Surgeries for SUI are not without hazards.
Proper preoperative assessment, patient counseling, meticulous postoperative care& early discovery of complications are the mainstays of management.
Voiding difficulty after anti-incontinence surgeries can become persistent and have a significant impact on quality of life.
Supra-pubic catheter & CISC should be added to our practice.
Careful surgical technique with avoidance of over-elevation might play a role in prevention of VD.
Preoperative and postoperative Nursing care(ayoub ) for presentation Ayoub Abdul Majeed
Photo: Pre and post-operative care
During the perioperative period, specialised nursing care is needed during each phase of treatment. For nurses to give effective and competent care, they need to understand the full perioperative experience for the patient.
Perioperative refers to the three phases of surgery.
Preoperative stage
Intraoperative stage
Postoperative stage
Within these stages there are many different roles for nurses and different care needed for the patient dependent on which stage they are in.
As with any nursing care, the goal during these stages is to provide holistic and evidence-based care as well as support to the individual
Preoperative and postoperative Nursing care(ayoub ) for presentation Ayoub Abdul Majeed
Photo: Pre and post-operative care
During the perioperative period, specialised nursing care is needed during each phase of treatment. For nurses to give effective and competent care, they need to understand the full perioperative experience for the patient.
Perioperative refers to the three phases of surgery.
Preoperative stage
Intraoperative stage
Postoperative stage
Within these stages there are many different roles for nurses and different care needed for the patient dependent on which stage they are in.
As with any nursing care, the goal during these stages is to provide holistic and evidence-based care as well as support to the individual
Post-Operative Managment
• The post operative period begins from the time
• The patients leaves the operating room and ends with the
follow up visit by the surgeon.
• The post operative care is provided by
-- PACU
-- SICU
Things to ensure and check off the list before a patient is shifted to the OR for surgery. The responsibility rests mainly with the resident doctor and the registered nurse to ensure complete preoperative preparation of the patient.
Post-Operative Managment
• The post operative period begins from the time
• The patients leaves the operating room and ends with the
follow up visit by the surgeon.
• The post operative care is provided by
-- PACU
-- SICU
Things to ensure and check off the list before a patient is shifted to the OR for surgery. The responsibility rests mainly with the resident doctor and the registered nurse to ensure complete preoperative preparation of the patient.
Bladder injuries may result from blunt,Penetrating and Iatrogenic trauma.
Full bladder is more susceptible to injury than empty bladder.
Management varies from conservative to surgical aiming to directly repair the injury.
surgery, minimally invasive techniques, continuous closed ;lavage, necrosectomy, VARD, ideal time for intervention, role of antibiotics , laparoscpic surgery
Urinary diversion procedures are performed to divert urine from the bladder to a new exit site, usually through a surgically created opening (stoma) in the skin.
These procedures are primarily performed when a bladder tumor necessitates removal of the entire bladder (cystectomy).
Urinary diversion has also been used in managing pelvic malignancy, birth defects, strictures, trauma to ureters and urethra, neurogenic bladder, chronic infection causing severe ureteral and renal damage, and intractable interstitial cystitis and as a last resort in managing incontinence.
There are two categories of urinary diversion:
1. Cutaneous urinary diversion : in which urine drains through an opening created in the abdominal wall and skin.
2. Continent urinary diversion : in which a portion of the intestine is used to create a new reservoir for urine.
Pre-term labour, could it be predicted?
Pre-term labour (PTL) is defined as labour less than 37 completed weeks or 259 days. 15 million PT babies are delivered annually worldwide with a global rate of about 11% with rising trends in most countries. This represents a serious health and economic challenge.
The objective of early prediction of PTL is to Identify women at risk so, delaying preterm birth by Interventions long enough to optimize the outcome for the fetus.
Prediction could be done by:
-Pre-conceptual/early prenatal evaluation
- Prenatal Ultrasound markers
- Biomarker predictors
Highlights on diagnosing PTL for women with intact membranes and preterm prelabour rupture of membranes (P-PROM) will be presented plus recommended prophylactic interventions as prophylactic vaginal progesterone, prophylactic cervical cerclage & 'Rescue' cervical cerclage. Treatment essentials of PTL include tocolysis, maternal corticosteroids & Magnesium Sulphate.
