballert et al, 2009
  • Conclusions
    • Barrier tests have low sensitivity but patients with pre-op
    • leakages are at higher risk to develop POSUI
    • Urodynamics does not predict outcome or which procedure is
    • needed. It may be helpful for counselling patients
    • There is no clear evidence that concomitant SUI surgery in
    • occult SUI should be performed as quite half of the patients
    • are continent of urine after prolapse repair by itself.
    • POSUI might be considered as a unsucessfull treatment but
    • warn patients about increased intraoperative morbidity and
    • voiding dysfunction