CTG Interpretation, evidence based approach
Cardiotocography (CTG) or electronic fetal monitoring (EFM) is the most widely used technique for assessing fetal wellbeing in labour in the developed world. The primary purpose of fetal surveillance by CTG is to prevent adverse fetal outcomes. Continuous electronic foetal monitoring is recommended to assure fetal wellbeing in labour in high risk pregnant women. Understanding pathophysiology of fetal heart rate variation will help appropriate interpretation of the CTG.
Features & classification of CTG according to RCOG will be demonstrated in this presentation with sufficient trace demonstration.
obstetric and gynaecological management with breast cancer .pptxWafaa Benjamin
Obstetric & Gynaecological Management with Breast Cancer
Breast cancer is the most common cancer in females worldwide. It increasingly affects women through their reproductive age. The prognosis of breast cancer is improving, with 5-year survival 80% ( >50years(. As a result, obstetrician and gynaecologists are nowadays facing more women who are:
◦ Diagnosed with breast cancer during pregnancy
◦ Coming for Pre-pregnancy counselling following breast cancer treatment
◦ Asking for fertility preservation with breast cancer
◦ Having a Genetic predisposition to breast cancer
On this presentation I am going to address those problems in clinical case scenarios in line with latest evidences.
Teenagers are at risk of a range of adverse pregnancy outcomes, particularly preterm birth.
The reasons for this are complex and reflect a combination of adverse socioeconomic pressures and gynaecological and biological immaturity.
The obstetrician providing care for women in this age group should be aware of the potential challenges.
Studies have shown that delaying adolescent births could significantly lower population growth rates, potentially generating broad economic and social benefits, in addition to improving the health of adolescents.
A national target should be set to decrease the incidence of teenage pregnancy in our country .
Obstetricians should have a major role in such health education.
,
tranexamic acid in postpartum hemorrhage :
Reduces death due to bleeding overall by one fifth
Reduces death due to bleeding within 3 hours by about one third
No effect on other causes of death
Did not reduce hysterectomy
Reduces laparotomy for bleeding by over 35%
No evidence of adverse effects acid in post-partum hemorrhage
Recommendation for implementation at national level:
Need for uniform training program.
Develop curriculum
Consultant lead training.
TOT courses, (electronic training)
Yearly appraisal for trainers .
Yearly assessment of trainees (In depth workplace assessment of trainees)
Obligatory Courses: basic & advanced
Offer simulators, videos.
Revise obstacles at hospitals
Investigate workload & no of trainees at hospitals.
Iron deficiency anaemia in pregnancy- evidence based approachWafaa Benjamin
Iron deficiency is the most common deficiency state in the world, affecting more than 2 billion people globally.
Iron Depletion affects 20-40% of Egyptian women in childbearing period.
Effective management is needed to prevent adverse maternal and pregnancy outcomes, including the need for red cell transfusion.
There should be clear and simple recommendations for the diagnosis, treatment and prevention of iron deficiency in pregnancy and the postpartum period.
Universal iron supplementation in pregnancy is more suitable for our local protocol.
Haemoglopinopathy screening program for pregnant women is awaited.
The use of algorithms & emergency boxes in obstetric emergencyWafaa Benjamin
obstetric hemorrhage Is the major cause of maternal mortality globally.
Substandard management identified as a contributor for maternal mortality in UK in 80% of the cases.
Is the major cause of mortality in Egypt ,according to the last Egyptian Maternal Mortality Report in 2001.
So we need to Work in a team, Do all needed steps, In the proper sequence of the steps,
competent emergency team should have Knowledge ,Skills , Attitude & exposed to regular Labor Ward drills.
Ready available Algorithms & Emergency Boxes are found to be helpful in emergency situations.
Recurrent urinary tract infection-Evidence based approachWafaa Benjamin
Recurrent UTI is a common problem encountered in many areas of clinical practice.
It is a cause of significant morbidity: urinary infection is one of the commonest indications for antibiotic prescription in community and hospital settings.
The majority of cases are uncomplicated and respond rapidly to appropriate treatment.
In the management of women with any type of UTI, it is important to have an appreciation of the pathogenesis, host and bacterial interaction, methods of diagnosis, treatment algorithms and local antibiotic sensitivities.
It should be remembered that 20-30% of women with UTI develop at least one recurrent infection
Management of SLE with pregnancy ,the difficult missionWafaa Benjamin
Involvement of obstetricians and physicians with experience of managing SLE in pregnancy improves the outcome for the mother and foetus.
MDT
Pre-pregnancy clinics
Triage of low& high risk women
Be alert to detect a flare
Wait for PE & distinguish from L.nephritis
TOP when in risk
Investigations for iufd & sb, how to select?Wafaa Benjamin
Foetal loss is a distressing situation for the lady ,family and medical staff as well.
Investigating the cause of death has many benefits .
Meticulous history taking and clinical assessment is of at most importance.
There are routine standard tests & others arte selective directed by clinical scenarios.
Researches & recording are required to estimate main causes of foetal death at local level, so, investigations could be directed.
In presence of lack of resources, selection of investigations should be prioritized by most relevant and most informative ones.
Post-mortem examination should be re-included at least external examination & placental histopathology.
How evidence affects clinical practice in egyptWafaa Benjamin
Evidence based medicine is the gold standard for clinical care.
It implies the integration of best research evidence with clinical expertise and patient values.
There is still a wide gap between availability of evidence and its incorporation into routine practice in our country.
Barriers to implementation could be personal, social, institutional, financial and legal barriers.
True practice of evidence based care can only occur where evidence based decisions coincide with patients’ beliefs and clinicians’ preferences.
Continuing medical education programs should be set with integrating evidence based medicine teaching and learning within clinical training.
The importance of presence of local national guidelines which need to take into account variation in expertise, resources and patient preferences across our geographical and cultural contexts .
Customisation of a guideline to meet the local needs of a target patient population is critical to successful implementation.
Obesity is now clearly established as a major risk factor for endometrial cancer.
In medium income country like ours , Obesity prevention and lifestyle initiatives should become the responsibility of public health services. Stepwise programmes with realistic time-related goals are required, starting with modification of lifestyle, progressing to pharmacotherapy and ultimately obesity surgery.
The real challenge now is to triage those women at a higher risk and offer them prophylactic measures as COCPs ,DMPA, oral progesterone or Mirena coil.
Standard treatment for endometrial cancer is surgery.
Obesity is associated with numerous disorders which put the patient at increase risk of peri-operative complications that require more detailed pre-operative assessment and more intensive post-operative care.
Thus treatment for endometrial cancer needs to be reassessed in the complex and increasingly common situation of the obese, older women with this disease.
Pruritus vulvae and vulval pain are very common complaints and most women initially self medicate. Although it is often selflimiting, chronic vulval pruritus suggests an underlying vulval dermatosis.
Careful and systemic examination is fundamental to making a diagnosis.
Skin biopsies are not always necessary but are essential if VIN or invasive disease is suspected or if the condition does not respond to treatment.
General care of vulval skin is a fundamental component of treatment.Avoidance of potential irritants will benefit most conditions.
The mainstay of the management of lichen sclerosus is topical ultrapotent steroids. Women require clear advice on the appropriate treatment regimes.
Women with VIN require a biopsy to confirm disease.Longterm surveillance is necessary, particularly when a medical or conservative approach to management is taken.
All gynaecological trainees require experience in the management of common skin disorders, but a specialist service improves care for women by improving the accuracy of diagnosis and the implementation of adequate and appropriate treatment.
Manegement of adenexal masses in pregnancyWafaa Benjamin
Over the last 20 years, the use of ultrasound in pregnancy has dramatically increased the numbers of ovarian cysts diagnosed.
The majority of these ovarian cysts in pregnancy either resolve spontaneously or are due to benign conditions.
Ovarian cancer is extremely rare in women of childbearing age and thus most of these cysts can be managed conservatively.
In terms of malignancy potential, those that are malignant are likely to be borderline.
Unless there is a suspicion of malignancy or there is a significant cyst complication, such as torsion, surgery is not indicated.
MRI is a safe and useful tool to help evaluate cysts in more detail in situations where ultrasound provides an inconclusive answer.
If surgery is planned, this should take place during the second trimester to minimise the risk of miscarriage.
Whether surgery is done laparoscopically or using a traditional open approach, it is largely dependent on operator experience and patient preference.
Aspiration of ovarian cysts is only indicated where they appear simple on ultrasound and where they are causing pain or are thought to be obstructing the birth canal.
If surgery does not take place, then ultrasound follow-up during and after pregnancy may be advised accordingly.
The role of bariatric surgery in the managementWafaa Benjamin
Despite the fact that bariatric surgery does not reduce absolute BMI to within normal range in most patients, studies suggest it improves some important markers of fertility including hyper-insulinemia and ovulation in polycystic ovary syndrome.
Moreover, maternal outcomes and morbidity in pregnancy are better than for women who are similarly obese and are comparable with that of the general population.
Obese women who have weight loss surgery before becoming pregnant have a lower risk of pregnancy-related health problems and their children are less likely to be born with complications.
Life-long vitamin supplementation is advised.
It is advised against falling pregnant during the initial weight loss phase (1 year)
Obesity has many deleterious effects for women of reproductive age.
In the first place, obese women are more likely to encounter problems becoming pregnant and they are more likely to miscarry
They are at greater risk of developing pregnancy complications and problems associated with labour and delivery.
Finally, obese women are more at risk of postpartum complications .
Taken all together, maternal mortality and morbidity is significantly elevated for obese women .
Maternal obesity is also dangerous for the fetus and the newborn.The management of obesity requires a multidisciplinary approach.
Stepwise programmes with realistic time-related goals are required, starting with modification of lifestyle, progressing to pharmacotherapy and ultimately obesity surgery.
Weight loss interventions do not appear to be common practice among fertility centres& pre-pregnancy clinics in spite of clear evidence as to the benefits.
Women should be referred to a nutritionist in cases where clinicians lack the knowledge and/or time to provide adequate counselling.
Blood transfusion in obstetric haemorrhageWafaa Benjamin
Blood transfusion may be a life-saving procedure but it is not without risk.
Obstetric conditions associated with the need for blood transfusion (whether emergency or not) may lead to morbidity and mortality if not managed correctly.
Adverse events associated with transfusion are increasingly important:
So, strict adherence to correct sampling, cross-match and administration procedures is therefore of paramount importance, even in an emergency.
As more women are concerned with their hereditary breast & Gyneacological cancer risk, the threshold for genetic testing is falling .
Patients and family members should be supported & given information about chemoprevention, surveillance & risk-reducing surgery .
The true challenge lies in translation of this knowledge into clinical practice, such that a definitive improvement in longevity and quality of life for patients and their families is realized.
Medicalization of FGM/C is a challenge that Egypt is currently facing. According to the 2008 EDHS, three quarters of the circumcisions in Egypt are performed by trained medical personnel.
Stopping medicalization of FGM/C is an essential component of the holistic, human rights-based approach for the elimination of FGM/C.
Despite the claims that it is safer to be done by health care professionals, the performance of FGM/C by health care providers constitutes a break in medical professionalism and ethical responsibility.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Postoperative care & management after sui operations
1. Postoperative care & management
after SUI operations
Wafaa B. Basta
Consultant Gynaecology & Obstetrics at Mataria Teaching Hospital,
MRCOG
ERC MEMBER
2.
3. Complications of MUS
• Intra-operative
– Major
• Vascular lesions < 0.01%
• Nerve injuries < 0.0005%
• Gut lesions < 0.007%
– Minor
• Bladder injury 0.5–14%
• Repeated bladder injury
1.2%
• Peri-operative
– Retropubic haematoma 2–
4.3%
– Blood loss > 200 ml 2.7–3.3%
– Urinary tract infections 10%
– Spondylitis 0.3–0.8%
• Post-operative
– Transient urinary retention
1.4–15%
– Permanent urinary retention
2.4–2.8%
– Vaginal erosion 0.7–33%
– Urethral erosion 2.7–33%
– De novo urgency 7.2–25%
– Bladder erosion 0.5–0.6%
– Urethral obstruction 3.6–
6.4%
Managing Complications after Midurethral Sling for Stress Urinary Incontinence
Elisabetta Costantini *, Massimo Lazzeri, Massimo Porenae a u - e b u update s e r i e s 5 ( 2 0 0 7 ) 232–240
4. Pre-operative Counseling
• Voiding difficulty is common .
• Go home with a catheter maybe required .
• Detrusor over-activity might be unmasked.
• More time should be spent counselling at risk
group.
• Preoperative CISC training.
5. Prediction of voiding difficulty
• risk factors for postoperative voiding
dysfunction:
– Advanced patient age (decrease detrusor
contractility, increase urethral rigidity ).
– Patients who undergone prior prolapse surgery,
prior incontinence surgery.
Cho ST, Song HC, Song HJ, et al. Predictors of postoperative voiding dysfunction Following transobsturator sling procedures in
patients with stress urinary incontinence. Int Neurourol J. 2010;14:26.
6. Prediction of voiding difficulty
• pre-operative urodynamics:
– the presence of a high post-void residual volume.
– the use of Valsalva effort to void = Abdominal
straining (abdominal pressure rise during voiding).
– Low maximum detrusor pressure. ( >15-20 cm
H2O).
– Peak flow rate--- less than 15 ml /second .
Kraus SR, Lemack GE, Richter HE, et al. Changes in urodynamic measures two years after Burch colposuspension or autologous sling
surgery. Urology. 2001;78:1263.
Mutone N, Brizendine E, Hale D. Factors that influence voiding function after the tension-free vaginal tape procedure for stress
urinary incontinence. Am J Obstet Gynecol. 2003;188:1477.
7. The management of voiding difficulty after incontinence surgery
Luigi Bombieri, Robert M Freeman TOG 2003;5:66-71
9. Proper surgery selection
• Short-term voiding difficulties following Burch
procedure appear to be more likely than
following TVT
Ward K, Hilton P. United Kingdom and Ireland Tension-free Vaginal Tape Trial Group, et al: Prospective multicentre
randomised trial of tension-free vaginal tape and colposuspension as primary treatment for stress incontinence. BMJ
2002; 325:67.
10. Proper surgery selection
• TOT have been found to promote a lower rate
of postoperative voiding dysfunction than
retropubic TVT.
• Urinary retention and de-novo urgency / urge
incontinence is less likely when using the
transobturator versus the retropubic approach
.
Schierlitz L, Dwyer PL, Rosamilia A, et al. Effectiveness of tension-free vaginal tape compared with transobturator tape in women
with stress urinary incontinence and intrinsic sphincter deficiency: a randomized controlled trial. Obstet Gynecol.
2008;112:1253.
11. Proper surgery selection
• Retrospective data suggests that resolution of
pre-operative detrusor overactivity is greater
in patients undergoing TOT as compared to
retropubic midurethral slings and bladder
neck slings (47 % resolution versus 35 % and
14 % respectively)
Gamble TL, Botros SM, Beaumont JL, et al. Predictors of persistent detrusor overactivity after transvaginal sling
procedures. Am J Obstet Gynecol. 2008;199:696 e1.
12. Prediction of ISD
• Abdominal leak point pressure = ALPP >
60cmH2O.
• Maximal uretheral closure pressure= MUCP
>20 cm H2O.
• + loss of uretheral motility
• Low tension retropubic tape / rectus sling are
preferred than Burch /TVT
13. Intra-operative measures
• Proper surgical technique.
• Use the procedure you are confident with &
the tape you are familiar with.
• Cystoscope when required.
• Conscious effort to avoid over-elevation of the
bladder neck .
• Consider suprapubic catheter if VD is
anticipated.
14. Patient post-operative instructions
• Drink plenty of water (8 glasses/day) but without
overdoing.
• Voiding at regular intervals (3-4 hours during the
day).
• Avoid constipation.(laxatives).
• Good analgesia.
• No intercourse ,no weight bearing for 6 weeks.
• local estrogen in post-menopause is
controversial.
15. Patient post-operative instructions
• Relax rather than pushing as pushing will cause
the urine flow to stop .
• Give the bladder plenty of time to empty.
• Provocation by tape water sound or putting
hands in cold water.
• Try standing or leaning forward during voiding
• Double voiding.
• Urine stream may feel slow and weak initially but
will become stronger with healing.
20. Supra-pubic catheter
• Is preferred than uretheral in the short term VD:
– more practical
– allow patients to attempt urethral voiding without the
need to be re-catheterised .
– The residual urine volume can be measured directly
– Lower incidence of significant bacteriuria compared to
urethral catheters
– voiding occurs earlier.
– patient acceptability appears to be higher.
– Less sexually inhibiting in cases of long term use.
– Less bypass & blockage.
– No urethral stricture or erosion.
Andersen JT,H eiscecberg L, Hebjorn !$ Peersen K, S m p e Sorensen S. Fischer-Rumurren W. et a/.
Suprapubic versus cnnsuttthnl bladder drainage &er colposuspension/vaginal repair.
Ada Obsfrf Gynccol Sand 1985;6(:139-43.
21. Supra-pubic catheter
• Initial insertion requires
training, surgical skills and
equipment.
• Risk of bowel perforation,
(in adhesions and
contracted bladder)
• Better to be inserted intra-
operative.
• Under local anaesthesia?
patient acceptance?
• Availability ?
22. Supra-pubic catheter
• Granulation at
cystostomy entry site.
• Bypassing of urine via
cystostomy channel.
• Skin ulcers.
• Limited time to insert a
new catheter if the
catheter is pulled or fell
out.
23.
24.
25. CISC (advantages)
• Freedom from urinary
collection systems .
• Allow catheterization at
times convenient to individual
lifestyles.
• CISC can reduce and avoid the
risk of :
• infection
• blockage
• Encrustation
• catheter rejection
• pain
• trauma.
26. CISC
• Is based on the principle that retention rather than
catheterisation is the cause of infection.
• Used as a short-term or a long-term strategy.
• The frequency of catheterisation depends on the
severity of the voiding disorder and residual urine
volume.
• Voiding should be attempted before every
catheterisation, and PVR measured and recorded, if
possible.
• Patient motivation is essential, the majority of VD
resolve within 12 weeks after CISC.
27. The role of drug therapy in managing VD
• Alpha-adrenoreceptor antagonists to relax the urethra (e.g.
phenoxybenzamine hydrochloride)
• Detrusor-stimulating drugs such as cholinergic agents (e.g.
bethanechol chloride), anticholinesterase (e.g. distigmine
bromide)
• Prostaglandins.
• An uncontrolled non randomised study found diazepam to be
more effective than other drugs.
• Due to their inconsistent effect and unproven value, drugs are
not currently recommended for the prevention and treatment
of postoperative voiding difficulty.
Stanton SL. cudou, LD, Kcrr-Whn R.Trcatment of delayed o mof spontaneous voiding afar s u m
for incontinence. U m l 1~97 9;13:494-6.
28. The role of surgery in VD
• Urethral dilatation and urethrotomy
– Effective in urethral narrowing
– recurrence of scarring- worsening obstruction
– stress incontinence reappear.
• Supra-pubic and vaginal ‘take-down’ procedures involving urethrolysis,
with or without additional re-suspension procedures:
– suitable for patients who are unwilling or unable to perform CISCI
– cases of voiding difficulty combined with urge symptoms.
– reported success rate is variable and unpredictable
– risk of recurrent stress incontinence
29. The role of surgery in VD
• After TVT procedures:
– Loosening of the tape by applying gentle
downward traction.
– or alternatively transection of the tape (if scarring
does not allow the tape to descend), ------
immediate symptomatic relief.
– The risk of recurrence of SUI has been reported to
be low after both methods.
30. Vaginal mesh erosion
• Can be managed:
– conservative
– non conservative
• Depends on:
– erosion site
– Extension
– mesh material
– patient’s clinical status.
• Oestrogen:
– favour spontaneous
healing in small erosion
– prepare the vagina for
surgical repair.
31. Vaginal mesh erosion
• If synthetic materials e.g
polyester and silicone slings,----
mesh removal ( epithelialisation
is unlikely ).
• if autologous, allograft and new,
loosely woven polypropylene
material -----conservative
management with observation (
tissue ingrowth and healing).
• the self-fixing nature of
polypropylene may allow the
integration into surrounding
tissues .
32. Vaginal mesh erosion
• Kobashi et al suggested that when the
vaginal epithelium appears to cover
the mesh but has not completely
grown over all of it, further
observation might be considered
• Up to approximately 1 cm of mesh
exposure should become
epithelialised within 6 wk.
• Larger areas ----- longer observation
period.
• When the erosion involves the vagina
and is 1 cm, one should preserve the
sling.
• If no starting or partial overgrowth is
evident by 3 mo postoperatively, sling
removal should be seriously
considered.
33. Vaginal mesh erosion
• Surgical approach :
– partial, simple excision
of the exposed mesh
– surgical exploration for
total graft removal and
tissue reconstruction
34. Bladder erosion
• Primary : (perforation)
– perioperative
complication
– evident at cystoscopy
– prevalent after TVT.
– drainage for 2–4 d.
35. Bladder/uretheral erosion
• Secondary: (erosion)
– not evident at cystoscopy
– emerges weeks later
– due to submucosally placed tape .
– Polypropylene mesh contact with
urine--- tape incrustation, no
possibility of correcting the tape
position .
– The earlier a misplaced tape is
explanted, the fewer the scars, the
less inflammation, and the easier
complete removal.
– In selected, complicated cases,(
stones, bleeding, or recurrent
infection) , an open suprapubic
approach with cystotomy is
recommended
36. De novo urgency
• negative impact on QOL
• sometimes self-limiting.
• rule out :
– urethral erosion
– intra-vesical tape
– urinary retention
– Recurrent UTI.
• If persist
– oral anti-muscarinic agents are first-line.
• If fails:
– intra-vesical vanilloids
– intra-detrusor injection of botulinum toxin
– sacral neuro-modulation.
37. Retzius haematoma
• Surgical evacuation of Retzius haematoma is
rare.
• Bleeding usually originates from pelvic floor
veins or epigastric vessels.
• Evacuation is decided on the basis of the
patient’s clinical condition.
38. Conclusion
• Surgeries for SUI are not without hazards.
• Proper preoperative assessment, patient counseling,
meticulous postoperative care& early discovery of
complications are the mainstays of management.
• Voiding difficulty after anti-incontinence surgeries can
become persistent and have a significant impact on
quality of life.
• Supra-pubic catheter & CISC should be added to our
practice.
• Careful surgical technique with avoidance of over-
elevation might play a role in prevention of VD.
not all patients wish, or are able, to master the technique
CISC is easier to learn before rather than after surgery, when the bladder neck is in a higher position.
Low detrusor pressure at maximum flow
patients with a maximum urinary flow rate
Epithelium will form in the tract in six to eight weeks.
A size 14F catheter should be used to keep the tract open and should be changed every 8-12 weeks.
The rationale for the use of these drugs is not clear, as women have few alphaadrenergic receptors in the urethra and there is no convincing evidence that postoperative voiding dysfunction is due to poor detrusor function.
Urodynamics performed in the immediate postoperative period following colposuspension’z have shown that obstructionis more likely to be relevant
Adverse factors for urethrolysis were the presence of detrusor instability and high preoperative residuals.
a challenging complication, particularly in obese, diabetic, or immunocompromised patients.
Because chronic tape inflammation is the main cause of disturbed wound healing, vaginal resection of the periurethral parts of the tape is mandatory.
